India a hot destination for Pakistani medical tourists

3

Arpita Singh and Bilal Ahmed

Sitting in a room in India, Hadiya from Sindh, Pakistan talks fondly about her home, siblings and friends. The 15-year-old girl came to India for her liver transplant in December 2017. Hadiya arrived in India with her parents and maternal uncle. However, the last-minute U-turn by her uncle, who refused to donate the liver, left the family devastated. Luckily for Hadiya, her mother Nausheen, who was not in a condition to donate her liver earlier when the family was still in Pakistan, was cleared for donating liver after undergoing tests in India.

India is a growing destination for medical tourism. The number of foreign patients coming to India is constantly rising as suggested by the data of the last six years issued by Ministry of External Affairs last year. India’s potential as a hub for medical tourism was formally recognized by the Indian government over a decade ago.

In an attempt to make India a lucrative destination, Union Budget of 2003 stated that India must come up as a “global health destination.” This was followed up by the introduction of a new category of visa, the Medical (M) Visa, by the Ministry of External Affairs.

People from all over the world including countries from Europe and the Middle East have benefitted from this initiative. However, the strained relationship between India and Pakistan makes it difficult for patients from the latter country to get a visa. Suhail Aarbi, Hadiya’s father says “We had to wait for three months and called the embassy every day to check if we were granted the visa or not. Then last year, visas were granted on the occasion of Diwali. Knowing this I applied again but I didn’t get any response for another week. Then, my daughter tweeted Sushma Swaraj and we were assured about the visa the very next day.”

India is considered to be one of the most favourable destinations for medical tourism. “There are multiple reasons for patients from Pakistan to choose India over China, Singapore, and Thailand”, says Dr Shaleen Aggarwal, Associate Director, liver transplant, Max Hospital. He cites language, cost and the success of Indian doctors as the main reasons.

Some Indian hospitals have tie-ups with hospitals in Pakistan, which serve as information centres that facilitate the arrival of the patients in India. For example, Apollo Hospital in India and the Dr Ziauddin Hospital in Karachi ran a flagship programme, called the Peace Clinic. Such flagship programmes serve as a precedent. They show how collaborations can bridge geographical and historical barriers and provide better health facilities to the people of Pakistan.

Afza Asim, a resident of Lahore, came to India for her husband Asim Bhatti’s treatment. He needed an urgent transplant. Earlier, Bhattis had gone to several hospitals in Pakistan. The family also went to China and Turkey for treatment. However, after thorough research and several recommendations, they chose India. Like in the case of Hadiya, Bhattis also took to Twitter to request for their visa approval. “We were aware of complexities that come in the process of getting a visa. Therefore, my daughter tweeted to Sushma Swaraj, India’s Minister of External Affairs, and she issued us visa immediately,” Afza says.

According to Bhatti, they decided to choose India over other countries because the Indian doctors have a very good reputation in Pakistan. “Doctors and hospital staff were extremely nice to us. I still don’t feel that I had such a major surgery. I am completely satisfied with the treatment I got in India,” says Asim Bhatti.

It is not just the Pakistani patients who benefit from the cooperation, the Indian health sector earns huge revenue from them as well. At $2906 per patient, a Pakistani national, according to a survey by the Directorate General of Commercial Intelligence and Statistics, earns Indian hospitals more revenue than a medical tourist from other nations.

A key competitive advantage India has in medical tourism, in comparison to other countries, lies in the cost-effectiveness it has to offer to its patients. A person coming to India for his/her medical treatment can have savings anywhere in the range of 30 to 70 percent.

There are many key players in the business of medical tourism like medical facilitators, who work as a bridge between patients and hospital. Medical facilitator, Sumit Wadhwa says that patients contact him through his website MediGuardians. “Our primary work is to establish a contact between patients and hospital according to their budget and kind of treatment they want,” he adds.

Mujahid Malik, another facilitator, says “We help the patients throughout their stay in India, with the accommodation and paper work.” He adds, “Doctors in Pakistan often recommends Indian doctors to critical patients. The respective Indian hospital then sends a formal invitation to the patient in Pakistan.”

According to the FICCI-IMS report published in 2016 by the Ministry of Commerce, India is ranked third amongst the top 6 MVT (Medical Value Travel) destinations in the world which include Thailand, Singapore, India, Malaysia, Taiwan and Mexico. It also says that through adequate focus and effective execution, Indian Medical Value Travel, pegged at 3 billion USD in 2015, can be a 9 billion USD opportunity by 2020.

But the doctors have a different thing to say on the issue. Dr. Aggarwal says, “When patients seek for a visa in emergency cases, the governments should not let their diplomatic bitterness to come in between. Due to the problem in the issuance of medical visas, the doctors are unable to see the emergency cases.” He adds, “Healthcare sector has played an important role in curbing the bitterness among the two nations. For instance, patients tell us that before coming to India they were skeptical, but after coming here they realized that there are no differences.”

Better co-operation in the field of medical tourism can certainly be a step in the direction of long-lasting peace between the two neighboring countries.

TREATMENT ACROSS BORDERS

Zulfiqar Ali Khan and Yousuf Sajjad

When you run out of options to save your life at home, a determination to cross any obstacle to save yourself can emerge. This determination, to obtain life-saving treatments, not available in Pakistan has motivated citizens of this country to cross one of the world’s most contentious border in search of cures for their diseases that are unobtainable in their own country. The antagonism of Pakistan and India’s relationship has impeded a great deal in its history but slowing down the treatment of patients is a particularly disgraceful consequence of the two nations’ hostility.

“The fact that we were travelling, that was the primary concern,” said Mohsin Sayeed, when speaking about taking his late father to India for treatment in 2003. As people who badly need medical treatment for rare medical conditions, waiting for over a month for a visa and then travelling may harm their health even further. Mohsin’s father, Qazi Ahmed Sayeed, suffered a medical emergency en-route to Trivandrum at their transit in Madras. The difficulty of obtaining an Indian visa pushes many of those who need treatment away from making the journey across the international boundary. Medical exchange between India and Pakistan can be a potentially lucrative market, as data has revealed that Pakistanis spend the most in India on medical treatment amongst all the nationalities that come to India for treatment.

These patients find India cheaper and more culturally comfortable for their treatment, but the stringency in the visa issuing process takes time which takes a toll on their health and may push them away from India as a source of medical treatment. This represents added costs for the patient and the loss of an opportunity for India’s medical economy.

The nature of Pakistan’s medical complex means that the country cannot always provide the medical treatments that its patients need. The lack of facilities for some of the most complex medical procedures necessitates travel across the frontier to access hospitals. Dr Saad Khalid Niaz, a renowned hepatologist and gastroenterologist we spoke with for this report, said in regards to Pakistanis traveling to India for liver transplants, “because we don’t have transplant in Karachi so we offer them to go either to Islamabad or to India and some opt for India and some for Islamabad.”

Naved Aslam was the man who helped set up the Peace Clinic at Ziauddin Hospital. A member of the airline industry, after he himself had to travel to India in 2007 for treatment of his heart problems, he assisted in setting up a “Peace Camp” between Ziauddin Hospital and Apollo Hospital, which screened Pakistanis for their illnesses. He is now reluctant to do so due to what he currently finds to be a hostile atmosphere between Pakistan and India. He is now focused on connecting Turkish doctors to Pakistani patients.

Even a report by the Indian Council for Research on International Economic Relations (ICRIER) found that India had much more stricter policies for Pakistani visitors than any other country that receives medical tourists. With visa requirements that restrict Pakistani medical tourists to one city and the demand that they report to the police upon arrival, the report found that Pakistanis were bound by more regulations than Bangladeshis, who had to show more documents when applying for a visa.

The Hindu reported that Pakistan was only issued 1,678 medical visas in 2016. There is a pressing need for India to revise its policies in regards to Pakistani medical travellers to its country. Problems involving visas have gone the other way as Dr Subhash Gupta, an Indian doctor who has performed liver surgeries for many Pakistanis, has had trouble getting a visa for Pakistan.

Dr Gupta is an Indian surgeon who has performed complex transplant surgeries on multiple Pakistanis who needed a new liver. When the Pakistanis Dr Gupta has treated return home, it is Dr Saad Khalid Niaz who facilitates them as their body has to accept the new organ and is adjusting to the surgery.

Dr Niaz has established himself as a well-known hepatologist and gastroenterologist across the region. The post-operative care he provides is extremely vital as liver transplants are among the most complex surgeries in the world. Patients who undergo them need intense care and scrutiny.When speaking about the need for cross-border medical treatment for certain medical conditions, Dr Niaz said, “The thing is that a lot of people may not agree with me and maybe they will question but Indian medicine is actually more advanced than what we have here and there is a lot for us to learn from them.”

A man with a second opinion

Former journalist, Mohsin Sayeed, 50, accompanied his father in 2003 for treatment in India. His views are thus informed by an experience accompanying an extremely ill family member for successful treatment across the Indo-Pak border.

Sayeed’s father, Qazi Ahmed Sayeed, suffered from oral cancer in 2003 and his Pakistani doctors misdiagnosed it as being at the first stage. After Sayeed took his father to India for treatment, his doctor at the Regional Cancer Centre in Trivandrum revealed that he only had a few months to live. Pakistani doctors recommended that the family take him abroad for treatment as they also lacked the radiological equipment to treat the cancer due to then nuclear sanctions the country was under. Sayeed had arranged for his father to be treated at the Regional Cancer Centre in Trivandrum. Over there he received an affordable and effective treatment that cured his cancer. His father’s cancer did not relapse and Qazi Sayeed lived for twelve more years.

Sayeed has a lot to say about the current state of Indo-Pak relations when it came to how they affected cross border treatment. He recalled that back in the early 2000’s that many people travelled to India for treatment and that “many Pakistanis were receiving medical treatment in Bangalore.” Now he says the Indian Government is “not even issuing visa on humanitarian basis.”

In regards on how to improve travel for cross-border treatment, Sayeed said “Just open a (medical visa) cell. And Indian Government should start a Consulate in Karachi. Enough, enough (has) happened. And the Pakistani Government should start a Consulate in Mumbai, it is reciprocal.”

As the difficulty in obtaining visas is related partially to the lack of people to people contact between the citizens of Pakistan and India,Sayeed even mentioned a unique idea to decrease tension between the peoples of both nations. He said that “Peace Parks needed to be established on borders, where people from both sides establish markets to maintain peace. People should come in the morning, spend time, meet each other and go back in evening.”

Considering the length of time that Pakistan and India have remained hostile to each other, unconventional recommendations to improve relations between the two neighbours are to be expected. As Sayeed observed, “For God’s sake, we fought for 70 years and what did we get?”

Qazi Sayeed’s treatment in India had come at time of thawing relations between Pakistan and India, during the spring and summer of 2003. While the US was invading Iraq and consolidated its hold over it, Pakistan was sending its patients to India, where they were being treated for illnesses, the treatments for which were too advanced to be found in Pakistan. At that time, both nations were trying to move beyond the dangers of the nuclear standoff that they had mutually endured in 2002. Among the patients who arrived in the summer of 2003 was Noor, a two year old girl with holes in her heart who became the talk of the town that season, among the Indian media. Noor came to represent the trend of Pakistanis travelling to India for treatment. Sayeed wrote back to Pakistan in emails about his experiences on his family’s travels across the border for treatment, which eventually became a blog that proved was popular with Indians.

Visa refusals

A year and a half ago, Teonmal Sarwani, 49, suffered a major setback in his battle against a chronic renal disease. He exhausted the limited treatment options in Karachi and the struggle was to explore other options or resign to his fate.  

Hailing from Thana Bula Khan village of district Jamshoro in Sindh, Sarwani, along with his wife and son, travelled for over 1,050 miles in 2016 for his kidney treatment, where he was also diagnosed with throat cancer at BLK Hospital, Delhi. He was lucky to get his first visa very easily and quickly.

“I was diagnosed with stage 1 throat cancer.  Dr. Manu Vergis at Apollo Hospital removed my cancer,” said Sarwani in a thick Sindhi accent.

His throat cancer was controlled but the actual fight was with his dysfunctional kidneys. The medication helped him drop the creatinine level from 4.1 to 3.8. “The doctor said the medicines will only let my kidneys work for 2 -3 years, after which they will need to be replaced,” said Sarwani.

Sarwani’s troubles were, however, far from over. Now the problem is much bigger as he has been refused a visa twice, and has not been able to travel to Delhi for a follow-up with his doctor who was to see him three months after his first visit. “I feel troubled as my medical visa applications were rejected twice without giving any reason,” decried Sarwani. He appealed to the authorities on both sides to “depoliticize the visa process and allow patients to get the treatments on humanitarian grounds”.

Sarwani now faces the risk of losing his kidneys as the creatinine level has jumped to 4.8 and his kidneys are only functioning at 10.42%.  “I will try to get treatment from the same place in India as the treatment had benefited me a lot as compared to the treatment here,” said Sarwani.  

Comparing the quality of treatment between Pakistan and India, Sarwani said the quality of medicine is better in India that is why he wants to visit again for the advised follow-up.  “I am doing the treatment in Karachi out of compulsion,” he added.

Counting his medical bills, Sarwani recalls spending over 1.5 million Pakistani rupees on his treatment in India. He said it’s not that much cheaper that you would consider it economical.  “It improved my health so it was worth it,” said Sarwani.

The 49 year-old renal disease patient  is happy with his previous treatment experience in India and is hoping to get visa for his follow-up soon.

The best option is to bring doctors to Pakistan

Hardship struck Aslam was 51 when doctors diagnosed a critical heart ailment. His options in Pakistan exhausted and the only lifeline he could avail was available abroad.

“In 2007, I was diagnosed with a critical heart ailment and reliable treatment was not available so I had to go abroad to get the surgery done,” said Aslam, adding that “For someone who has been diagnosed with an illness and no local treatment is available, figuring out the country, the hospital and the doctor, and getting the visa process done is a lot of trouble.”

Aslam recalls there were very few vascular surgeons in Pakistan at the time of his diagnosis. “Even, if people operate, the success rate was very low” adding that “Getting a surgery done is not enough and the post-surgery situation is crucial.”

The difficulties faced in finding a credible doctor for his rare heart ailment encouraged Naved Aslam, a charter aviation professional, to assist other patients confronting hardships due to the limited treatment options in Karachi. He put his efforts to connect hospitals from Pakistan and India and organized “peace clinic” twice and facilitated online OPD.  

He said the reason why people go to England or other places is because of the high success rate. “In India, the survival rate in cardiac surgery was 98.8 percent”.

He said the treatment costed him about $ 7,000  which was expensive as compared to Pakistan.

He mentioned that the political situation was not so bad back that time. “I was at the hospital the day Benazir Bhutto was assassinated. People were offering condolences to us,” he recollected his memory.   

Talking about the idea behind the peace clinic, Aslam said, “This thought came to me when I was in Delhi for my treatment and the intention was to do something in cross border healthcare for the benefit of people”.  After several months of talking to hospitals in both countries, he was able to connect Ziauddin Hospital to Medanta and Apollo Hospital under the flagship “peace clinic” program to bridge the geographical barriers and facilitate Pakistani patients in their home country. The peace clinic at Ziauddin Hospital facilitated consultation of about 250 patients online with senior doctors from Medanta and Apollo Hospitals. He said, “If you go outside Karachi there is a vacuum with regards to treatment of liver diseases.”

Similarly, through the peace clinic platform he set up liver camp twice in 2015 in which senior liver transplant surgeons Dr Anupam Sibal from Apollo Hospital and Dr Arvinder Singh Soin from Medanta Hospital examined over 100 patients at Ziauddin Hospital in Karachi.  “These were free clinics for the public so that they can get liver treatments after consulting the doctors,” Aslam added.

Commenting on the overall exchange of patients, Aslam said, “People go from Pakistan for treatment as the last resort. When it is at the last stage then they decide to travel. Till the last moment they try other methods, to seek advice from a hakeem or eat homoeopathic medicines.” He said it gets very difficult at the last minute to get visa for the treatment. “They cannot wait for three months to get the visa.”     

Aslam said, “In 2016, there were not as many political issues as we have today.”  He said the objective was to start liver transplant in Pakistan. “It is a big problem for the patient to take the donor and caregivers along to India,” said Aslam. “It would be ideal if Indian doctors come to Pakistan, do the surgeries and go back,”he further added.

Aslam said the government in Pakistan is working to have transplants done locally but the challenge is to get and retain doctors.  “Faculty would come if they get the same payment that they get abroad,” he said. “Instead of a patient travelling across the borders,  doctors should come and work here” and “I used to have this approach and I still think that this is a more feasible plan,” he added.

Crossing the Border for Healthcare

Sitting in a room in India, Hadiya from Sindh, Pakistan talks fondly about her siblings and friends. The 15-year-old girl came to India for her liver transplant in 2017 and is still receiving treatment.

Hadiya arrived in India with her parents and maternal uncle. However, the last-minute U-turn by her uncle, who refused to donate his liver, left the family devastated. Luckily for Hadiya, her mother Nausheen, who was not in a condition to donate her liver earlier when the family was still in Pakistan, was cleared for donating liver after undergoing tests in India.  

India is a growing destination for medical tourism. The number of foreign patients coming to India is constantly rising as suggested by the data of last six years issued by Ministry of External Affairs last year. India’s potential as a hub for medical tourism was formally recognized by the Indian government over a decade ago.

In an attempt to make India a lucrative destination, Union Budget of 2003 stated that India must come up as a “global health destination.” This was followed up by the introduction of a new category of visa, the Medical (M) Visa, by the Ministry of External Affairs.

Although people from all over the world including countries from Europe and Middle East have benefitted from this initiative. However, the strained relationship between India and Pakistan makes it difficult for the patients from the latter country to get visa. Suhail Aarbi, Hadiya’s father says “They had to wait for three months and called the embassy every day to check if we were granted the visa or not. Then last year, visas were granted on the occasion of Diwali. Knowing this I applied again but I didn’t get any response for another week. Lastly, my daughter tweeted Sushma Swaraj and we were assured for the visa the very next day.”

India is considered to be one of the most favourable destination for medical tourism. “There are multiple reasons for patients from Pakistan to choose India over China, Singapore, and Thailand, mainly because of the language and cost barriers and also because of the success rate of Indian doctors,” said Dr Shaleen Aggarwal, Associate Director, liver transplant, Max Hospital.

Some Indian hospitals have tie-ups with hospitals in Pakistan, which serve as information centres that facilitate the arrival of the patients in India. For example, Apollo Hospital in India and the Dr. Ziauddin Hospital in Karachi ran a flagship programme, called the Peace Clinic. Such flagship programmes serve as a precedent. They show how collaborations can bridge geographical and historical barriers and provide better health facilities to the people of Pakistan.

At $2,906 per patient, a Pakistani national, according to a survey by the Directorate General of Commercial Intelligence and Statistics, earns Indian hospitals more revenue than a medical tourist from other nations.

A key competitive advantage India has in medical tourism, in comparison to other countries, lies in the cost effectiveness it has to offer to its patients. A person coming to India for his/her medical treatment can have savings anywhere in the range of 30 to 70 per cent.

There are many key players in the business of medical tourism like medical facilitators, who works as a bridge between patients and hospital. Medical facilitator, Sumit Wadhwa says “Patients contact him through his website MediGuardians. Our primary work is to establish a contact between patients and hospital according to their budget and kind of treatment they want”.

Mujahid Malik, another facilitator, says “We help the patients throughout their stay in India, with the accommodation and paperwork.” He adds “Doctors in Pakistan often recommends Indian doctors to critical patients. The respective Indian hospital then sends a formal invitation to the patient in Pakistan.”

According to the FICCI-IMS report published in 2016 by the Ministry of Commerce, India is ranked third amongst the top 6 MVT (Medical Value Travel) destinations in the world which include Thailand, Singapore, India, Malaysia, Taiwan and Mexico. It also says that through adequate focus and effective execution, Indian Medical Value Travel, pegged at 3 billion USD in 2015, can be a 9 billion USD opportunity by 2020.

But the doctors have a different thing to say on the issue. Dr. Aggarwal says, “When patients seek for a visa in emergency cases, the governments should not let their diplomatic bitterness to come in between their lives. Due to the problem in the issuance of medical visas, the doctors are unable to see the emergency cases.” He adds, “Healthcare sector has played an important role in curbing the bitterness among the two nations as for instance, patients tell us that before coming to India they were skeptical but after coming here they realized that there are no differences.”

 

 

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