Medical Tourism THE ETHICS OF MEDICAL TOURISM: FROM THE UNITED KINGDOM TO INDIA SEEKING MEDICAL CARE Zahra Meghani

Is the practice of UK patients traveling to India as medical tourists morally justified? This article addresses that question by examining three ethically relevant issues. First, the key factor motivating citizens of the United Kingdom to seek medical treatment in India is identified and analyzed. Second, the life prospects of the majority of the citizens of the two nations are compared to determine whether the United Kingdom is morally warranted in relying on India to meet the medical needs of its citizens. Third, as neoliberal reforms are justified on the grounds that they will help the indigent populations affected by them, the impact of medical tourism—a neoliberal initiative—on India’s socially and economically marginalized groups is scrutinized.

In recent years, patients from the United Kingdom have been traveling to India as medical tourists for treatments they cannot obtain in a timely manner from the United Kingdom’s National Health Service (NHS). This amounts to the United Kingdom, a wealthy nation, using the meager health care resources of India. Is it ethical for it to do so? This article offers an answer to that question that takes into account the morally salient particulars of this case of medical tourism. That approach is predicated on the idea that ethical dilemmas tend to be the product of complex, complicated interactions between certain features of situations. Those specifics may be termed the “morally relevant particulars.” Acting in conjunction, the key ethically salient features of moral dilemmas define what qualifies as morally permissible or impermissible, or what is obligatory rather than supererogatory. Determining the right course of action or allocating responsibility International Journal of Health Services, Volume 43, Number 4, Pages 779–800, 2013 © 2013, Baywood Publishing Co., Inc. doi: http://dx.doi.org/10.2190/HS.43.4.k http://baywood.com

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among agents requires recognizing the role of individuals as well as systems, organizations, and nations as crucial, morally relevant particulars if they have played a significant part in creating or giving shape to the ethical dilemma. Thus, in the interest of evaluating the practice of UK patients traveling to India as medical tourists, this article identifies and analyzes the key morally relevant specifics. There are at least three crucial, ethically salient features of this case of medical tourism. This article considers each of them in turn. Part One details the deficiency in the United Kingdom’s health care system that motivates patients to seek medical care in India. Part Two examines the differences in the conditions of life for the majority of citizens of the two countries. The third part of the article is concerned with the impact of medical tourism—a neoliberal initiative—on India’s vulnerable and marginalized populations. As neoliberal programs, policies, and initiatives have been justified on the grounds that they will improve the life prospects of the affected poor, the significance of medical tourism for India’s economically and socially deprived groups qualifies as a factor that ought to inform any attempt to evaluate the ethical merits of the practice. In the fourth and final section, these three factors are analyzed to determine whether the United Kingdom is morally justified in relying on India to meet its citizenry’s medical needs. DEFICIENCIES IN THE UNITED KINGDOM’S NATIONAL HEALTH SYSTEM MOTIVATING PATIENTS TO BECOME MEDICAL TOURISTS Patients from the United Kingdom have been seeking medical care in India and other poor nations. While the practice of the United Kingdom using the health care resources of a poorer nation to meet its citizens’ medical needs may seem to be a novel phenomenon, in reality it is not. It is another, albeit new, manifestation of the United Kingdom’s tradition of relying on poorer countries to address the health care needs of its population. Since the creation of the NHS, a taxpayer-funded health care system that is free at point-of-use (1, p. 1), the United Kingdom has pursued a policy of relying on temporary hire of medical professionals from poorer countries, including former colonies such as India, to meet its citizens’ health care needs.1 That strategy’s adoption can be traced back to the 1 In 1999, the United Kingdom issued an ethics code recommending conditions under which health care personnel from poorer nations could be recruited for the NHS. Compliance with the Code was and remains voluntary. The Code was ineffective in reducing the recruitment of doctors from poorer nations like India and Pakistan because, in 2000 and 2002, the NHS initiated a global recruitment campaign for physicians (64). Thus, the number of physicians from poorer countries entering the United Kingdom continued to grow. It only fell with the implementation of immigration policies aimed at tightening entry into the United Kingdom of immigrants from poorer, non-European Union regions (64).

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establishment of the NHS in 1948. In the interest of coaxing United Kingdomeducated citizen-physicians to participate in the newly established NHS, the United Kingdom promised them that if they joined the NHS, their ability to maintain a profitable private practice on the side would not be affected (2, p. 184). To ensure that, the United Kingdom limited the number of physicians who could establish private practice within its borders by controlling the quantity of places available in UK medical schools and stipulating that only doctors who graduated from those institutions could enter into private practice. That “solution,” however, created a chronic shortage of physicians. To partially alleviate that problem, the United Kingdom allowed a limited number of physicians from other countries (usually, poorer nations like India) to work within its borders for the NHS for a specified period. In return for their service, it would provide them with postgraduate medical training (3), after which they would return to their nation of origin2 (2, 4). Thus, for the sake of protecting its physician-citizens’ interest, the United Kingdom instituted a system that resulted in the NHS being chronically understaffed by physicians.3 Given the persistent shortage of NHS physicians, waiting time to see specialists for non-urgent but serious conditions, such as diseased hip joints, was for years unacceptably long, seriously affecting patients’ life quality. In 2004, the United Kingdom promised its citizens that they would be able to see a specialist within 18 weeks of referral by their primary care physician (5, p. 4). That policy was effective, with virtually all patients seeing a specialist within 13 weeks of referral (6). However, even with that change, all patients do not receive treatment for non-urgent but serious conditions within a time frame they consider acceptable. The NHS gives patients the right to seek medical care in another European Economic Area nation or in Switzerland if, according to clinical assessment of the individual patient’s circumstance, there is undue delay in treatment (7). In such cases, it wholly or partially reimburses them for the cost of their care, provided certain conditions are met (7). Some patients have sought treatment in poorer countries like India because they do not meet the clinical assessment criteria of undue treatment delay and they do not want to (or cannot) pay for the cost of treatment at a private facility in the United Kingdom (8, p. 671) or another European nation. They have traveled to a poorer nation as medical tourists.

2

During the colonial period, postgraduate medical training was not available in countries ruled by the British (2). Moreover, following the independence of the colonies, few such opportunities became available in the newly established nations. Thus, the United Kingdom could hire medical graduates from its former colonies for its purposes by promising them training in return (2). 3 The policies and rules governing employment of migrant foreign-educated physicians put them at a systematic “disadvantage in terms of access to jobs, career mobility, the places where they found employment and the specialties they could occupy” (3). Also see 4, 65, and 66.

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They have paid for treatment themselves or by means of private health insurance. These are patients who are not among the poor of the United Kingdom; they do have access to some resources. (The subgroup of patients who need such treatment but cannot afford to become medical tourists have to endure the NHS waiting time.) Given the exchange rate between the UK pound and, for instance, the Indian rupee, the cost of medical care at India’s world-class medical tourism hospitals is inexpensive compared to the treatment cost at a private (non-NHS) UK facility (Table 1). In India, the majority of hospitals that serve medical tourists have received Joint Commission International accreditation, considered the international gold standard of quality for hospitals (12). For instance, the Hyderabad branch of the Apollo Hospitals has the unique honor of being the first hospital worldwide to receive Joint Commission International accreditation for Disease- or ConditionSpecific Care Certification for Acute Stroke (13). Moreover, New Delhi’s Fortis Escorts Heart Institute, another Joint Commission International-accredited facility, stands out because it has conducted more than 131,939 angiographies, 33,958 angioplasties, and 72,820 cardiac surgical procedures with a success rate of more than 99.7 percent (14). In other words, some of India’s hospitals that serve medical tourists have a greater success rate than some UK hospitals (15). All in all, there are compelling reasons for UK patients to seek medical care in India that they cannot get in a timely manner from the NHS. At least some UK patients are aware of these reasons. They have gone to India as medical tourists (9, 16). Precise numbers are not available as patients prefer using a tourist visa rather than applying for a medical visa; the latter kind of visa requires that the visa holder register with regional authorities within two weeks of arrival in India (17). The Indian government is making considerable efforts to establish the nation as a medical tourism destination by providing medical tourism facilities with a range of state aid, including reduced duties on imported medical equipment and land at subsidized rates (18). India’s private

Table 1 Cost comparison of medical care at United Kingdom’s private facility and India’s medical tourism hospitals

Heart bypass Hip replacement Cataract operation Source: Ramesh (9).

UK (£)

India (£)

15,000 9,000 2,900

4,300 3,180 660

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health care sector is aggressively recruiting medical tourists from wealthy countries. For instance, the Apollo Indraprastha Hospital asked the NHS to refer to it patients requiring cataract surgery, cardiac surgery, joint replacements, and neurosurgery (19). Kolkata’s Ruby Hospital contracted with BUPA, a British insurance company, to attract British patients who are unable to get timely care through the NHS (20). In 2010, to draw patients from the United Kingdom, representatives of India’s health care sector traveled to Britain “to market India as an efficient and cost-effective medical tourism destination” (21). As part of their strategy to attract paying patients from wealthy nations, medical tourism facilities are highly luxurious (22). Undoubtedly, the government of India and the private sector, along with some British companies, are promoting medical tourism. However, the United Kingdom’s role in allowing this practice to develop must not be overlooked. It is because it has chosen to keep the supply of NHS physicians much below the need level of its population that some patients are going to India for medical care. A wealthy nation like the United Kingdom should not underinvest in medical education (23, p. 391) and, thereby, knowingly create a perpetual shortage of locally educated physicians. In contrast to the United Kingdom, other wealthy European nations are much more responsive to the needs of their citizens. In 2008, the United Kingdom had 21.4 physicians and 6.3 nurses and midwives per 10,000 population, while comparable European countries had 32.5 physicians and 68.1 nurses and midwives per 10,000 population (11). Clearly, UK patients feel compelled to seek care in India because of a state policy of understaffing the health care sector. But is there ethical warrant for this case of medical tourism given the acute disparity in wealth between the two nations? LIFE PROSPECTS OF UNITED KINGDOM’S CITIZENS VERSUS THOSE OF INDIA There is severe and extensive poverty and underdevelopment in India. If the poverty line is taken to be $1.35 (all figures in U.S. dollars) per day, the number of poor in India during 1981–2005 ranged from 644 million to 740 million (24, p. 2). It is not the case that hundreds of millions in the United Kingdom are desperately poor. The discrepancies in the conditions of life in India and the United Kingdom are profound (Table 2). India’s gross national product per capita is approximately 12 times lower than that of the United Kingdom, and India’s per capita health expenditure is 100 times lower than that of the United Kingdom. Moreover, the number of physicians per 10,000 population in the United Kingdom (while low compared to similarly wealthy European nations) is at least 3.6 times more than the number of physicians in India. Poverty and a dearth of health care resources have translated into significantly lower life expectancy at birth for women and men in India. Wealth and higher levels of health care resources ensure increased life expectancy in the United Kingdom for females and males (Table 3).

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Population Gross national product per capita Per capita health expenditure Physicians per 10,000 population Life expectancy at birth (women) Life expectancy at birth (men)

India

UK

1,181 million US$2,930 US$40 5.8 66 years 63 years

61 million US$36,240 US$4,000 21.4 82 years 78 years

Source: World Health Organization (10, 11).

Table 3 Rural and urban populations in India and the United Kingdom: Comparative living standard status, 2008 India Rural

UK Urban

Rural Urban

Population distribution

838.8 million (71%)

342.6 million (29%)

N/A

N/A

Lack of access to improved drinking water source

167.76 million (20% of rural population)

34.26 million (10% of urban population)

0%

0%

Lack of access to improved sanitation facilities

671.04 million (80% of rural population)

171.3 million (50% of urban population)

0%

0%

Source: World Health Organization (10, 11).

Poverty results in undernourishment. That is true for India’s poor. Among females and males in the 15–49 age group, during 2005–2006, 36 percent of females and 34 percent of males were undernourished (25, p. 44). In severely poverty-stricken and underdeveloped nations, children are likely to be underweight, stunted, or wasted. In India, during 2005–2006, 48 percent of children under the age of 5 were stunted, 20 percent were wasted, and 43 percent were underweight (25, p. 6). There is no such crisis among children in the United Kingdom.

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It is because of poverty and underdevelopment that hundreds of millions in India lack access to necessities such as clean water and sanitation facilities, with the deprivations concentrated among rural populations. That is not the case in the United Kingdom (Table 3). In India, the paucity of clean water and sanitation facilities in urban and rural areas translates into appallingly high rates of mortality among children under the age of 5. Those deaths are attributable to preventable and treatable conditions such as diarrhea and measles. There is no such child mortality crisis in the United Kingdom (Table 4). These statistics forcefully raise the question of whether India’s meager resources should be diverted to subsidize the cost of treating medical tourists from the United Kingdom, a country whose wealth far surpasses that of its poverty-stricken and underdeveloped former colony. Any answer to that question should take into account another factor, specifically, the impact of medical tourism—a neoliberal initiative—on India’s vulnerable and marginalized groups. Neoliberal reforms are justified on the grounds that they ultimately benefit the poor (26). THE IMPACT OF MEDICAL TOURISM (A NEOLIBERAL INITIATIVE) ON INDIA’S VULNERABLE AND MARGINALIZED POPULATIONS The phenomenon of UK patients seeking treatment in India is the product of neoliberal policies. As medical tourism is a relatively new practice, it will be

Table 4 Comparative mortality rates among children under 5 in India and UK, 2008 India

UK

Mortality rates for children younger than 5

69 per 1,000 live births (94 deaths per 1,000 live births in rural areas and 61 deaths per 1,000 live births in urban regions)

6 per 1,000 live births

Percentage of mortality, children younger than 5, attributable to diarrhea

13%

Statistically insignificant

Percentage of mortality, children younger than 5, attributable to measles

4%

Statistically insignificant

Source: World Health Organization (10, 11).

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useful to consider the effect that a variety of other neoliberal initiatives have had on India’s severely compromised populations. That should provide insight about the possible impact of medical tourism on those groups. In the interest of a cohesive, organized, and clear analysis, first, India’s vulnerable and marginalized populations are identified. Second, neoliberalism’s tendency to make false promises to the poor is discussed. Third, the possible ramifications of medical tourism for those groups are outlined. India’s Vulnerable and Marginalized Groups The landless, the rural poor, Scheduled Castes (SC), Scheduled Tribes (ST), and Other Backwards Classes (OBC) are the most socially and economically compromised populations of India (“OBC” is a legal term used by the Indian government to denote socially, educationally, and economically disadvantaged groups).4 Usually, women from these communities are particularly vulnerable and marginalized because of sexist cultural norms and practices. For instance, female landless laborers are paid 30 percent less for casual labor and 20 percent less for the same task than male landless laborers (27, p. viii). While women make up about 66 percent of India’s agricultural workforce, they own less than 10 percent of agricultural land (27, p. viii). Gender discrimination in the workplace translates into fewer kinds of work opportunities as well as lower pay and fewer days of work for females who are poor than for males. Caste and tribal membership also make a difference, with the SC, ST, and OBC faring worse than other populations. Most landless agricultural workers belong to these communities (28, Section IV). With some exception, there is a significant correlation between a group’s location on the caste hierarchy and its place in the agrarian hierarchy (28, Section IV). The latter structure is akin to a three-level pyramid dominated by a small number of upper caste landowners who have vast land holdings. The middle level comprises cultivators belonging to the middle castes. They are more numerous than the landowners. The vast majority of agricultural workers are the landless poor who belong to SC, ST, or OBC (28, Section IV). Women workers from those groups are likely to be more disadvantaged than higher caste females. A 2005 three-state study showed that higher caste women had better and longer employment prospects than ST, SC, and OBC females (29), with ST women employed fewer work days than SC females (27, p. 10). 4 According to the National Commission for Scheduled Tribes, communities that suffered from “. . . [e]xtreme [s]ocial & [e]conomic backwardness¾like [u]ntouchability[,] [p]rimitive [a]gri-Practices, [l]ack of [i]nfrastructural facilities, [g]eographical [i]solation¾needed special consideration for safeguarding their interests. . . . These communities were notified as Scheduled Castes and Scheduled Tribes as per provisions of Art. 341(1) and 342(1) of the [Indian] Constitution respectively…” (67). For a fuller account of the category of OBC, see 68.

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It is indicative of the vulnerability and marginalization of poverty-stricken, rural populations, especially those who belong to SC, ST, or OBC, that their children fare worse than children of other groups. Infant mortality rates and under-5 mortality rates are substantially higher for these populations than other demographics (Tables 5 and 6). Neoliberalism’s Empty Promises to the Poor Neoliberalism promises to improve the life prospects of the global billions mired in poverty (31, p. 169). Since the 1990s, the World Bank and the International Monetary Fund (IMF) (and the nations that are dominant in them, such as the United Kingdom [32]) have ostensibly identified helping the poor worldwide as the moral and economic grounds for the neoliberal reforms they advocate. In fact, since the 1990s, the World Bank and the IMF have termed their neoliberal reforms “poverty reduction strategies,” rejecting the term “structural adjustment policies” that they had previously used. However, this switch in terminology does not signify a real commitment to improving the lot of the global poor, because

Table 5 Infant mortality rates per 1,000 live births

Scheduled Caste Scheduled Tribes Other Backward Class Other

Urban

Rural

Total

50.7 43.8 42.2 36.1

71.0 63.9 61.1 55.7

66.4 62.1 56.6 48.9

Source: Ministry of Health and Family Welfare (30).

Table 6 Under-5 mortality rates per 1,000 live births

Scheduled Caste Scheduled Tribes Other Backward Class Other

Urban

Rural

Total

65.4 53.8 54.5 42.1

94.7 99.8 78.7 68.2

88.1 95.7 72.8 59.2

Source: Ministry of Health and Family Welfare (30).

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the policies still require that debtor nations cut public spending on the poor, subsidize private enterprise, and allow market forces that benefit transnational corporations to prevail unchecked, regardless of the harm they do to the rest of society (33). In India, with the adoption of neoliberal reform in the late 1980s, the rate of poverty reduction has decreased, especially in rural areas (34, pp. 16–17). The effect of neoliberalism on India’s vulnerable and marginalized groups— the landless, the rural poor, the SC, ST, and OBC—are tracked in this section. It has the following three parts: 1. The impact of neoliberal reform of the agricultural sector on India’s vulnerable and marginalized demographics 2. The effect of neoliberal reform on India’s vulnerable and marginalized populations’ access to food 3. The significance of neoliberal reform for India’s vulnerable and marginalized groups’ access to health care The Impact of Neoliberal Reform of the Agricultural Sector on India’s Vulnerable and Marginalized Demographics. Neoliberalism calls on nations to open their agricultural sectors to foreign competition. Moreover, it contends the state should not provide subsidies to farmers nor fund agricultural infrastructure. The neoliberal justification for those reforms is that they will foster farming-sector growth, improving rural incomes and life prospects (35). Obeying the dictates of neoliberalism, India cut state investment in agricultural infrastructure, such as canal irrigation systems (38, p. 183). According to neoliberal logic, it had been crowding out private investors (36, p. 166). However, the private sector did not rush in to invest in agricultural infrastructure when the state reduced its spending. Thus, India’s farming sector suffered substantial setbacks because of underinvestment in fundamental agricultural infrastructure. Neoliberalism dictated that the state cut lending to farmers (37; 38, p. 183), thus, poor farmers (male and female) had to take out high-interest, non-state loans to finance seed purchases. But they could not repay them because of low yield and competition from cheaper imports. As a result, from 1997 to 2007, 182,936 rural poor farmers committed suicide (37). The official statistic for “farmer suicide” is lower than the actual 182,936 figure because female farmer suicides are not included in the tabulation (37). Women farmers are classified as “farmers’ wives” by the state because, while they do most of the agricultural work, they do not own the land and thus, their suicide is not considered a “farmer suicide” (37). The decline in state investment and support for farmers, along with the high prices for seed charged by transnational corporations, which own the patents on those seeds, has been a disaster for the rural poor. That harm has been compounded by a rise in global food prices—also attributable to neoliberal policies (39).

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The Effect of Neoliberal Reform on India’s Vulnerable and Marginalized Populations’ Access to Food. Neoliberalism requires that the state allow market forces to set food prices and that it reduce (or, ideally, eliminate) tariffs and duties on food imports. Food subsidies are considered pernicious by neoliberalism. It contends that, like other forms of welfare, such subsidies discourage individuals from being self-sufficient and productive. The impact of these neoliberal reforms on access to food has been marked. Calorie intake fell between 1972–1973 and 1993–1994 in both urban and rural areas (Table 7); Kerela and West Bengal were the exceptions (40, p. 35). The decline is troubling because in India, the “average calorie intake is below the average norm used to define absolute poverty [, which] is 2,400 Kcal in rural areas and 2,100 Kcal in urban areas” (40). India’s poor have been acutely compromised by the increase in relative food prices (31; 34, pp. 22–23) because it has been accompanied by the shift away from a food policy of universal coverage, the Public Distribution System, to a limited coverage system, Targeted Public Distribution System (TPDS). In 1996, India introduced TPDS, which distinguished below-the-poverty-level and above-the-poverty-level households, with the aim of guaranteeing food subsidy only to the former (40, p. 42). Neoliberalism’s proponents contended that food subsidies for the latter population were a waste of public resources and TPDS would ensure that only those who needed assistance would get it. But confidence in TPDS is not justified because, while the universal coverage system is vulnerable to the error of inclusion (i.e., those who are rich and do not need the subsidy receiving it anyway), a morally worse error occurs with the implementation of TPDS (40, p. 43). TPDS results in those who need food subsidy, but are not below the poverty level, not receiving desperately required food aid. That is because, first, in India, the majority of the work force is concentrated in the informal sector, where workers do not receive regular monthly salaries, thus it is difficult to accurately estimate their annual incomes for the purposes of determining eligibility for inclusion in the food subsidy program (40, p. 44). Second, India’s official income poverty line denotes an income level that verges on destitution. Therefore, it should not be employed to identify all those who ought to receive

Table 7 Rural and urban caloric intake pattern 1972–1994 1972–1973

1983

1993–1994

2,107 2,266

2,089 2,221

2,071 2,183

Urban caloric intake Rural caloric intake Source: Swaninathan (40).

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food subsidy. Its use only allows the identification of a subset of the relevant group (i.e., those who are utterly compromised), excluding those who need assistance but do not meet the all too narrow criterion of poverty (40, p. 44). The landless rural populations and members of ST, SC, and OBC tend to be the most poverty-stricken. So, it is probable that their access to food has been disproportionately affected by neoliberal food reforms. Among the ST, SC, and OBC that are patriarchal, it is likely that females have suffered more than males. In patriarchies, females (young and old) have less access to household resources, including food, than males (41, Section III). A rise in food prices without a corresponding increase in household income usually results in a lower allotment of food for females than for males. The Significance of Neoliberal Reform for India’s Vulnerable and Marginalized Groups’ Access to Health Care. Neoliberalism contends the state must reduce or eliminate subsidized or free health care services and goods it provides to its citizens, even if they are poor. Health care should be a profit-making, privatized enterprise. Neoliberalism’s proponents claim people are willing and able to pay for good quality health care and the appropriate implementation of user fees for health care, even for the poor, is acceptable (42, p. 164). They assert user fees will reduce health care resource wastage by the poor (42, p. 166). From 1947 to 1983, India’s health policy was based on two principles. First, even those who could not pay should get health care, and second, it was the duty of the state to provide health care to all (43, p. 43; 44). The 1983 National Health Policy marked a drastic change in that policy. India decided to foster private-sector involvement in health care delivery. This was a radical shift, characterized by a significant roll-back of the state’s responsibility to the people (44). Moreover, it set the stage for neoliberalization of the health care sector that continues today. Since the 1980s and into the 1990s, India’s budget plans have articulated a commitment to providing only primary health care (not comprehensive health care) for the underprivileged. In the 1990s, the state decided to focus only on family planning services along with primary care for the poor (45, p. 70). It also turned to private, corporate, and nongovernment entities to assist in that endeavor (45, p. 70), motivated, presumably, by neoliberal ideology. The neoliberalization of India’s health care sector was a condition of IMF’s multi-billion-dollar loan to India (46, p. 268). Public health spending fell from 1.4 percent of the gross domestic product in the mid-1980s to 0.9 percent in 2002 (46, p. 268). Along with cuts in publicly funded health care programs (47, p. 164), user fees have been implemented to discourage alleged wasteful use of health care resources by the poor. But those fees are neither morally nor economically warranted. First, they generate miniscule revenue (42, p. 165). Second, given the limited resources of the poor, they are deterred by the fees from seeking vital treatment. They wait to get care until their condition worsens considerably, and then they are forced to pay even more than they might have paid if they had

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sought treatment sooner. User fees “. . . further decrease access for the more vulnerable sections among the poor, such as women, children, and the scheduled castes and scheduled tribes in India” (42, p. 166). For instance, the poor among the dalits (a group at the lower end of the caste hierarchy) have great difficulty in getting medical care because of the high cost of care in private facilities (47), resulting in “widespread neglect of health, frequent diseases, and chronic ailments, often with fatal consequences” in that population (47, p. 167). To get treatment at private medical facilities, the poor must incur considerable debts that push them deeper into poverty (47, p. 168; 48). With the implementation of neoliberal reform, “treatment costs measured through average episodic expenditure have gone up from $20 to $35 in rural and $24 to $42 in urban India. This increasing cost is primarily borne by consumers, and around 87 percent of expenses are met through private financing. As a result of these rising costs, the proportion of poor who do not seek any health care has gone up from 15 percent to 24 percent in rural and from 10 percent to 21 percent in urban India in the last two decades” (47, p. 165). All in all, the reduction in public health spending, the introduction of health care user fees, the cuts in state support for the agricultural sector, the rise in food prices, and the shift from a food policy of universal coverage (i.e., Public Distribution System) to a limited coverage system (i.e., TPDS) have had severe consequences for the vast majority of India’s vulnerable and marginalized populations. Neoliberal initiatives have not improved their life conditions; rather, they have worsened them. The development of India’s medical tourism industry is yet another, albeit new, neoliberal initiative aimed at making health care a profitable enterprise. Next, its implications for India’s socially and economically compromised groups are considered. Medical Tourism (a Neoliberal Initiative) and India’s Vulnerable and Marginalized Populations The growth of medical tourism facilities in India is the product of neoliberal reform. Bookman and Bookman note that “. . . without extensive (neo)liberalization, India would not be at the (medical tourism) industry’s forefront” (49, p. 130). Neoliberalism contends that for the sake of development, poor nations should attract foreign investment and revenues. Thus, India has decided to pursue a policy of aggressively fostering medical tourism. The 2002 National Health Policy stated (Section 4.25.1), “To capitalize on the comparative cost advantage enjoyed by domestic health facilities in the secondary and tertiary sector, the policy will encourage the supply of services to patients of foreign origin on payment. The rendering of such services on payment in foreign exchange will be treated as ‘deemed exports’ and will be made eligible for all fiscal incentives extended to export earnings” (50). India has given “private hospitals treating

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foreign patients benefits such as lower import duties and an increased rate of depreciation (from 25% to 40%) for life-saving medical equipment. Prime land is provided (to them) at subsidised rates” (49, p. 130). The precise amount of state subsidies for private medical tourism facilities is not available. However, given the concessions offered to them, it is likely to be substantial. But as India cannot provide even basic health care (and other necessities such as adequate nutrition and access to clean water and sanitation facilities) to hundreds of millions of its people, should it be subsidizing the cost of treatment for paying patients from richer nations by supporting medical tourism? Proponents of medical tourism are likely to respond in the affirmative to that question, using the same argument they use to justify neoliberal reforms in general. They would probably claim the state should support and encourage the privatization of health care so that it can be a profitable enterprise. That will result in an efficient and fair distribution of health care resources, while creating wealth for those who provide those goods and services. That, in turn, will benefit the poor. While that argument has rhetorical appeal, there is a dearth of evidence supporting it. In fact, studies (cited above) demonstrate that neoliberal reforms have not benefitted the vast majority of India’s vulnerable and marginalized populations. The roll-back of the state’s commitment to providing health care services and goods to its citizens has particularly compromised those groups’ life circumstances, with de-acceleration in reduction in infant mortality rates and under-5 mortality rates among those populations (30, pp. 181–182). Fewer adults and children from those demographics are able to get needed medical care. Thus, it seems likely that medical tourism—another neoliberal initiative—will further constrain the ability of India’s severely compromised populations to get medical care and will affect for the worse their life prospects. Advocates of medical tourism (and other neoliberal reforms) will probably reject that conclusion. They might argue that medical tourism benefits vulnerable and marginalized groups because private, for-profit hospitals that cater to paying foreign patients provide subsidized or free care to India’s poor. There is something to that claim. For instance, the chain of Apollo Hospitals in India has at least four programs that provide medical care or advice for free or at a discounted rate to the poor. The Distance Healthcare Advancement Project is one of them. It is a joint initiative between the Apollo Hospitals and three other organizations (51). The aim is to offer health care to underserved, vulnerable populations in remote parts of India at an affordable price by means of telemedicine. According to the Apollo Hospitals’ website, vans equipped with teleclinics will travel to rural regions to offer cuttingedge medical care at prices that are within the means of the local population who, presumably, are the rural poor. The number of vans is not specified; the expectation is that this initiative will cover a population of 750,000 in its initial phase.

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Established in 2003, Apollo Hospitals’ Save a Child’s Heart initiative aims to offer pediatric cardiac care and financial support to children of vulnerable and marginalized populations (52). Since its inception, under its auspices, 900 surgeries or interventions have been performed with a success rate of 97 percent. The cost of the surgery is jointly covered by the Apollo Hospitals, philanthropic organizations, and individuals (the website solicits donations nationally and internationally). Apollo Hospitals’ Society to Aid the Hearing Impaired program runs camps in rural areas for hearing-impaired children of poor families (53). It provides hearing aids and creates awareness for prevention of hearing loss. In some cases, surgeries are performed on children with hearing problems. The CURE Foundation, established in 2002, is another Apollo Hospitals initiative (54). Its goal is to provide cancer prevention education. It also has programs for early detection and cure of cancer and for rehabilitation of cancer patients. It has so far provided free and subsidized medical care to more than 500 poor patients. Undoubtedly, these initiatives of the Apollo Hospitals (and similar programs run by other private medical tourism hospitals) provide some assistance to India’s socially and economically vulnerable populations. But it should be noted that at least some of the initiatives for helping India’s poor are not financed solely by the medical tourism facilities that run them. The Apollo Hospitals, for instance, partially rely on donors to fund Save a Child’s Heart. The question must also be asked whether these programs justify, presumably, the millions in subsidies that India gives the medical tourism facilities. Screening, preventative programs, and medical treatments for hundreds or even thousands of those mired in poverty is a meager trade-off for the amount that goes into supporting medical tourism and that India could have used to provide medical care to a number of its vulnerable and marginalized citizenry. Of course, there is no guarantee that the subsidies provided to medical tourism facilities (and, thus, utilized to subsidize the cost of medical care for patients from richer nations like the United Kingdom) would otherwise have been used to provide health care to India’s economically and socially marginalized populations. But that does not mean the use of those resources to support medical tourism is justified. It is still wrong given that there are hundreds of millions in India who are desperately poor and who have to go without needed medical care, while wealthy nations like the United Kingdom deliberately underfund their health care sectors, choosing instead to use the meager health care resources of poorer countries to meet the medical needs of their populations. Medical tourism’s advocates might argue that hospitals that cater to foreign paying patients generate dollars that India can use to provide medical care for its indigent populations. While appealing, it is unlikely that proposal can be implemented in a substantive sense. India cannot demand that any meaningful portion of the profits of medical tourism facilities be utilized to provide medical

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treatment for local indigent populations. If a medical tourism facility is financed by foreign investments, those creditors have claim on its profits (55, p. 357). A number of India’s medical tourism facilities are financed by transnational corporations. The Sir Edward Dunlop Hospital, a $40 million cardiac care facility in Faridabad, has been co-financed by Australian, Canadian, and Indian businesses (56, p. 226). A 90 percent stake in a 200-bed hospital in New Delhi is held by a German business (57, p. 80). The Apollo Hospitals chain was funded by Citigroup, Goldman Sachs Group, Schroders PLC, and Indian investors (58, p. 97). India cannot insist their profits be used to provide medical care for vulnerable and marginalized populations, without incurring a significant punitive response from the World Trade Organization, the IMF, and the World Bank. Given the neoliberal commitment of the nations dominant in those organizations, they would oppose measures by poorer countries that undermined free trade (read: transnational corporate interests) by limiting the flow of profits from foreign investments out of their borders, even if those policies aimed at fostering the well-being of vulnerable and marginalized populations of those countries. For the same reason, the proposal that some beds at medical tourism facilities be provided at a subsidized rate or for free to the local indigent population (57, 59) might be implemented only insofar as it did not cut into the facilities’ profits and could be offset by significant tax breaks. Changing tack, proponents of India’s medical tourism facilities might contend medical tourism in the long run will benefit all of India, including its vulnerable and marginalized populations. The hardships suffered by those groups will bear fruit in the future. For instance, the existence of medical tourism facilities has and will further reverse the international medical brain drain India has been experiencing, and the introduction of cutting-edge technology and techniques used at medical tourism facilities will benefit the local population as those equipment and practices are shared with public hospitals that serve India’s indigent (60; 61, p. 1639). This “trickle-down benefits” argument in support of medical tourism must be rigorously interrogated for at least two reasons. First, it is arguable indigent populations will benefit in significant numbers from the reverse international medical brain drain attributable to medical tourism. Treatment at the private expensive facilities that serve medical tourists and very wealthy Indians (a tiny percentage of Indian society) lies beyond the means of India’s poor (62, p. 89) and even middle class. For instance, a Kerala hospital that caters to medical tourists offered a 10 percent discount on heart bypass surgeries to local patients that did not qualify as indigent. The cost of the discounted surgery was Indian rupees 90,000 (estimated $2,000). That is a significant amount for India’s middle class, which is a minority within India. It is the group that is “able to spend between $2 to $20 a day in 2005 purchasing power parity dollars” (63). The promise of medical technology and technique transfer from medical tourism facilities to state hospitals and clinics that serve the indigent is a mostly

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meaningless one. In rural areas, hospitals are rare and the state health care centers that serve the poor are grossly underequipped. There are delivery rooms or laboratories in fewer than 50 percent of them and less than 20 percent have a phone (17). In addition, stocks of essential drugs are available in fewer than 33 percent of primary health care centers (17). Thus, the claim that sophisticated medical tourism facilities can transfer advanced medical technologies and techniques to them is unrealistic. The second reason that the trickle-down benefits argument lacks credibility is that it is based on unwarranted, morally flawed assumptions. Did the vulnerable and marginalized populations—the landless, the rural poor, SC, ST, and OBC—who bear the brunt of neoliberal health care initiatives (such as state subsidization of medical tourism facilities in lieu of funding for public health care programs) agree to shoulder the enormous cost to them and their children? Would policymakers and members of the private sector who advocate neoliberal health care reform have supported those changes if they and their families, including their young children, were the ones who stood to lose (or forgo possible) access to medical care? The point is, if reforms come at a substantial cost to certain populations, they should have significant say in whether those changes should be implemented. Otherwise, great injustice is done to them. When those in positions of power justify policy reforms (whose costs they themselves do not bear) on the grounds that even though those changes will mean immediate hardships for the vulnerable and marginalized, in the long run those populations will be better off by virtue of the new policies, their assertions must not be accepted unquestioningly. Not every kind of harm suffered by those who cannot get medical care in the here and the now can be “made up” later. For instance, loss of life cannot be “made up” by providing health care in the future. Medical tourism—a neoliberal initiative—cannot be considered a boon for India’s poor. DISCUSSION This article examined each of the three key morally significant factors of the case of UK patients going to India for medical care. First, an analysis of the feature of the United Kingdom’s health care system that motivates patients to seek care in poorer nations—the long waiting time for serious but non-urgent conditions—reveals that it is the product of state policy. Given the United Kingdom’s wealth, it has the ability to remedy that shortcoming. It should not be saving on its health care cost by delaying treatment for a subset of its citizens such that they feel compelled to travel to poorer nations as medical tourists. Second, a comparison of the conditions of life of the majority of citizens of the two nations forces the conclusion that the United Kingdom’s reliance on India to meet its citizens’ medical needs is morally unacceptable. Third, an assessment of the impact of a variety of neoliberal policies, programs, and initiatives on the vulnerable and marginalized of India showed that they do not tend to improve

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the lives of those groups. While proponents of medical tourism may contend that it will better the prospects of the poor in destination nations by providing them with increased access to medical care, in the case of India, there is no evidence that supports that claim except in a minimal, nominal sense. Some medical tourism hospitals do provide no-cost screening services for certain illnesses and they do offer free treatments to a miniscule fraction of India’s poor, which number in the hundreds of millions. The degree to which such charitable programs are funded from the profits of medical tourism facilities, if any, is unknown. As mentioned earlier, these programs solicit donations in support of their charitable efforts. It is also arguable whether these charitable programs are substantive payback for the significant subsidies India provides to luxurious medical tourism hospitals that offer top-notch medical care to paying patients from wealthy nations like the United Kingdom. Besides medical tourists, transnational corporations that have invested in medical tourism facilities are significant beneficiaries of medical tourism from the United Kingdom to India. They are able to rake in profits because of the state aid India provides to medical tourism facilities and low labor costs, even as hundreds of millions of the local population go without access to crucial medical care. Taken in conjunction, these morally salient facts serve as a forceful ethical argument against this case of medical tourism. Acknowledgment — This article draws and builds on the author’s earlier work on medical tourism (69), which was funded by a Career Enhancement Grant from the University of Rhode Island’s Council for Research. REFERENCES 1. Black, N. ‘Liberating the NHS’—another attempt to implement market forces in English health care. New Engl. J. Med. 363:1103-1105, 2010. 2. Raghuram, P. Thinking UK’s medical labour market transnationally. In The International Migration of Health Workers, ed. J. Connell. Routledge, New York, 2008. 3. Raghuram, P. The Asian doctors who shaped the NHS. OpenLearn, July 2, 2008. 4. Decker, K. Overseas doctors: Past and present. In Racism in Medicine: An Agenda for Change, ed. N. Coker. The King’s Fund, London, 2001. 5. Harrison, A., and Appleby, J. The war on waiting for hospital treatment: What has Labour achieved and what challenges remain? The King’s Fund, August 4, 2005. http://www.kingsfund.org.uk/publications/war-waiting-hospital-treatment (accessed June 5, 2013). 6. National Statistics. Statistical Press Notice NHS Inpatient and Outpatient Waiting Times Figures. July 31, 2008. http://webarchive.nationalarchives.gov.uk/20130107 105354/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/ documents/digitalasset/dh_087419.pdf (accessed June 5, 2013). 7. National Health Service (NHS). NHS Choices: Your Health, Your Choices: Planned Treatment Abroad: Introduction. 2010. http://www.nhs.uk/NHSEngland/Healthcare abroad/plannedtreatment/Pages/Introduction.aspx (accessed June 5, 2013).

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Direct reprint requests to: Zahra Meghani Department of Philosophy University of Rhode Island 170 Chafee Hall Kingston, RI 02881 [email protected]