ISA S Internship Programme 2008

Emergence of corporate hospitals in the metropolises in India: viable partnerships with Singapore Yvonne Yap Table of Contents Section 1.......................................................................................................................................... 2 Objectives and scope....................................................................................................................... 2 Data, material and methods ......................................................................................................... 5 Section scheme ............................................................................................................................ 6 Section 2.... .8 Driving forces for the emergence of corporate hospitals ................................................................ 7 Historical perspectives ................................................................................................................ 7 Lack of resources in public healthcare sector ............................................................................. 8 Rising demand for healthcare from domestic patients .............................................................. 11 Economic growth in India ......................................................................................................... 14 Section 3........................................................................................................................................ 18 Patients perceiptions on quality of healthcare of Corporate Hospitals: Survey results ............... 18 Patients profile ............................................................................................................................. 18 Patients perception on quality of healthcare provided by corporate hospitals at the metropolises in India .......................................................................................................................................... 22 Section 4........................................................................................................................................ 29 Analysis of the hospital facilities survey ...................................................................................... 29 Hospital characteristics ................................................................................................................. 29 Eligibility for international partnerships ....................................................................................... 33 Section 5........................................................................................................................................ 40 Corporate hospitals: viable partnerships for Singapore ................................................................ 40 Bibliography ................................................................................................................................. 65

Section 1 Objectives and scope 1.0. Introduction: The main objective of the research paper is to understand the growth of the corporate hospitals and its impact on the health care at the domestic and international levels. Healthcare sector alone has been growing massively, accounting for almost 5.2 per cent of India's GDP today (Mathiyazhagan, 2003a; Nichter & Sickle, 2002). Medical care is an enormous business, with the private sector being the most dominant in this industry, accounting for more than 70 per cent of India's urban healthcare service market (Mudur, 2003). This unequivocal dominance of the private sector has been headed by the emergence of the corporate hospitals in India, especially in the metropolises, where the middle class are multiplying in size and affluence (Mathiyazhagan 2003b). In fact, the corporate hospitals industry has been estimated to be a $20 billion industry by the year 2010 (Mathiyazhagan, 2008). Therefore, it can be seen that the corporate hospitals form a very large business in India and the rest of the world. There is a need to study this trend because of the following reasons: Lack of literature written on the impacts of the emergence from the Singapores perspectives. To understand if the corporate hospitals meet the demands of their target consumers, the international patients and the urban middle income patients. Help to evaluate the viability of the partnerships between Singapore and Indias corporate hospitals.

The emergence has been the result of various forces, ranging from the growth of the urban middle class to government economic policies to market forces (Nichter & Sickle, 2002). In fact, the two largest forces are the emergence of these two groups: the middle class and the international patient population. However, it is rare to find any evidence to validate these facts and thus understanding the origins of these two groups will be helpful to find out if the emergence of the corporate hospitals in the metropolises truly fulfills the demands of these two groups of patient. (Kaur et al, 2007). In addition, there have been numerous studies done to understand its emergence better especially its impacts on the healthcare scene in India and to find out the quality and performance of the hospitals. It has been concluded on multiple occasions that the hospitals are indeed quality oriented. However, insufficient studies have been done on the impacts of the emergence of these corporate hospitals on the healthcare industry worldwide and on the viable partnerships that can be set up to tap into the new emergent markets of international and middle income patients. In fact, there is virtually no literature written on this trend from the Singapore's perspectives, which puts Singapore healthcare sector at a disadvantage to build up its competitiveness. With the initiation of Comprehensive Economic Cooperation Agreement in 2003, healthcare has been highlighted as one of the key areas for greater Singapore-India collaboration (Mukherjee, et al., 2003). Therefore, greater networking and partnership sourcing need to be strengthened between Singapore and India to sustain the unprecedented economic growth for both countries. In this context, this research study sets out to understand the emergence of the corporate hospitals in India and its impact on Singapore's healthcare industry to explore more viable partnerships.

Lastly, the Singapore vision 2020 likes to seek out opportunities for Indian hospital groups to participate in Singapore and increase the collaborations in areas like medical equipment trading (Saw, 2006). The stronger networking will help Singapore establish its presence in the huge untapped Indian market and the hospitals can capitalise on Indias comparative cost advantage to provide internationally accredited healthcare services at a much lower cost (Mukherjee, et al., 2003). This will boost Singapores competitiveness tremendously in the world market. For the Indian side, the Confederation of Indian Industry is roping Singapore in to establish greater presence for both healthcare industries in third countries markets (Mudur, 2003). The corporate hospitals are also constantly innovating and improving their technological, clinical and service aspects to provide world class services and to get accreditation. This is a way to ensure that their services are of high quality and meet the demands set by the patients and more critically become a signaling device for other corporate hospitals to indicate that that these Indian hospitals are suitable for partnerships. With their desire to outsource their high quality service, these corporate hospitals are now looking outwards to Singapore, since collaborations will boost their reputation and allow the inflow of management and clinical expertise (Mukherjee, et al., 2003). Henceforth, the benefits from collaborations with the hospitals in both countries are manifold as these hospitals tap their respective comparative advantages complementarily to enhance their competitiveness in the world markets (Manjunath, et al., 2007). This calls for the need to study the quality and the performance of these corporate hospitals to ensure that partnerships between Singaproe and Indias corporate hospitals are viable and profitable so that both countries can reap all those potential benefits suggested above.

Thus, there is an utmost priority to do more research on corporate hospitals in India from Singapores perspectives to fully understand the impact of this growth on India's and Singapore's health care industry. The research study should achieve the following objectives: to study the driving forces of the emergence of corporate hospitals. To examine the quality and performance of corporate hospitals according of key performance indicators To infer viable partnerships for Singapore 1.1. Data, material and methods: In order to analyse the above objectives, this study has selected purposely 16 hospitals in the 3 metropolises in India, Chennai, Mumbai and Delhi. 2 surveys have been used to collect data required for analysis and the surveys are the hospital facilities survey and the short form patients satisfaction questionnaire. The hospital facilities survey has been conducted with the hospital management executives to fully capture the organisational attributes of the hospitals like the services offered and the charges. This information can be used to evaluate the performance and quality of the hospitals. The evaluation will shed some light about the potential of the hospitals to draw in patients and the size of the market they can attract. It is also important for validating the comparative cost advantage that the Indian corporate hospitals has, which could be crucial for any viable partnerships with Singapore. For the short form patients satisfaction questionnaire, patients are interviewed in each hospital to find out the patients user attributes. This gives the extent of the use of the medical services of these hospitals by middle income and international patients to validate the fact that these two groups of patients are indeed the driving forces behind the emergence of corporate hospitals in India.
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While the groundwork has been rather comprehensive, the surveys for this research cannot be used to generalise for all the corporate hospitals in the metropolises. However, it throws some light on the organisational structure and the performance pattern in terms of quality and costs of the corporate hospitals in India. 1.2. Section scheme: The report is written in 5 sections. The first section has given a general overview of the objectives and scope for this research project. This gives a rational for studying the emergence of corporate hospitals in the metropolises in India and viable partnerships for Singapore. The rest of the report lays out the issue clearly and systematically. Section 2 of the report delves deeper into the issue by describing the driving forces behind the emergence of corporate hospitals to give a better understanding of the economic and social development of India. Section 3 explains the performance of the corporate hospitals by cross examining the data collated from the field trip. Section 4 evaluates the quality of the corporate hospitals. Lastly, section 5 wraps up the issue by explaining the significance of the emergence of corporate hospitals for Singapores healthcare industry. Viable partnerships between these hospitals are further explored and suggested.

Section 2 Driving forces for the emergence of corporate hospitals There has been a steady growth in the corporate hospitals throughout India since the 1970s, which makes it for the world to recognise its dominant role in providing the best hospital services to meet the demand for healthcare in India. The driving forces behind this emergence are plenty, namely the historical influence of the British, the lack of financial and physical resources in the public healthcare sector, the rising demand for healthcare from domestic patients, the demand of the international patients and finally, the economic growth of India. 2.0. Historical perspectives:

The influence of the British has been unprecedented in the running of the country including in the area of healthcare, where it had always given more edge to the private healthcare sector. In fact, the British even attempted to model the Indian health system according to that of the National Health System (NHS) in the UK, creating comprehensive and free healthcare service system, creating a comprehensive and free healthcare service system (Baru, 1998). However, like the British system, which failed to separate the private and public spheres, the Indian health system gave huge edge to the private sector. Even in the independence struggle, the Indian National Congress (INC), influenced by the Fabian socialist ideals, introduced the Bombay Plan that did not abolish the private interests in the economy but accommodate them (Baru, 1998). This created an inept healthcare system, reflecting how the former British colonial rule has set the tone of reliance on the private sector in Indias healthcare sector. As a response to the failures in the public healthcare system, the British government introduced the Bhore committee, which set up the blueprint for the development of a holistic healthcare system for the state to be central

in the provision (Baru, 1998). The private sector was only supposed to have a residual role in serving the wealthier urban population or providing supplementary services. This explained why 92% of the financing was expected to come from public expenditures with only 8% of it from private sources (Baru, 1998). However, its implementation was unsuccessful due to the lack of finance and the lack in government will to fulfill the recommendations by the committee. This led to the continued failures of the public sector at the turn of independence and more crucially, creating a supply gap for the private sector to gain dominance in the healthcare system. Subsequently, Indian public policy makers introduced the Mudalier committee in 1961, which endorsed the failures of the public healthcare system and became the official gateway for the prominence of the private sector (Baru, 1998). This was because private practitioners were given more opportunities to serve in the government hospitals on a part time basis, allowing both public and private sector to be intricately interlinked and more importantly giving the private sector the official dominance. Thus, the historical context of Indias relations with the British has a huge influence in setting the tone for the dominance of the private sector in the provision of healthcare, since it allowed them to further their interests almost uninhibitedly after independence to set up their corporate hospitals. 2.1. Lack of resources in public healthcare sector:

The advantage of the private sector is further established with the massive resource crunch in the public sector, which led to the underproduction of the sector. The resource crunch is firstly due to financial constraints, since India has not met the financial allocation of 5% of the GDP on healthcare as recommended by the Bhore committee until now (Mathiyazhagan, 1999; Berman, 1998). This financial constraint is further compounded by the economic recession in the 1970s,

which led to the structural adjustment programs being introduced as the result of the bank loans that India took from the World Bank (Baru, 1998). This saw the state rolling back its welfare spending in order to allow the maximal market efficiency. Thus, the GDP spent on healthcare dropped to an appalling proportion of only 1.25%, making it completely insufficient for any adequate governmental infrastructural support for the public health sector (Berman, 1998). The financial burden caused the human and physical resources to be overextended, shrinking the public healthcare system massively. Both constraints led to the erosion of employment opportunities in this public healthcare sector and the supply of employment opportunities was not able to meet the uncurbed supply from the production of newly graduated doctors in the 1970s, forcing them to go into private practice (Baru, 1998). This led to an enormous inadequacy of doctors in the public health sector and in addition, the shift of the doctors allowed the corporate hospitals to boost their own technical expertise, which further boosted the position of the private sector. The private sector now has the capacity to build their own specialised hospitals with high quality and costlier services, which expedited the emergence of the corporate hospitals in the metropolises. Thus, the resource crunch in the public sector has created a supply gap, which multiplied the opportunities for the private sector to step in and become the default for the public sector. This explains why almost 85% of the services are being paid out of the pocket and about 20% of the patients in the OPD nationwide have indicated that they prefer go to the private hospitals despite higher out of pocket payments (Nichter et al., 2000; Bhat, 1999). Therefore, this emergence of corporate hospitals is really the result of the failings of the public healthcare system, pushing patients away from the public healthcare system into the corporate hospitals to seek medical treatment instead.

Therefore, in order to cover up the supply gap, the government consequently has responded by wooing the private investors to the healthcare sector particularly in the 1980s and 90s through various mechanisms. The government firstly nationalised the banks in 1969 and recognised medical care as an industry (Baru, 1998). This allowed the hospitals to be eligible for loans from banks and public finance companies like the Industrial Development Bank of India (Baru, 1998). The government also reduced the import duties on high technological medical equipment and gave special concessions to the NRI doctors to set up corporate hospitals, like offering total tax exemption as long as they treated 40% of their patients for free (Berman, 1998). The private sector practitioners now enjoyed the privileges of the state protection in Indias mixed economy of service provision. The privileges are like government subsidies and import subsidies on equipment and drugs. They are able to use the privileges from the public sector as a springboard to acquire status and power, allowing them to pressurise the public authorities to loosen control over medical care and create a monopoly over the control of health in India. The government also supported their effort with the implementation of the National Health Policy in 1982, stating the need to open up medical care to for profit and non-profit institutions (Bhat, 1999). All these government efforts complemented the opportunities that are extended to the private sector from the failings of the public healthcare system, which demonstrates that the emergence of the corporate hospitals is very dependent on the edge that the government gives to the corporate hospitals. This government lean for the private sector due to the failings of the public healthcare resource crunch has allowed the corporate hospitals to contribute to more than 70% of Indias urban healthcare service market (Mudur, 2003).

2.2. Rising demand for healthcare from domestic patients:

There is definitely an increase in the supply of corporate hospitals. This must be matched with the increase in the demand for them and the greater demand stemmed from two sources: the growing middle class with rising affluence and the changes in the morbidity patterns. 2.2.1. Growing middle class: The rapid economic development in India has brought the most benefits to the middle class in India, increasing the population size to 40 to 50 million people (Bhat, 1999). The middle class population is becoming more affluent, giving them higher purchasing power. Consequently, they are able to demand and lobby for hi tech hospitals, which conformed to their perceptions of international standards (Mathiyazhagan, 2003a; Qadeer, 2000). Since the corporate hospitals are often believed to be capable of meeting the international standards and offer the flexibility in location and timing to suit the conveniences and the needs of the middle income groups, this amplifies the demand for the corporate hospitals, leading to the emergence of the corporate hospitals (Bhat, 1999). Thus, the middle-income population is significant in the emergence of the corporate hospitals, especially with the corporate hospitals being fully capable of fulfilling their demands. It is no wonder that the corporate hospitals find it lucrative to do business in India and the demands have triggered off the request for better medical education for the local students (Baru, 1998). Medical schools get built, but they limit only those from middle and upper income families to enter with the outrageously high school fees. This places the higher income families at a positional advantage in the medical field to gain dominance in the industry, since only those from these families can afford to be doctors. With the doctors coming mainly from this background, the private healthcare sector is made even more exclusive and those who would
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demand for their medical services and corporate hospitals are mostly those belonging to the upper income group. Their demands will be great, causing corporate hospitals to be built. Therefore, the emergence of the corporate hospitals have been proven to be strongly correlated to the overall socio economic growth of India, which signals that the rapid economic boom will only serve to fuel its emergence even more by increasing the pool of middle income families that can afford to pay and invest in these hospitals. This results in the continued and strong growth of the corporate hospitals in the metropolises in India. 2.2.2 Changes in morbidity pattern: With the rapid industrialisation in India, the population continues to boom uncontrollably, causing more people to demand for healthcare naturally. Furthermore, with the government trying to control the population since the 1950s, its age structure is beginning to change. There is a significant decline in the younger population, which would mean that by the year 2050, the aging population would increase, despite a reduced population in the productive age group. Consequently, the again population will demand for greater healthcare services, which is supported by a smaller productive population. This mounts even more pressure on the public healthcare sector, worsening the resource crunch and widening the supply gap for the private sector to step in. This further fuels the growth of the corporate hospitals in India. In addition, with the massive urban bias in Indias economic growth, the urban centers are expected to flourish. This increases the pull factor to draw out more human resources from the rural areas to the urban areas, causing the urban population to rise dramatically. Since the rural migrants are often poor, they often find themselves living in the slums or pavements in very poor conditions and they become public health hazards, bringing in new diseases and illnesses into the cities. This complicates the variety of epidemiological patterns and due to the heightened

mobility of people today, these illnesses and diseases have high chances of transmission to the middle and upper income groups. Thus, the urban population will see a more complex epidemiological pattern and more advanced medical technology would be required to treat those diseases, especially since the public healthcare sector is expectedly unable to meet their demands. Thus, the population begins to search for alternative solution in the private hospitals for better quality healthcare services. This need to search for alternative healthcare providers fuels the growth of corporate hospitals in the metropolises further. Besides the complex epidemiological pattern and booming urban population, the rise in the occurrence of lifestyle diseases is another factor pushing the demand for the corporate hospitals. The disease like cancer, cardiovascular diseases and diabetes, are beginning to rise rapidly because of the increasingly latent lifestyles of the urban middle class, which came with the conveniences that modernisation and wealth brought for the middle class (Qadeer, 2000). Therefore, lifestyle diseases occupy the center for the agenda of health service provision, placing further emphasis on individual curative services for the set of diseases that required the promotion of drug and equipment industry (Qadeer, 2000). This vertical and technical intensive approach to treatment causes more people to demand for individualised and highly technical services which can only be available at the corporate hospuitals, multiplying the domestic demand for the corporate hospitals tremendously (Mathiyazhagan, 2007). Together with the onslaught of the epidemiological transition, the corporate hospitals naturally respond to the hgh demand, resulting in the emergence of these hospitals in the metropolises. 2.2.3 Demands from international patients: Other than the domestic patients, the corproate hospitals also garner the attention of the international healthcare market for their high quality and low cost healthcare services.

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Consequently, the international patients have been flocking to India for treatment for various reasonss and they have been contributing signifcantly to the emergence of the corparote hospitals in the metropolises in India. These patients originate from two sources. The first one is due to the generally weak public and private healthcare systems in neighboring Asian countries like Bangladesh. These weak healthcare systems are unable to meet the demands of the population in their countries and this made them look to India for affordable and quality oriented healthcare services. The second crowd of international patients hauls from the Western and industrialised countries like the US who look towards India to attain affordable medical care as well as to avoid long waiting quese like the overstretched National Health System in Britain. Therefore, the corproate hospitals have been able to fill up the supply gap, providing high quality, low cost medical services which are easily accessible. Therefore, both groups generate massive demands for the corproate hospitals in India, contributing to the emergence of the corporate hospitals in the metropolises in India. 2.2.4. Economic growth in India: As India is becoming more interconnected with the world through globalisation, it is inevitable that private players are beginning to gain a stronghold in the medical industry. The US is one of the pioneers in propagating their interests into India through various ways like using returning NRI doctors and pharmaceutical and medical industries (Baru, 1998). The first form of influence is the US based NRI doctors and its origins begin from the relaxed immigration procedures in the 1960s, which led an influx of foreign Indian doctors into the UK and US looking for better career opportunities (Baru, 1998). This led to brain drain but as India starts to develop as an economic powerhouse, these NRI doctors recognise the tremendous opportunities in the private healthcare sector. These doctors brought back their expertise and knowledge to invest in specialty hospitals

in India, modeled along the lines of the American ones. This meets the demand of the middle class and helps to strengthen the role of the private sector in this healthcare field (Baru, 1998). The investment environment is further enhanced with both governments taking initiatives to give concessions, like the Indian government offering to give 100% equity to foreign hospital companies to invest (Baru, 1998). All these concessions have been relatively successful in triggering the expansion of these corporate hospitals in India. The Apollo Hospital Group definitely rode on this wave of government and private support, seeing that the group has expanded its network with 41 specialty hospitals and clinics and made multiple collaborations with other medical institutes worldwide (Balakrishna, 2007). Therefore the globalisation of healthcare has definitely allowed the corporate hospitals to strengthen its position, pushing the emergence of these hospitals even more. Besides creating the perfect investment environemnt for the NRI doctors, the government also encouraged the development of other medical related industries, like pharmaceutical and medical equipment industries, to set up businesses in India. The government does it through the strengthening of the human and institutional support for these companies, like issuing Indias industrial policy statement, which proclaimed that India gave no discrimination on foreign and Indian undertakings (Balakrishna, 2007). This gave the private sector more leverage in the hospital industry, since corporate hospitals are so dependent on the use of foreign-based and modern technologies and diagnostics with high obsolescence rate (Purohit, 2001). Thus, the development of the medical related industries lowers the cost of this IT architecture tremendously, enhancing the emergence of the corporate hospitals further (Balakrishna, 2007). Thus, in response to the globalisation of healthcare, both the private sector and the government have reacted to provide more lean for the private healthcare sector. This is evident in

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the way the practitioners can work around the two sectors freely. This free movement of doctors began from the Mudalier committee, in which the public sector doctors are allowed to work in the private sector (Baru, 1998). Although the government attempted to ban this practice in 1968 and 1984 respectively, they failed both times and in fact, they even triggered waves of doctors quitting the public sector completely (Baru, 1998). The remaining government doctors also ended up working in the private healthcare sector and even become the mechanism by which the corporate hospitals divert the patients away from public hospitals into their private practice. Therefore, with the globalisation of healthcare, the government finds it even harder to regulate this mechanism because of the need to create the most conducive environment for private investors to invest. This gives the doctors even more power in the healthcare sector, boosting the demands for the corporate hospitals even more. Therefore, it is right to conclude that the competitive globalised healthcare system of today has placed the Indian government in a nonnegotiable position to open up the healthcare sector to stay competitive, which inevitably provides even more support for the emergence of the corporate hospitals in the metropolises in India. In conclusion, it is proven that healthcare seekers depend highly on the corporate hospital, since they provide a wider variety of services and are considerably more efficient. In fact, more than 50% of the urban population in Mumbai has expressed their preference for the corporate hospitals for their higher efficiency (Newbrander, 1997). These corporate hospitals, with a rising demand, are attracting more business groups, like Apollo Tyres, to collaborate with medical institutions like, Artemis Health Institute, to form conglomeration of medical cities, like the Medi City in Bangalore (Balakrishna, 2007). Thus, with the corporate hospitals becoming more prominent in the Indian market, it becomes even more imperative that India continues to

ride this wave and makes more collaboration to bring the people of India a truly global healthcare delivery system at affordable prices.

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Section 3 Patients Perception on Quality of Healthcare of Corporate Hospitals The survey results from a short fort patient satisfaction questionnaire (PSQ-18) is used to analyse address the objectives of the research study by validating that the corporate hospitals are serving their target consumers: the middle income group and international patients and affirming the quality of the medical services as well. 3.0. Patients profile: On this account, to assess the categories of patients the corporate hospitals serve, the PSQ-18 is used to attain the patients user attributes, which consists of ones educational level, occupation, social status, monthly income and their origin of country. All the statistics are being presented in Table 1 through Table 7 in the appendix. 3.1.1. Social caste: The social caste is used to find out ones social status. This caste system places people to different social strata and occupation groups according to their family origins in India. Being in the lower caste signifies that generations of the same family remain in the same social strata. This system is very deeply entrenched across India, creating substantial immobility for individuals to move across the social groups. Thus, even the economic and social opportunities that one obtains are being dictated by ones social caste. This is being proven with Table 4. and Figure 1. It reflects a positive correlation between the variables, the mean monthly income and the social caste categories. Being in a higher social caste category (i.e. the forward caste) positively correlates with higher monthly income, which directly implies that the social caste has significant bearing on determining ones opportunities to climb the social ladder for better economic power. Thus, the social caste makes a more accurate indicator of ones social and

economic position and is more reflective of the type of users these hospitals get. This is used to conclude whether the hospitals are indeed meeting to the demands of the first target consumer group, the growing urban middle income population. Figure 1. Correlation betwen economic and social status of the patients

Source: Survey Results Yap (2008) The distribution table of the patients in terms of their castes illustrates that nearly half of the patients interviewed come from the forward castes and have higher social status. This possibly comes with greater financial capacity to afford higher quality and costlier healthcare services (Table 4.). About 40 per cent of the patients surveyed are in the backward castes with a small percentage of about 5 per cent in the scheduled tribes and castes, the lowest level of the society. The smaller proportion of patients confirms that the patients from lower social hierarchies either choose not to use the services or cannot afford these medical services from the corporate hospitals. Since the caste indirectly determines ones income levels, the latter is right. This

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suggests that there is a certain level of exclusivity in the categories of patients who can afford and use services from corporate hospitals and the patients are usually of higher social hierarchy. 3.1.2. Educational and career background: Besides the social caste, the educational background also gives a good indicator of ones social status. More than 50 per cent of the patients surveyed are graduates and another 25 per cent of them are post graduates (Table 2). Because there is an education premium that goes hand-inhand with higher education in terms of career opportunities, the higher educational background hints at the fact that these patients have advanced careers with fat paychecks to build up their financial capability. They are likely able to demand for good medical services offered by the corporate hospitals. This also explains why the patients surveyed are largely civil servants and salaried professionals, the careers that are respectable in the society. Another 45 per cent of them are also self-employed, like setting up their own businesses or being in the service industries (Table 3). Thus, both groups of patients are likely commanding respectable monthly incomes of greater than Rs. 20000, suggesting again those corporate hospitals are serving patients who have greater social background, with greater financial stability, better educational status and careers. 3.1.3. Monthly household income: The household income tabulation is another way to affirm that the higher income patients are being served by the hospitals. However, it has to be duly noted that the monthly incomes divulged by the patients are not very accurate due to confidentiality issues, even though the data sheds some light on the urban population and the kind of salaries they are commanding. Furthermore, this income profile reveals many other significant trends. The profile confirms that the corporate hospitals serve mainly the lower middle, the middle and the upper middle-income group, which is the 2nd, 3rd and 4th quintile respectively, since the three groups make up 63.6 per

cent of the patient population (Table 6). Since these patients mainly have higher social and educational standing, this validates the fact that the patients are indeed from the middle-income group. The corporate hospitals thus have reached their target consumers and the rise of the middle income population in urban India can qualify as one of the driving forces behind the emergence of corporate hospitals. However, an unexpected result is being observed: the largest population of patients actually comes from the lower middle income group of about 29 per cent where the patients earn less than Rs. 20000. In fact, 20 per cent of the patients population belongs to the poorest income group, commanding less than Rs. 10400 per month. This starling observation that almost 50 per cent of the patient population surveyed is in the lowest and lower middle income groups disproves the hypothesis that the hospitals are only for the elite Indian in the urban cities. The hospital services are in fact more affordable than previously thought to be. However, this peculiar trend must be put into context with the overall healthcare situation of India. It is commonly known that there are massive deficiencies with the public hospitals and the situation is worsened with the ballooning urban population. This forces many, even those who are less well off, to seek quality medical care from the corporate hospitals, despite the higher out of pocket payments. Thus, the unusually high proportion of lower middle and lowest income population of patients may be the result of the default of the public healthcare system. In spite of this, the healthcare services offered by the corporate hospitals are still considered more affordable than previously thought to be. The hospitals may have the comparative cost advantage, offering high quality medical care services at a lower cost. This would make the hospitals more competent to compete in the global healthcare market for international patients. This is further supported by the findings, where 5.50 per cent originates from other countries

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(Table 5). Despite the small proportion, it is recorded that 10 per cent of the patients in big corporate hospitals like Apollo Hospital are international patients (Express, 2006). This proportion is slowly beginning to rise, which implies that the corporate hospitals are getting greater international recognition and drawing a wider international market. It can be concluded that the corporate hospitals are meeting the demands of their 2 target consumer groups, the middle income population and the international patients. Another conclusion can be drawn with the data analysis that the corporate hospitals have the comparative cost advantage as their main selling point to market their services to the international market. This will help to boost their medical tourism industry to greater heights for India to become a healthcare hub of Asia.

3.2. Patients perception on quality of healthcare by the corporate hospitals in India: 3.2.1. The need for quality assessment: Besides the patients attributes, the other dimension, the quality of the corporate hospitals, can also be assessed based on the PSQ-18 results. This quality assessment is based on the patients perception of the quality of medical services offered by the corporate hospitals. This perceptionbased assessment is particularly crucial because of various reasons listed below. Firstly, this assessment allows patients feedback, which creates the channel for open communication between the hospitals and patients. In addition, the development of quality assessment has to be supported at the highest levels of administration to be effective, which will help to build a culture of accountability in the corporate hospitals as well (Bhat, 1999). This is especially significant in this globalised age of healthcare, where healthcare delivery system needs to be market oriented and customer driven to compete in the global markets (Manjunath, et

al., 2007). After all, the service providers are mostly offering similar services at competitive prices. The rational consumers have the information to go to any service providers that they deem to provide good quality services at the best value (Manjunath, et al., 2007). Thus, the only differentiation that will set apart any hospital from others is its perceived quality by the patients to attract a larger population. 3.2.2. Survey Objectives: In order to analyse the quality of healthcare services offered by corporate hospitals, the study assess the patients perception on the quality on healthcare provided by these hospitals in metropolises in India. This serves our purpose of studying whether the hospitals are indeed quality oriented. 3.2.3. Framework: The PSQ-18 has 18 items to assess patients satisfaction for the quality of the hospital services. The questionnaire assesses the quality of medical care services according to 7 parameters: General satisfaction, technical quality, interpersonal manner, communication, financial aspects, time spent with doctors, accessibility and convenience (Marquis, et al., 1983). This questionnaire is a shortened version of PSQ-III, which is revised from the previous PSQ-I and PSQ-II questionnaires, to reflect the patients satisfaction more accurately (Marquis, et al., 1983). The first revision is that more generic items were added to assess attitudes toward financial aspects of healthcare. This is so as to ensure that the financial aspects of healthcare can be assessed in all medical care settings. Second, the General Satisfaction scale has more items added to ensure greater reliability and precision for hypothesis testing since it is crucial as a summary indicator. Third, for the interpersonal and technical aspects of the quality of care to be measured more accurately, the questions regarding the communication between doctors and patients and the
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quality of care are revised. Fifth, the PSQ items regarding the doctors and medical care are rewritten, so that they are directed specifically to the respondents experiences with the hospital services (Marquis, et al., 1983). The questionnaire comprehensively measures the quality of the corporate hospitals with the 18 items. These items are asked such that they are statements of opinion, since each is accompanied by five response categories from 1 to 5 (strongly agree, agree, uncertain, disagree, and strongly disagree). The questions are being modified and revised according to predicted local circumstances before the field trip is conducted. The explanation of the revisions for each item is being transcribed for better communication between research assistant and the researcher herself. This also ensures that the scoring for patients interviews remains consistent. The explanation is attached in the appendix behind. For this questionnaire, the questions are worded differently such that for some, agreement reflects satisfaction with medical care, whereas for others, agreement reflects dissatisfaction with medical care. Thus, the item scoring rules depend on whether the item represents a favorable or unfavorable opinion about medical care (Marquis, et al., 1983). Since all subscales are scored such that higher scores mean greater satisfaction with the aspect of care, the items need to be rescored for the highest score to indicate greatest satisfaction. (The score of 5 reflects the greatest satisfaction and the score of 1 reflects the least satisfaction.) Item scoring rules appear in Table 9. After item scoring, items within the same subscale should be averaged together to create 7 subscale scores as listed above. The grouping of the items into subscales is mentioned in Table 3. These 7 subscales scores are then used to evaluate the quality of the healthcare services offered by corporate hospitals (Marquis, et al.,1983). The explanations of these parameters are

being explained as follows. The general satisfaction parameter ensures that the medical care that the patient has been receiving is just about perfect, allowing him to be fully satisfied with it. The parameter, technical quality, evaluates the technical aspects of the medical care. To ensure good technical quality, the hospital should fulfill these four criteria: Everything should be available at the doctors office to provide complete medical care. The patients should be completely confident about the doctors diagnosis The patients should have no doubts about the doctors ability to treat them. The medical staff is very thorough in treating and examining the patient for every medical checkup. Next, regarding the parameter, interpersonal manner, it assesses whether the doctors are friendly and personable with the patients and thus examines the relationships between the doctors and patients. The communication parameter describes the doctor-patient relationship again, but this time, it does so by gauging the doctors ability to listen and explain to the patients about their medical conditions and tests. For the financial aspect, it measures the patients ability to be confident about paying for ones medical care without being set back financially and affirms the affordability of the healthcare services. The parameter, time spent with doctor, questions the attitude that the medical staff, including doctors, gives to the patient. This is to ensure that there is enough quality time spent on the part of the doctors and that the patient are not treated and examined hastily, affecting the quality of medical care he is receiving. Lastly, accessibility and convenience indicates the availability and frequency of medical services for the patients. This is guaranteed as long as the patient agrees that he is able to get medical care and reach the medical specialists easily whenever he needs it. Also, the patient should be able to fix an appointment easily and should be able to receive emergency treatment quickly. Thus, the 7 subscales
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succinctly describe the healthcare services and the scores are then averaged out to give the overall quality index, measuring the overall quality of the healthcare services of corporate hospitals. 3.2.3. Reliability testing: This method of surveying and tabulation is then tested for its reliability. There have been a number of validity studies linking PSQ scores to healthcare experiences, expectations, behavioral intentions and various health and illness behaviors (Ware and Davies, 1983). Empirical evidence also supports the predictive validity of the PSW (Marquis, et al., 1983; Ware and Davies, 1983). Thus, the source for the method can be concluded as valid and reliable. Following this, the seven PSQ-18 subscales are being tested for reliability. Since reliability estimates for the average value of the 7 subscales is 0.711 (see Table 12), the result is highly reliable and it can be used for data analysis for the patients perceptions on the quality of healthcare provided by the corporate hospitals in the metropolises in India. 3.2.4. Research and discussion: The overall quality index reflects the overall healthcare status of the corporate hospitals and is tabulated by averaging the 7 subscale scores recorded for the 7 parameters in Table 12. The average score is 4.46. The overall quality is therefore concluded to be very good in all aspects, since the patients have all explicitly indicated to be generally satisfied with the quality of the healthcare in these hospitals. However, looking at the overall quality score is insufficient in explaining the true picture of the quality of healthcare in these hospitals. The analysis should be broken down into the 7 parameters as listed and the score for each parameter can be found in Table 11 as well. The score

for the parameter for general satisfaction is 4.50. Therefore, it can be concluded that the patients are almost fully satisfied with the overall performance of the corporate hospital and the medical care that the patient has been receiving is just about perfect. The technical quality score is 4.66 and this indicates that the medical services offered by these hospitals are of good technical quality. Everything is more or less available at the doctors office to provide complete medical care and the patients have no doubts about the doctors diagnosis or their ability to treat them. The medical staff is almost completely thorough in treating and examining the patients. Next, regarding the parameter, interpersonal manner, the score received is 4.65. This highlights the professional relationships between doctors and patients are not as impersonal. Furthermore, with the communication parameter scoring 4.72, this emphasises that the doctors even listen and explain the medical conditions and tests properly to the patients. Next, the parameter, time spent with doctor, attained a score of 4.39. This implies that the attitude that the medical staff, including doctors, gives to the patient is relatively good, since the doctors mostly spent enough time with the patients. The patient are also not treated and examined too hastily. Lastly, accessibility and convenience receives a high score of 4.41. This highlights that the availability and frequency of medical services for the patients is good, since they are able to get medical care and reach the medical specialists easily whenever they needs it. Also, they can fix an appointment easily and receive emergency treatment quickly. However, it has to be highlighted that for the financial aspect, the score it received is the lowest of the 7 parameters at 3.74. This means that the cost of healthcare services offered by the hospitals is slightly more than what the patients can afford and they do not feel fully confident about paying for ones medical care without being set back financially. This affirms that the healthcare services are not (the first income quintile) as affordable for some patients, which
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reflects the fact that although the patient population has a high proportion of lower income patients , these lower income patients may be forced into seeking treatment from the corporate hospitals. They might not be able to afford the treatment as well as the cost of these services is still beyond the reach for them. This can be a huge disadvantage for the corporate hospitals, affecting their ability to tap maximally into the massive local market. However, this does not negate the fact that these corporate hospitals still have a huge demand from the local market, proving the quality of the healthcare services are more important than the high cost of these services for the local markets. The urban population is still willing to pay for higher quality but costlier healthcare, which concludes that the quality of the healthcare services has met the demands set by this growing middle class population. More importantly, it signifies to the global healthcare industry that the corporate hospitals provide services that match up with the international standard, making them eligible to export their services through partnerships and collaborations with other hospitals like the ones in Singapore.

Section 4 Analysis of the hospital facilities survey 4.0. Hospital characteristics: After looking at the corporate hospitals from the patients perspectives, it is equally justifiable to look at the hospitals from the hospitals perspectives to obtain a more balanced picture of the corporate hospitals in the metropolises in India. This would also help to validate if they are viable for international partnerships as well. 4.1.1. Financing of the hospitals: These corporate hospitals have been the dominant force driving the healthcare industry and they are categorised into two groups, the profit and the trust hospitals. The for-profit corporate hospitals aim to maximise their revenues and use the revenues mainly with the intention of expanding their market size through building up their medical facilities. For the corporate trust hospitals however, private investors finance them and their intention is mainly to be financially profitable for the profits to be used for charity. Out of these corporate hospitals surveyed, 12 of them are for-profit hospitals while 4 of them are corporate trust hospitals (Table 13). Most of these corporate hospitals are generally profit oriented and seeking for more opportunities like partnerships to boost their profitability. 4.1.2. Dominance of the corporate hospitals: There is a need to understand the role of corporate hospitals in the healthcare sector in the metropolises. Their dominance is the results of many years of experience, their annual patient

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flow and the expansion capacity of these hospitals. Regarding their experience, the corporate hospitals have been functioning in the metropolises for around 17 years (Table 14.). The experience of tapping into the local urban market is also revealed in the expansion capacity of the hospitals in the metropolises. The many years of experience explains why 62.5% of the hospitals have more than one chain around India and the world (Table 15.). They also have an average of 6.19 branches in total and an average of 5.88 branches locally (Table 15). Thus, there are about 96 branches by these 16 hospitals alone in India, indicating that these hospitals share in the healthcare industry in urban India is very enormous. Lastly, these hospitals also receive an average of 52200 outpatients and 51355 inpatients a year (Table 17). With all the 16 hospitals, their overall patient population is huge, revealing that the corporate hospitals have the potential to cater to an even larger population of patients, including the international patients. This also affirms the international partners that networking with these local corporate hospitals would assure that they establish their physical presence throughout the whole of India. Therefore, their expansion capacity, patient flow and experience substantiate their dominance and sustainability in the domestic markets, proving to interested international partners that any partnerships with the corporate hospitals will be profitable. 4.1.3. Popularity of the hospitals: The corporate hospitals have definitely proven its dominance in the urban healthcare industry in India and its popularity in the Indias growing urban middle population. This popularity can be explained with the types of services that the hospitals offer, the quality of the hospitals and lastly, the affordability of these services. These hospitals after all offer all the services, both diagnostic and curative, in almost all the departments. In fact, Apollo hospital in Chennai has a total of 52 departments, equipped with the highest technologically facilities and well-trained doctors and

medical staff. These hospitals also offer many non-medical amenities, like help desks to make the experience of seeking medical care more enjoyable. In addition, the popularity of the corporate hospitals is boosted by the perception of the quality by the patients. After all, the overall quality index tabulated from the patients short form questionnaire (PSQ-18) is 4.46, proving that the hospitals offer medical care of a very high quality. This would boost the image of these hospitals in the urban population and international population, with these patients putting out a good name for these hospitals. Thus, this explains why the corporate hospitals continued to be the preferred choice for the urban population in India. Lastly, these corporate hospitals also seem to try to cater to the largest local population possible. This explains although they serve mostly upper and middle-income patients, they all still serve lower income patients. In fact, 94% of these hospitals offer programs, which have lower tariffs for the indigent patients (Table 18). This explains why 10 per cent of the patient population in these hospitals is from lower income groups, proving that the healthcare services by the corporate hospitals are affordable even though they are costly. Thus, because these hospitals do not exclude any portion of the urban population, their popularity is enhanced, which pushes their brand name to the international market to enhance the business of the corporate hospitals.

4.1.4. Intention for the expansion of the hospitals: In this regard, the large proportion of corporate hospitals is looking towards expanding outwards into the international markets. The corporate hospitals actually have about 3 branches outside India in total, affirming that these corporate hospitals not only have the interest to expand internationally but more importantly have the capability to do so. Thus, the corporate sector is indeed a very dominant and popular sector in the healthcare industry and these traits will

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certainly help the corporate hospitals to become more competitive. International partnerships are definitely the way to go to maximise the profits that are available in the internationally globalised healthcare industry of today.

4.1.5. Eligibility for international partnerships: With respect to the corporate hospitals, it is not presumptuous to conclude that these hospitals are indeed performing very well in the metropolises in India, with its huge popularity and market share in these metropolises. They provide an all rounded, high quality and affordable healthcare to meet the demands of the urban middle-income population, with excess capacity to expand outwards into the international healthcare industry. In fact, these corporate hospitals have even made their intention of competing in the international markets clear, seeking out for viable partnerships with other international medical institutions to expand their market size and profitability in the age of globalised medical and healthcare. 4.1.6. Test for eligibility for international partnerships: With regard to this, the corporate hospitals have to be tested for its eligibility for partnerships for any international networking. The test looks into the traits of the corporate hospitals that are required to attract medical tourists. Studies have shown that the 3 most important traits to attract international patients are quality, price and amenities available (Kaur, Sundar, Vaidya, & Bhargava, 2007). These 3 pillars are characterised into indicators in this study, which are the quality indicator, comparative cost advantage and outsourcing capability. All these 3 pillars have to be supported by sound financial performance by the corporate hospitals for them to expand their market size internationally and maintain their quality and price. This explains why the financial performance is being converted into the fourth indicator. These 4 indicators partially adopts the concept from the Excellent Healthcare Service Model (EHSM), which advocates that the healthcare industry should use a system view to deliver quality healthcare by taking into account quality, cost and efficiency factors in a holistic manner (Lee, Khong, & Ghista, 2006). Therefore, all 4 indicators are being integrated into a synergistic model to enhance the service

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quality and more importantly prove the credibility of the corporate hospitals as world-class healthcare institutions for international collaborations (Lee, et al., 2006). 4.1.7. Financial performance: The first indicator, financial performance, is crucial for eligibility for partnership because international partners like Singapores Parkway Health Group are looking for profits as a signal for the market size that the corporate hospitals commands. This is due to the fact that the financial profits will instill financial independence for these corporate hospitals, enabling their directors to govern the affairs through internal process of needs evaluation rather than being tied down by loans (Bhat, 1999). This will augment the availability of super speciality services across India, allowing the hospitals to offer even better quality services to attract international patients (Bhat, 2006). Furthermore, the better financial performance signals greater efficiency in hospital management, which means that the patients are guaranteed of good quality services. They will continue to patron the hospitals despite the competitive environment with so many other corporate hospitals. With a stable patient population, this emphasises on the importance of the financial performance on the credibility of the corporate hospitals for any international partnerships. Profits are to ensure that these corporate hospitals can sustain both nationally and globally for international partnerships as well. In order to indicate adequate profit margin for international collaborations, the financial expansion capacity is measured by taking the 40th percentile of the profit of the hospitals. Any hospitals with their profits higher than that will be considered financially sound and have the capacity to expand through international collaborations. It is found that the financial profit needed to indicate its financial expansion capacity is Rs. 138600000 annually (Table 19). Since 13 hospitals have had profits greater than Rs. 138600000, it is not presumptuous to conclude that a large proportion of the hospitals in

India have the financial performance to stay competitive the ability to expand internationally without being jeopardised as an institution. 4.1.8. Quality indicator: The second indicator, quality, is being measured on 2 parameters, the accreditation score and the overall quality index attained from the previous PSQ-18 questionnaire. The first parameter, the overall quality index is based on the patients perceptions, which reflects the ability of the corporate hospitals to meet and exceed customer expectations to capture a larger population of patients. With the increasingly competitive and globalised healthcare industry, almost all the hospitals are offering similar medical services at competitive prices. Thus, the only point of differentiation that will set any hospital apart from the rest is the patients perception of the quality of the healthcare services. With the overall quality index being 4.46 out of 5, it is unquestionable that these corporate hospitals match up to the expectations of the consumers (Table 12). The international partners are therefore guaranteed good quality healthcare as well as a wide consumer market in India through its collaborations with the corporate hospitals in India. The second parameter, the accreditation indicator, receives a score of 0.9375, where 0 means no accreditation received by the corporate hospitals, 1 means receiving national accreditations and 2 means receiving international accreditations (Table 16). This means that the corporate hospitals mostly have been accredited nationally but not internationally. Hence, only 25 per cent of these hospitals have Joint Commission International (JCI) accreditation (Table 16). However, the score still proves that the hospitals at least meet the criteria set by domestic external healthcare organisations. These external confirmations allow more patients to be convinced of the quality of services, increasing the population of patients who will patron their hospitals. The larger patient population will have an amplifying effect because these patients will then spread the reputation

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of these corporate hospitals through word of mouth. This mechanism has been proven to be an important marketing strategy, since it is proven that for every 100 customers that experienced deficient service, about 70 customers are unlikely to patronise the same hospitals again (Lee, et al., 2006). 75 of them will go on to tell an average of 9 family members and friends about their experiences and it is possible that through the word-of-mouth, 465 potential customers are lost (Lee, et al., 2006). Thus, these external reviews, especially the international accreditations like the JCI, are in fact the Global Good Housekeeping Seal of Approval, confirming the international community of its quality and credibility as world class hospitals to attract the international patient population as well as reduce any potential loss of customers through the word-of-mouth (Manjunath, et al., 2007). Hence, the fact that these corporate hospitals are being validated by the high overall quality index and the accreditations confirms that their services are of good quality to match up to the international standards and are eligible for partnerships. 4.1.9. Outsourcing capacity: The third parameter, the outsourcing capacity is being measured by the following aspects, the medical imports, proportion of hospitals with telemedicine facilities, the number of international branches of the corporate hospitals, the average proportion of international patients and availability of medical tourism facilities. With the medical imports, all hospitals are found to import medical equipment and facilities (Table 21). This high dependence highlights the importance for these corporate hospitals to seek out for more collaboration to lower their import tariffs to bring in hi-tech medical equipment for their hospitals at lower costs. Therefore the underlying interest of the corporate hospitals for partnerships is being affirmed and this interest can be seen again in the proportion of hospitals with telemedicine facilities. 62.5 per cent of the hospitals have the facilities which are largely catered to the rural areas in India with only 2

hospitals, Apollo Hospital and Wockhardt Hospital, having the facilities with international patients (Table 20). This implies easy accessibility to telemedicine facilities, which proves that hospitals are not just confined to the urban areas but have far reaching abilities and interests to expand its services abroad. Thirdly, these 16 hospitals also have about a total of 4 overseas branches combined and the international patients make up an average of 9.44 per cent of the patient population in the branches (Table 18). The patients mainly come from the Middle East and the South Asia region. 56.25 per cent of the hospitals have patients from the Middle East and 62.5 per cent of them have patients from South Asia (Table 22). The hospitals also receive patients from other parts of the world, with Africa and Europe being the next most popular regions. An average of 20 per cent of the hospitals also draw in patients from other regions like the US, Australia and Southeast and East Asia (Table 22). This clearly indicates that these hospitals have managed to make their mark on the global healthcare industry successfully and their past experiences should prepare them for any future partnership. Furthermore, with the hospitals having almost 96 branches all over India and telemedicine facilities, this will assure the international hospitals, which are interested in partnerships, that any tie ups with the Indian corporate hospitals mean that they are able to tap into the entire Indian market and not just the location where the collaborations occur. Therefore, with their physical presence stamped, these hospitals are eligible for partnerships with other international hospitals. Furthermore, 62.5 per cent of these corporate hospitals have medical tourism facilities like international patient department, which caters to every need of the international patients (Table 22). Their intention for partnership to reach the international arena is underlined by their efforts to set up medical tourism facilities and international branches, proving that they have the outsourcing capability for partnerships.

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4.1.10. Comparative cost advantage: The last indicator, the comparative cost advantage, has been listed commonly as one of the prime attraction of India as a region for medical collaborations. Conducted by many surveys, the corporate hospitals in India are said to offer medical services that cost about 50 to 75 per cent lower than the US and the UK. (Indian healthtour.com). The greatest cost saving are said to be in orthopedics and cardiac procedures, where the fees for the procedures are 75 to 90 per cent of the fees in the US. (Indianhealthtour.com). Therefore, this comparative advantage seems to have been the main drawing point for Indias medical tourism industry and this should be validated to ensure that the comparative advantage is indeed significant and assure that these hospitals have something to offer in any international partnerships. Using the interview data, the table for the comparison of the prices for the 4 most commonly used departments, orthopedics, cardiology, neurology and nephrology, in US, UK and India is as in Table 25. To make this easier for comparison, the charges are being converted into USD and the charges now are US$2252.66 and US$4473.40 respectively for orthopedics and cardiac procedures (Table 25). These figures are then used for cross comparison with the average prices of these procedures in the US and the UK. For the orthopedics procedures, the average charge for them is US$24500 and for the cardiac procedures, the average charge is US$40000. Comparing these prices quoted, the orthopedics procedures cost only 1/11th in India and the cardiac procedures cost about 1/9th in India as compared to the US and UK. Similarly, the charges for neurological services in India is only 1/12th the charges for similar services in the UK and US, since the average charge in India is US$7800 and the average charge in US and UK is US$94000 (Table 25). Lastly, the charges for services in the nephrology department in India is only 1/14th the charges for similar services in the UK and US, since the average charge in India is

US$6382.98 and the average charge in US and UK is US$87500. Therefore, this validates the fact from other surveys mentioned above. There is indeed significant cost savings with the medical services in India, which permits the patients to receive high quality medical services and use the extra savings to visit the country for a pleasant tourist experience. Thus, the combination of medical care and tourist experience creates the selling point for the corporate hospitals in India. This signals to the other international hospitals that the hospitals are eligible for partnerships and may even have excess capital to boost their own facilities for medical tourism industry. Therefore, any partnerships with the Indian corporate hospitals will possibly reap countless rewards as well.

4.1.11. Analysis of the test for eligibility for international partnership: In conclusion, these corporate hospitals have passed 4 indicating tests for their eligibility for partnerships. The corporate hospitals have had sound financial performance to prove its credibility as hospitals and its ability to expand outwards with their high annual profit. They have also shown to offer medical services of high perceived and accredited quality. This will serve to push their brand name out to the international healthcare markets, making them more suitable for partnerships. In addition, the hospitals have indicated their interests to outsource strongly and their previous outsourcing attempts have only made them more prominent in the international healthcare industry. Finally these corporate hospitals validated their own comparative advantage, offering high quality medical services at significantly lower costs. This thus confirms their selling point, especially in the medical tourism industry, proving that these corporate hospitals are indeed eligible for international partnerships.

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Section 5 Corporate hospitals: Viable partnerships for Singapore It has been proven that the corporate hospitals in the metropolises in India have fulfilled the two criteria that the research study sets out to find, as discussed in the last 2 sections. Firstly, the hospitals offer good quality healthcare services, receiving a very impressive overall quality index score of 4.46. Secondly, they are eligible for international partnerships with corporate hospitals in Singapore, since they have sound financial performance; good quality services with cost effective prices and are capable of outsourcing. With the quality and the eligibility of partnership assured, there is undeniably great potential for collaborations between India and Singapore in the healthcare industry, especially with the immense credibility and profitability of the corporate hospitals (Knox, 2007). Thus, both governments realise the potential as shown the healthcare sector being identified as one of the key areas for greater partnership in the Comprehensive Economic Cooperation Agreement between Singapore and India in 2005. On this account, this study identifies three viable areas for partnerships, namely medical tourism, telemedicine and finally the medical equipment industry. 5.0. Medical tourism: 5.1.1. Market size for medical tourism: Medical tourism is a thriving business in India today, which is worth close to US$30 million in 2001 (Mathiyazhagan, 2005). It is set to add US$2 billion revenue by 2020 (Mathiyazhagan, 2008).

5.1.2. Driving factors for medical tourism:

This reflects high international demand for the Indians corporate hospitals and this is propelled by numerous factors as follow: comparable world-class standards of healthcare services, efficient and low cost medical care, efforts made by the hospitals and finally government support. The first factor is the comparable world-class standards of medical care that the hospitals are able to offer. These corporate hospitals are equipped with cutting edge technologies in specialties like cardiology, oncology and neurology, which help to improve the sensitivity and specificity of the medical treatment offered (Mumbai, 2006). The hospitals likewise receive accreditations from international medical bodies like JCI and have affiliations with prestigious medical institutions overseas. Furthermore, almost all the Indian surgeons and medical staff are trained and certified globally. All these affirmed the quality of medical services and their credibility as world-class hospitals. Secondly, the corporate hospitals have the low cost and efficient medical care. They have the comparative cost advantage, offering these services at only 1/10th of the costs in the US (Mumbai, 2006). Also, because of the larger pool of trained doctors, patients have greater accessibility to them. This explains why many medical tourists decide to go to India for treatment to avoid the long waiting queues like those British patients in the National Health System. Visiting India as a medical tourist also gives the patients the opportunity to combine a vacation with their medical treatment because of Indias rich cultural heritage and innumerable tourist destinations (Mumbai, 2006). All these are supported by good urban infrastructure and the common use of English as the language of communication (Mumbai, 2006). This attraction to international patients is also extended to patients from the poorer neighboring countries, who would flee to India for medical treatment in the corporate hospitals doe to the lack of available treatment in their poor healthcare system. Therefore, the low cost and efficient healthcare

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delivery system in the corporate hospitals generates huge international demand from both developing and developed countries. Furthermore, the international demand is being fully utilised by the hospitals themselves. They are actually keeping an eye out on the air load of patients looking for world-class medical treatment, creating international patient departments, which offer services tailored for foreign patients like airport pickups and provision of accommodation (Express, 2006). They specifically target the NRIs as potential patients hoping to nurture them as ambassadors to carry their brand name internationally after their treatment in India (Express, 2006). A good example of this is the Apollo Hospital Enterprises, which is attracting the Indian expats as patients and creating partnerships with hospitals in Kuwait, Sri Lanka and Nigeria (Express, 2006). These networking efforts paid off, with Apollo Hospital receiving patients from 60 different countries with the biggest share coming from the SARC countries, Oman, Bahrain, UAE and some African countries (Express, 2006). In fact, 10 to 15 % of their patient populations are foreign patients, proving that the hospitals have the capability of attracting patients from overseas and have been successful in doing so (Express, 2006). The efforts of the corporate hospitals are further being complemented the public sector through various mechanisms. The government has created the National Health Policy in 2002, making these foreign patients legal exports and allowing them to be eligible for all fiscal incentives extended to export earnings (Express, 2006). Since there is some form of financial incentives for them, the medical tourism industry is becoming more receptive, bringing in more medical tourism business into India. Therefore, it is clear that the four factors, government support, hospitals initiatives, low cost and efficient healthcare at comparable world standards,

have been the driving forces for the development of medical tourism, pushing this industry to flourish on the international arena. 5.1.3. Methods of partnerships in medical tourism: The thriving medical tourism business warrants greater involvement by the Singaporean government to support Singapores bid to stay competitive in the international healthcare industry. This is especially true with the globalisation of medicine and healthcare, where leading world players need to be physically present to continue offer affordable healthcare to prevent from lagging behind (Knox, 2007). In addition, although Singapore has 3 JCI accredited hospitals with specialised modern medical facilities, it is impossible for the hospitals to offer healthcare services at the low cost that India is offering because of the higher labor costs and standard of living (Herrick, 2007). Therefore, India has increasingly become a serious competitor in the medical tourism business for Singapore. It is imperative that the Singapores corporate hospitals find ways to collaborate with the Indias corporate hospitals to offer their services at similar competitive prices. Moreover, with so few foreign players in this vast Indian market, there is a lot of scope for the Singaporean players to gain a stronghold in the market and boost the medical tourism industry (Mathiyazhagan, 2008). Henceforth, Singapore has to ride this boom in the medical tourism industry to strengthen its position as the top class healthcare hub in Asia. With its aim of treating 2 million foreign patients by 2010, Singapore has started to take initiative in trying to break into this medical tourism industry with India (Mukherjee, et al., 2003). The first genuine attempt began when Gleneagles Hospital, under the Parkway Holdings Limited, set up the Apollo Gleneagles Hospital in Kolkata in 2003 as a joint venture with Indias Apollo Hospital Group (Mukherjee, et al., 2003). Pacific Healthcare Holdings also followed suit by opening up its pacific medical center in Hyderabad just a year after the hospital was built

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(Mukherjee, et al., 2003). Moreover, Singapore vision 2020 for healthcare even offers opportunities for Indian hospital groups to form consortiums with Singapore healthcare groups to tap third country markets (Saw, 2006). All these previous collaborations have definitely been effective for Singapore to stamp their physical presence in the huge Indian market. However, this does not negate the fact that Singapore has failed to fully capture the Indian market, since there is a lack of any real physical presence in huge metropolises like in Delhi. This is because all these previous collaborations are simply networking between individuals, where one corporate hospital in India will set up ties with only one corporate hospital in Singapore. Such individualised networking minimises the reach of the Singaporean hospitals dramatically and they are unable to tap into the Indian market efficiently. Therefore, there is a need to ensure to expand the scope of the collaborations, by forging more partnerships on the state level. This means that the governments of both nations should put in effort to consolidate stronger partnerships, which can occur in these three manners: stronger government support for collaborations, institutional collaborations and greater mobility of medical staff. 5.1.4. Stronger government support: As above mentioned, government collaboration is needed to make medical tourism even more effective. This is because it has been identified that one of the main obstacle to medical tourism is the inadequate follow up care for medical tourists all over the world. Patients receiving treatment from hospitals in other countries do not have the medical support in their home countries, which means that they cannot easily find doctors if further complications arise after their medical treatment abroad. This would deter people away from seeking better quality and more affordable treatment, fearing the possible hassle after. This obstacle can be overcome by having collaborations with government support. The governments can enforce regulations for

post-surgery care, assuring the patients that they have medical staff to depend on after their treatment overseas. Furthermore, the governments can create more formal organisations dealing with medical tourists. Medical packages can be created by these organisations to match the patients up with the hospitals that offer the most valued services for treatment. The movement of the patients is facilitated, encouraging more to take up the option of seeking treatment overseas. This will serve to boost the medical tourism business between both nations. 5.1.5. Greater mobility of medical staff: With the strong hand of the government supporting the corporate hospitals, it will help to facilitate the movement of medical staff between corporate hospitals in India and Singapore. This is one of the most efficient ways to ensure that knowledge gets spread around to improve the technical quality of the healthcare services and it can be done by removing significant entry barriers for the Indian doctors to work in Singapore. The barriers are erected because of Singapores unfamiliarity with the medical standards of other countries and the stringent conditions for employment passes for foreign medical staff (Mukherjee, et al., 2003). CECA has started to tackle this issue, by ensuring mutual recognition for each others medical degrees and lowering the criteria specifically for Indian medical staff to come to Singapore to work (Mukherjee, et al., 2003). Therefore, attempts have been made by the government to initiate the process of free movement for the doctors and it will bring countless benefits for both countries. After all, India has the comparative advantage of having a pool of highly skilled medical staff hired at competitive and lower wages. Singapore, where there is significant shortage of doctors and higher wages, can now tap into this pool of medical staff with the removal of entry barriers and this would allow India to send its medical talents out to spread the reputation of the Indias high quality medical education and services. This helps both countries gain more international

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recognition and more crucially, give international patients more assurance about the premier quality of the services offered. The quality assurance will definitely draw in more international patients, increasing the medical tourism industries in both nations. 5.1.6. Institutional collaborations: Besides greater government support, partnerships can take the form of individual institutional collaborations between the hospitals, particularly the specialty departments. Therefore, there is a need for the research study to identify these viable areas for collaborations. There are in fact 4 areas identified, which happen to be the 4 most commonly used services in the Indian corporate hospitals as well. They are neurosurgery, kidney transplant, orthopedics and cardiac and cardiothoracic surgeries (Tables 25 & 26). These 4 services have been validated for their high quality, through the analysis of the PSQ-18 questionnaire and the international accreditation score. Besides the good quality, the comparative cost advantage of Indias corporate hospitals is their most valued asset in boosting their popularity with international patients. This comparative cost analysis is being reassessed, using the data collected from the hospitals interviews and data from the other 3 JCI accredited hospitals in Singapore. The most commonly used service, orthopedics, has an average charge of around US$2252.66 in India and an average charge of US$13000 in Singapore, making it almost 6 times cheaper to be treated in India (Table 26). For the cardiac and cardiothoracic surgeries, the cost of treatment in India is about 6 times cheaper, with it being only about US$4500 in India and US$26500 in Singapore (Table 26). Similarly, the cost savings for neurological surgeries is almost 4 times, with the charge for brain surgery in India being US$7800 and the charge in Singapore being US$29000 (Table 26). Finally, for the services in the nephrology department, the charges for kidney transplant in Singapore is US$55000, more than 8.62 times the cost of

treatment of it in India, which is only about US$6400 (Table 26). Therefore, the average costs of the treatments in corporate hospitals in the metropolises in India for all 4 services are about 5 to 6 times cheaper than that in Singapore, proving that the comparative cost advantage is substantial for partnerships to be valuable and profitable. Looking into these 4 services is appropriate for the changing lifestyles of Singaporeans today, with more Singaporeans being plagued by lifestyle diseases. In fact, cardiac disease is the prime cause of death for Singaporeans between the ages of 45 to 65 and kidney failure is the 8th most common cause of death (Vathsala, 2007). There is 20 per cent increase in the patients with kidney failures who require dialysis from 564 new cases in 1998 to 675 new cases in 2003 (Vathsala, 2007). Therefore, possible collaborations between Singapore and Indias corporate hospitals will allow Singapores hospitals to lower the costs of healthcare in these 4 areas significantly, since the related diseases seem to hit the Singaporeans the worst. Besides lowering the costs of treatment, the hospitals in Singapore and India can tap into a bigger pool of resources and expertise to form higher quality super specialty conglomeration, making these hospitals even more competitive. This can be done in the field of cardiac and cardiothoracic surgeries, where Singapore is looking to become the center for cardiac surgery in Asia. Mount Elizabeth Hospital in Singapore has the most cutting edge technologies in its cardiac department. India likewise has the best cardiac hospitals in Asia: the Escorts heart Institute and Research Center (EHIRC) in New Delhi (Mukherjee, et al., 2003). EHIRC is also given the highest grade by Credit Rating Information Services India Limited (CRISIL), an acknowledgement of the quality of delivered patient care and it is the first outside America to receive this award (Mukherjee, et al., 2003). Thus, the greater networking between hosptials can occur in many ways, like using telemedicine to enhance communication between medical staff, outsourcing the processes that do not require

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the physical presence of the doctors and facilitating the movement of Indian doctors to work in Singapore. This will certainly help to improve the quality of healthcare services available in India and Singapore and more importantly, lower the costs of the services. Furthermore, the individual reputation of these hospitals will be boosted tremendously in the world markets. Since the hospitals image has been claimed by 37.5 per cent of the patient population to be the deciding factor for them to patron the hospitals, the stronger hospital image will definitely help to draw in a wider crowd of international patient population (Lee, et al., 2006). Therefore, the more efficient and cost effective medical services and the more favorable hospital image will definitely boost medical tourism in India and Singapore. However, there are still many obstacles that Singapore face in its attempt to forge ties with India. This is because despite their recent success in the medical tourism arena, the perceptions of the Indias healthcare sector and the country by the other foreigner have not been favorable. The poor infrastructure and facilities, like the inefficient transport system, reinforce the prejudices that the foreigners have about healthcare in India. The foreigners tend to perceive a lack in regulation and widespread unethical behavior by medical staff in these corporate hospitals. Those perceptions ended up pushing India behind in the competition for medical tourists, making many international partners doubt the quality of the healthcare services in these corporate hospitals. Therefore, it is crucial for the Indian government to step in to enforce the domestic accreditation system which sets minimal standards for the delivery of healthcare services, as proposed by the Confederation of the Indian Industry in 2005 (Express, 2006). The individual corporate hospitals can also change the perceptions for them by seeking out for international accreditations and having affiliations with other internationally prestigious medical institutions. This is because they realise from previous collaborations, like the Wockhardt

Hospitals affiliation with Harvard Medical International, that the corporate hospitals are able to attain the best practices from these prestigious institutions to lift their own medical care to worldclass standards. These accreditations and affiliations have the added bonus of being external confirmatory reviews for them, giving international patients to gain more confidence about the corporate hospitals (Knox, 2008). Therefore, it is crucial that India makes an effort to overcome this stumbling block to encourage even more international collaborations. It is then that hospitals in both Singapore and India can use their comparative advantages complementarily to bring in more patients into the medical tourism industry as well.

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5.2. Telemedicine: The increased partnerships between Singapore and Indias corporate hospitals can also occur by using telemedicine facilities to improve the communication between hospitals. 5.2.1. Market size for telemedicine and Driving forces behind telemedicine: Telemedicine makes use of communication and IT to provide healthcare services when distance separates patients from the doctors (Herrick, 2007). This is especially significant in countries like India, where there is no organised system or uniform distribution of specialists (Herrick, 2007). Telemedicine hence thrives in India, particularly in the rural areas, since it will provide access to the underserved areas, improve access to specialty care, reduce commuting time and cost for rural and semi urban patients and most importantly, overcome the distance barrier between the patients and doctors (Herrick, 2007). 5.2.2. Methods of collaboration: This concept of telemedicine and benefits of it can be extended into the international arena through partnerships with the corporate hospitals in Singapore and India. This would occur through the strengthening of the facilities for information communication, which taps into the immense potential of info tech applications in tertiary health care sector (Herrick, 2007). Info tech applications can enhance the capacity for professionals to pool their clinical experience, seek for second opinions and improve their medical education (Mukherjee, et al., 2003). Thus, telemedicine can eliminate duplicative testing, speeding up the process of treatment (Mathiyazhagan, 2005). In addition, since the telemedicine facilities will increase the speed of communication between the medical staff in both hospitals, Singaporean doctors can easily seek advice from their Indian counterparts and vice versa. The patients will get a more informed and comprehensive treatment plan, improving the quality of the medical services. Moreover,

consultation fees for the doctors and medical staff will be reduced with the substantially lower medical fees in India, allowing the costs of medical treatment to be lower in Singapore. India likewise can provide higher quality medical services for the same cost, since there is no need to travel to get another experts opinion. This would make the corporate hospitals in India and Singapore more cost efficient and more competitive in the medical tourism market. In addition, these facilities can help the patients in the hospitals in both countries get their treatment without the need to travel to India. This would provide more comfort for the patients, allowing them to be willing to pay more for better and value added services. This would allow the corporate hospitals in Singapore and India to draw in a greater international patient population, boosting their medical tourism businesses. Likewise, Indias corporate hospitals can also use the well-acclaimed reputation of Singapores corporate hospitals to consolidate their own brand name, reaching out to a wider target patient population. Hence, with Singapore IT 2000 plan in the way, where Singapore established links with international hospitals to allow local consultants to seek second opinion and enhance medical education as well, similar initiatives can be forged with Indian hospitals using telemedicine technology (Herrick, 2007). This has been used by Singapores polyclinics, which have telemedicine facilities with Indias corporate hospitals to lower the costs of treatment. (Mukherjee, et al., 2003) Therefore, telemedicine is certainly an area to look into to not only lower the costs of treatment for both countries but also improve the quality of treatment to boost their medical tourism business as well.

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5.3. Medical equipment industry 5.3.1 Market size for medical equipment industry: Another area for partnership is the medical import industry and this is a crucial area for India due to the large dependence of the corporate hospitals on them (Purohit, 2001). The large demand for these hi-tech medical technologies is being purred by the affluent and consumer oriented middleincome population and in response of that huge demand, the corporate hospitals are always seeking to upgrade the delivery of healthcare and improve their efficiency. Since there is a conspicuous absence of domestic manufacturers in this medical equipment industry of US$2.16 billion in India, more than 65% of the medical equipment used in India has to be imported from mainly Japan and Germany (Asher & Srivastava, 2003). This heavy dependence on IT architecture has been proven also with the interviews, with all the hospitals importing medical equipment. 5.3.2. Medical imports as a financial vulnerability: Hence, the hospitals have to find ways to lower the costs of medical imports or the medical imports will become a financial vulnerability for them (Balakrishna, 2007). This is because the corporate hospitals will be exposed to the foreign exchange rates, since the purchases are always in other currencies (Bhat, 2006). In addition, because the import industry is made up of a fragmented group of small local manufacturers, it is easy for these hospitals to fall prey for the monopolising ways of these manufacturers (Bhat, 2006). More importantly, the medical technology becomes obsolete very fast and the corporate hospitals constantly find the need to upgrade their medical equipment to ensure the high quality medical services. Therefore, it is undeniable that the medical imports impose a substantial financial burden on the corporate

hospitals, which emphasises the importance for the corporate hospitals to find ways to lower the costs of these medical imports. The government of India realises the financial vulnerability and has tried ways to spread the financial risks for the corporate hospitals. Since the entry of private hospitals raised the bar on use of advanced equipment, this makes government intervention even more urgent (Balakrishna, 2007). Responding to this dependence on medical imports, the government has given cheaper and long-term loans and reduced import duties to an average level of 15 per cent for medical equipment and extended these concessions to the corporate hospitals as well (Balakrishna, 2007; Purohit, 2001). All these concessional exemptions have helped the corporate hospitals tremendously, lowering the costs of imports. However the financial burden is still considerably high for the corporate hospitals, making the government more determined to find ways to collaborate with the medical equipment industries of other countries to push down the costs of imports further. Thus, the government is actually looking towards Singapore, the medical equipment hub of Asia, for any potential prospect of collaborations. This is due the fact that Singapore has been acclaimed as the medical equipment hub in the Asian region for almost a decade, with its multiple collaborations with medical equipment companies (Balakrishna, 2007). This has made India realise that partnerships with Singapore will have vast potential benefits. After all, Singapore undoubtedly has the skills and expertise in the manufacturing of medical equipment to produce the equipment to export to India. Furthermore, with the signing of CECA, both countries have strived to lower the import tariffs by half after 2005 (Mukherjee, et al., 2003). This would make any collaboration with Singapore lower the costs of the medical imports for the corporate hospitals even more, helping them reduce their financial vulnerability. This

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confirms the potential of the collaborations between Singapore and Indias medical equipment industry, which helps both countries step up the gear to form more partnerships with each other. 5.3.3. Partnerships in the medical equipment industry: There are various ways that Singapore and India can utilise the lowered tariffs and multiple concessions that CECA have acceded for both countries. They are the outsourcing of the production process and using Singapore as the middleman for medical import. 5.3.4. Outsourcing production process: The first partnership is in the medical equipment manufacturing industry, where both Singapore and India are powerhouses in. In fact, 90 per cent of Singapores production is meant for exports and India has always been globally renowned as the upcoming IT expert in the region (Mukherjee, et al., 2003). However, India faces a problem. Although they produce high quality medical equipment, they still find their export market very small, because importing nations are not confident of the quality of their products. Therefore, they can solve this problem by forging partnerships with Singapores biotech firms. This allows the Indias companies to use Singapores brand name to validate the quality of their equipment, expanding their market internationally and production. This will help to produce high-rated quality equipment for their own corporate hospitals, which will significantly reduce the costs of imports for them as well. Furthermore, this can help to overcome the main obstacle that Singapore faces as well: the cost of production in Singapore is increasing unprecedentedly, because of the rise in the standard of living. This pushes up the prices of the medical equipment for exports, causing Singapore to lose their competitiveness in the global markets. Therefore, there is a need for Singapore to outsource their production process to decrease the cost of production and India can be the solution to the obstacle. In fact, other biotech companies like GE medical systems, the leading supplier to

medical equipment in India, have partnered the Indian local biotech companies and set up their factories there. They use India as a low cost manufacturing base and export these Indian made products to South Asia, using their company name as a brand name to ensure quality (Balakrishna, 2007). Likewise, Singapore could outsource their production process, specifically the pathology and radiology services to India and benefit from the significant cost differentials of around 30-40% (Mukherjee, et al., 2003). Besides outsourcing, the IT expertise in the healthcare of India is so rich that they can offer other services like product engineering, technical and consulting solutions as well (Mukherjee, et al., 2003). All these sharing of expertise allow both countries to improve their technical expertise, allowing these companies to produce better quality medical equipment. This would allow both countries to import from each other, benefitting from the concessions and reduced tariffs that the CECA have brought. As a result, the financial vulnerability from the medical imports will be dropped substantially for the corporate hospitals in both countries to thrive even more. 5.3.4. Singapore as the middlemen: Besides collaborations between the medical equipment industries, both nations can use the lowered tariffs set by CECA effectively to reduce the costs of medical imports. Because of the large number of biotech companies in Singapore, it is completely advantageous for India to import medical equipment from Singapore rather than importing from elsewhere like Germany. Since Singapore has been viewed as the center of the medical equipment industry in Asia, the foreign companies are all seeking ways to set up their plants in Singapore to tap into the rich wealth of technical expertise that Singapore can offer. Having collaborations between India and Singapore will allow the exchange of expertise, which will draw even more international companies, like GE, to build their plants in both countries. This would mean that India and

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Singapore can import these products to each other at the lowered tariffs and duties, which will significantly reduce the costs of medical imports since tariffs often covers half of the cost of imports. Thus, partnerships in the medical equipment field will not only bring greater technical expertise, but also lower costs of imports to reduce the financial vulnerability that the corporate hospitals in both nations face.

5.4. Relevance of the study: This research paper has succinctly answered all three questions, which the research study sets out to find out initially. The corporate hospitals have become ever more emerging with the development of the medical tourism industry in the Asia region. Understanding the forces behind this emergence has definitely been useful in evaluating the performance and quality of these corporate hospitals in India. This is of course supported by empirical evidence from the fieldwork in the 3 metropolises in India. Hence, with both criteria fulfilled, the corporate hospitals in India have been proven to be viable for partnerships with Singapore. The viable areas of partnerships have been explored and these will definitely help to forge better linkages between Singapore and Indias healthcare sector. These partnerships will allow them to use their comparative advantage complementarily, improving the quality of medical services and reaching out to a wider international population. Thus, their competitiveness is being boosted, allowing both Singapore and India to be at the forefront of this globalised age of healthcare and medical services.

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Table 1: Gender profile of Patient Survey (PSQ-18) Gender Male Female Total (N=110) Table 2: Educational background of the Patient Educational status Up to primary school Primary to secondary school Graduate Post graduate Total (N=110) Table 3: Occupational background of the Patient Occupational groups Wage earners Agriculturists Salaried professionals Self employed Others Total (N=110) Table 4: Caste Categories of the Patient Caste categories SC/STs Backward Forward Others (includes foreign patients) Total (N=110) Table 5: Origins of the patients Origin of patients India Others Total (N=110) Table 6: Household income profile of the Patient Household income quintiles Percentage (%) Poorest (20%) 2nd quintile Middle (20%) 4th quintile Richest (20%) Total (N=110) 20.00 29.09 10.91 23.64 16.36 100.00

% 68.18 31.82 100.00

% 2.73 20.00 52.73 24.55 100.00

% 0.91 1.82 47.27 22.73 27.27 100.00

% 4.55 40.91 49.05 5.50 100.00

% 94.50 5.50 100.00

Mean monthly income (Rs.) 8090.91 16937.50 24791.67 39403.85 147777.78

Table 7: Correlation between economic and social status Caste categories SC/STs Backward Forward Others (includes international patients) Table 8: Item scoring in PSQ-18 Items numbers Original response value 1, 2, 3, 5, 6, 8, 11, 15, 18 1 ---------------------- 2 ---------------------- 3 ---------------------- 4 ---------------------- 5 ---------------------- 4, 7, 9, 10, 12, 13, 14, 16, 17 1 ---------------------- 2 ---------------------- 3 ---------------------- 4 ---------------------- 5 ----------------------

(Mean) monthly income (in Rs.) 11000 16401 63566 101,000

Scored value 5 4 3 2 1 1 2 3 4 5

Table 9: Creating scale scores from the Patients Survey (PSQ-18) Scale Average these items General satisfaction 3, 17 Technical quality 2, 4, 6, 14 Interpersonal manner 10, 11 Communication 1, 13 Financial aspects 5, 7 Time spent with doctors 12, 15 Accessibility and convenience 8, 9, 16, 18 Note: Items within each scale are averaged after scoring as shown in Table 2

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Table 10: Descriptive statistics for 18 scored items in PSQ-18 N Mean Q1 110 4.75 Q2 110 4.67 Q3 110 4.72 Q4 110 4.33 Q5 110 3.78 Q6 110 4.87 Q7 110 3.70 Q8 110 4.74 Q9 110 3.88 Q10 110 4.54 Q11 110 4.76 Q12 110 4.40 Q13 110 4.69 Q14 110 4.78 Q15 110 4.37 Q16 110 4.21 Q17 110 4.28 Q18 110 4.80 Valid N (listwise) 110

Std. Deviation 0.693 0.791 0.592 1.03 1.40 0.361 1.34 0.645 1.18 0.964 0.663 1.01 0.787 0.565 0.907 1.17 1.23 0.521

Table 11: Descriptive Statistics for the 7 parameters for PSQ-18 and summary statistics Quality indicators N Score Std. Deviation Variance General satisfaction 110 4.50 0.681 0.463 Technical quality 110 4.66 0.428 0.183 Interpersonal manner 110 4.65 0.662 0.438 Communication 110 4.72 0.569 0.324 Financial aspects 110 3.74 1.24 1.526 Time spent with doctor 110 4.39 0.686 0.471 Accessibility and 110 4.41 0.561 0.315 convenience Valid N (listwise) 110 Table 12: Summary item statistics of PSQ-18 N of Mean Minimum Maximum Range items Item 18 4.460 3.700 4.873 1.173 mean Table 13: Types of hospitals from the Hospital Facilities Survey Hospital types Numbers Corporate hospital for profit 12 Corporate hospital for charity (trust) 4 Table 14: Years of experience of corporate hospitals from the survey

Standard deviation 0.369

Variance 0.136

Average year of experience

16.5625

Table 15: Number of branches for corporate hospitals from the survey Expansion capacity for corporate hospital (%) Average Number of local branches for all the corporate hospitals(NL) Average number of international branches for the corporate hospitals (NI) Average number of branches for the corporate hospitals (N)

62.5 5.875 0.3125 6.1875

Table 16: International accreditation of the corporate hospitals from the survey International accreditation score (ICI) 0.9375 Proportion of hospitals with JCI accreditation (%) 25 Table 17: Patient flow statistics from the hospital facilities survey Average outpatients/year 52199.6875 Average inpatients/year 51355.6875 Table 18: Population of the patients in corporate hospitals served from the survey Average percentage of international patients (%) 9.4375 Proportion of hospitals serving Indigent patients (%) 100 Proportion of hospitals with lower charges for indigent patients (%) 93.75 Table 19: Financial performance of the corporate hospitals from the survey Average profits/year (Rs.) 2463848594 Financial expansion indicator (Rs.) 138600000 Source: Empirical evidence tabulated from the hospital facilities surveys Table 20: Telemedicine facility of the corporate hospitals from the survey Proportion of hospitals with telemedicine facilities (%) 62.50 Telemedicine score 0.9375 Table 21: Medical imports of the corporate hospitals Proportion of hospitals with medical imports (%)

100

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Table 22: Medical tourism indicators of the corporate hospitals Proportion of hospitals with medical tourism 62.50 facilities (%) Proportion of hospitals with patients from the following geographical areas (%) Europe 31.25 US and Canada 25.00 Australia 18.75 Africa 37.50 Middle East 56.25 Southeast Asia 18.75 East Asia 18.75 South Asia 62.50 Source: Empirical evidence tabulated from the hospital facilities surveys Table 23: Most commonly used services of the corporate hospitals Most commonly used services Orthopedics Cardiology, cardiothoracic and related cardiac surgery Neurology and neurosciences Gastroenterology Nephrology Cancer/ oncology Infertility and related illnesses Paediatrics Urology Radiology General medicine Gynaecology General surgery Plastic and cosmetic surgery Minimal access Imaging Pulmonology Diabetes Laboratory Total

N 12 12 6 4 4 3 3 2 2 2 2 1 1 1 1 1 1 1 1 60

Table 24: Average charges for the 4 most used services in the corporate hospitals in the metropolises Medical service Average charges (Rs.) Average Charges (USD) Orthopedics 105875 2252.66 Cardiac surgery and cardiothoracic 210250 4473.40 surgery Neurology and Neurosciences 366600 7800 Nephrology 300000 6382.98 Table 25: Price comparison of medical services with India and the US and UK Medical service Average charges in Average charges in Proportion of charges India (USD) the US and UK in the US and UK/ (USD) Charges in India Orthopedics 2252.66 24500 11 Cardiac and 4473.40 40000 9 cardiothoracic surgeries Neurology 7800 94000 12 Nephrology (Kidney 6382.98 87500 14 transplant) Table 26: Price comparison of medical services with India and Singapore Medical service Average charges in Average charges in Proportion of charges India (USD) Singapore(USD) in Singapore/ Charges in India Orthopedics 2252.66 13000 5.77 Cardiac and 4473.40 26500 5.92 cardiothoracic surgeries Neurology 7800 29000 3.72 Nephrology (Kidney 6382.98 55000 8.62 transplant) Source: Empirical evidence tabulated from the hospital facilities surveys (2008)

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