Kerala as an MVT Destination Upbeat Healthcare Providers Seek Teamwork

Kochi: On March 13, 2017, the fourth edition of RADO Switzerland presents Destination Kerala CEO Roundtable: The Growth Dialogues powered by INKEL Limited was held at the Le Meridien Kochi. This time, the panellists, all senior business leaders from the modern healthcare industry, discussed how Kerala can emerge as South Asia’s leading Medical Value Travel (MVT) destination. The distinguished panel consisted of S K Abdulla, CEO, VPS Lakeshore Hospital, Kochi; Ashok P Menon, CEO, Cosmopolitan Hospital, Thiruvananthapuram; Dr. Harish Pillai, Cluster Head-Kerala, Aster DM Healthcare and CEO, Aster Medcity, Kochi; Rev. Fr. Johnson Vazhapilly CMI, Executive Director, Rajagiri Hospital, Aluva; Krishnakumar Ananthasivan, Director, Grant Thornton India; P Neelakannan, Group COO, KIMS Healthcare Group; Dr. Prashant Pillai, Director & Chief Dental Officer,, Kochi and Dr. Rahul Menon, CEO, Aster MIMS, Kozhikode. The session was moderated by Jose Kunnappally, chief editor, Destination Kerala.

What has been achieved in the last three years to become an MVT destination of choice?

Dr. Harish Pillai: The policymakers at the Centre and State are in sync today in terms of agreeing on the potential of healthcare industry to create employment and provide better quality of care to the population. They recognise the demand-supply gap and want both the private and public sectors to address it. This is a historic opportunity for our State known for its healthcare professionals. In the last few years, infrastructure investments in healthcare have been massive, so the gaps are getting filled. A perfect winning strategy for Kerala is starting to play out.

Our healthcare industry has a fragmented approach where hospitals promote themselves and not Kerala as an MVT destination.

Krishnakumar Ananthasivan: When we did the concept paper on MVT some years ago, we found out that only a few players were working hard to build MVT as an industry. There are 42 large hospitals in Kerala but only 14 were serious about MVT agenda. PPP (Public-Private Partnership), government support and ‘One State’ approach are required to progress further. This has to be an industry initiative. Promoter’s vision, stake dilution for raising capital, receiving funding, certifications – all of these need to fall in place for each large player to kick-start MVT in a big way.

Dr. Rahul Menon: The cut-throat competition we see in the MVT segment should stop. There should be a level playing field and greater collaboration. However, public hygiene and cleanliness are also important. If we can take this up and adopt at least the surroundings of the hospital, then that’s a starting point.

Rev. Fr. Johnson Vazhapilly, CMI: Quality and affordability need to be brought into the sector as a baseline. And, if you pursue quality then there is a cost involved. I would say the biggest challenge is to balance these two. The one thing that can help us grow is quality service. Professionalism and teamwork are needed to drive quality and attract MVT traffic to Kerala. By God’s grace, these days we are seeing greater synergy and more hospitals have started talking to each other about how we can stand together and work alongside.

Dr. Harish: We can draw from the success of KTM (Kerala Travel Mart). There is a lot of synergy between travel tourism and healthcare. The best aspect of the KTM model is that all stakeholders, even though they compete with each other, collaborate to sell the destination, and this involves the government also. We, in the healthcare industry, can have a similar model. The underlining factor, as Fr. Johnson said, should be minimum assured quality of care across all providers. We should remove the differences between private and public hospitals.

How will we generate MVT dollars and cross-subsidize local patients when our hospitals are bursting with local population?

Dr. Rahul: I am not sure how much hospitals are bursting (laughs). For medical value travelers, the charges we levy here are cheaper from their country’s cost perspective but still higher when compared to what we collect from a local patient. This margin helps play out a ‘Robinhood’ theory benefitting our population. We have been talking for long about standardizing rates for MVT to avoid unhealthy competition in this space.

Dr. Harish: We have to approach MVT with social responsibility. Number one reason why we should promote MVT is its job-creation potential. If you look around this panel, we are easily employing about 15,000 people. That’s the power of the healthcare industry. We have clinical competency to reduce cost. If we have MVT dollars, we can pay healthcare professionals better. Our nurses in Syria and Yemen are economic migrants, and if we can pay better salaries here, they will not go there. MVT revenue can attract higher investments into healthcare, better technology and help train more people…

Is the MVT business’ dependence on facilitators healthy?

P Neelakannan: We depend heavily on facilitators and they behave like brokers and not professional business development executives. This is a major pain point. We need to streamline this activity with the support of the government to curtail unethical practices.

S K Abdulla: We have to remove these characters especially from the airports as the entire impression of MVT and Kerala is getting spoiled as they deal unprofessionally and are looking at only maximum commission. They are not worried about standards of healthcare or overall patient experience.

Dr. Harish: On the NABH (National Accreditation Board of Hospitals) website we have published standards for facilitators. We now have an inter-ministerial taskforce (Commerce, Home Affairs, External Affairs, Tourism and Healthcare) at the Central Government level. The Commerce Ministry takes the lead as Government of India (GoI) has categorized MVT as ‘service export’. The Service Export Promotion Council (SEPC) of India has a dedicated portal listing all MVT hospitals. Embassy/high commission websites have a list of accredited hospitals and facilitators, allowing a patient to choose wisely. The sad part is that there are only two accredited facilitators listed and both are from New Delhi.

The Ministry of External Affairs now issues an M-Visa only in the hospital’s name. So rogue facilitators cannot wean away patients at airport. On the issue of FRRO (Foreigner Regional Registration Office) regulations, which require a foreign patient to report to the nearest police station, we are discussing how to simplify this. Ministry of Home Affairs will soon send out a circular to all State Chief Secretaries informing that for patients on M-Visa, this regulatory requirement can be relaxed as the hospital will take the responsibility. The FICCI MVT taskforce has proposed to make the M-Visa electronic. We have offered to provide case-by-case validation report and take responsibility for the patient. Hopefully, this should happen.

What is Kerala doing to increase its share of MVT from current 5 per cent of national receipts to 10-12 per cent?

Dr. Harish: Mumbai was historically the MVT destination but not anymore. Today, Tamil Nadu followed by NCR (National Capital Region) take pole positions. Now even Hyderabad is catching up, so is Bengaluru. Kerala is nowhere in the national MVT race. Also, what is worrying is that in domestic tourist arrivals, Kerala is not in top 10. No. 1 in domestic tourist arrivals is Tamil Nadu. All of us need to think why Kerala is missing the boat.

Concerted efforts during the last two years have made the GoI recognise MVT as a key foreign exchange earner for the nation and we need to move forward from here. SEA countries are doing well in MVT and we have to compete hard. The present government at the Centre is talking about competitive federalism. So, if Kerala doesn’t get its act together then some other state like Gujarat or Tamil Nadu will walk away with the gains. It is matter of survival for us.

 Neelakannan: In Ayurveda, they do not further compartmentalise it as say panchakarma etc. but in modern medicine, they look at specialisation like orthopaedics or cardiac care or neurology. The preferred specialties are cardiology, orthopaedics, dentistry, ophthalmology and, of course, transplants. As far as oncology is concerned, we are not there at all in spite of having best facilities.

Dr. Harish: When we generalise, we make mistakes. The world is going towards super-specialisation. Many of us are still focused on a different world view which is more general in nature.

Krishnakumar: The Kerala healthcare website and app-based promotion which we have been discussing for two years now need to move forward fast.

Ashok P Menon: I was in Zambia for some time. When my son had to undergo a simple dental procedure I realised it was quite cheap in India whereas in Zambia it was costing a fortune. But not many people know about this cost advantage. We need to educate the markets about the world-class healthcare we are able to offer here and at what attractive rates. Also, I think lack of insurance facilities is a challenge.

Dr. Harish: Singapore has social health insurance, so there is a safety net for its nationals. Medical travelers do not go there for insurance but because of destination branding for healthcare services. Research shows that successful tourism destinations also reap MVT dollars. Best examples are Thailand, Singapore and Malaysia. Kerala and Goa are successful tourism markets in India.

Singapore has gone for high-end healthcare – tertiary and quaternary care-focused MVT. Thailand is much lower in the value chain. The Kerala brand is stronger due to Ayurveda and this is something we ought to leverage for our positioning.

But you have kept Ayurveda outside the MVT Society

Dr. Harish: Ayurveda already has a society. For years, Ayurveda has been offered the limelight in promoting the Kerala brand of healthcare globally. For MVT, nothing has been done so far. Also, if you look at it, KIMS has Ayurveda within their facility. They were the pioneers in offering Ayurveda within the premises of a modern medicine hospital. The others followed suit, including Aster. So, this concept of integrated medicine is growing.

Dr. Prashant: Forming the MVT Society is critical and awareness creation among all players about our top priorities and also what services each player can offer is important. We need a comprehensive website detailing all these and the website should be promoted globally.

Ashok: Andhra Pradesh already has a detailed website talking about MVT.

Is there a way to sync Ayurveda and MVT and have integrated promotion with Kerala Tourism?

Dr. Harish: In the last CII conclave in Kochi we had decided to create a Kerala MVT Society. Its memorandum and legal structure is similar to that of the KTM Society. We are waiting to get it approved by the Government of Kerala as some technical issues are there in using the word Kerala and we have to agree to include government nominees in the Society’s governing body.

Dr. Rahul: If you look at the Kerala Tourism campaigns, they have always promoted Ayurveda but overlooked modern healthcare in Kerala. If we do not promote modern medicine, then how will the world know about it?

Dr. Harish: The worrying part is that recently the Government of Tamil Nadu started roadshows in the Middle East with private industry partners to attract MVT visitors. The early bird catches the worm.

Some of our most modern facilities are funded by GCC entrepreneurs. Doing a roadshow in GCC must be a cakewalk for you. So why don’t you just do it?

Dr. Harish: As Aster DM we do not need to do a roadshow as we are already present in GCC. Tamil Nadu roadshow was by the government. Unless Kerala Government comes on board with the conviction that this is a powerful economic engine, and that validation is there, it will remain a non-starter.

How is your conversation on working with KTM progressing? How practical is it for Kerala to fly solo in MVT?

Dr. Harish: We cannot fly solo especially as it concerns M-Visa and FRRO. Government regulation is substantial in healthcare. E M Najeeb of KIMS Healthcare is one of the founders of the KTM Society. So he serves as the link between KTM Society and Kerala MVT Society. And that conversation is progressing well in terms of educating them about MVT as well as exploring synergies.

How can we drive positive clinical outcomes and what are we doing to market this globally?

Rev. Fr. Johnson: Your question points to quality. The best way to ensure quality is through accreditation. And our national accreditation (NABH) is capable of taking our healthcare organisations forward through better clinical results. Accredited organisations should support ones which aren’t. We should encourage more and more hospitals to go through the accreditation process and improve clinical outcomes. We have to educate them about returns from accreditation. I can confidently say that my hospital’s investment in NABH and JCI in two years’ time since inception will reap rich dividends in the long run. Ultimately, quality wins.

Abdulla: Currently, even GCC editions of our newspapers do not carry such stories on positive clinical outcomes. Only local editions do that. The positive news should be published online for wider reach in this digital era.

Dr. Harish: I have good news to share. There is a large forum in Delhi called Advantage Healthcare India sponsored by FICCI and GoI. The first edition had 500 foreign delegates. Last year, Fr. Johnson and I were there. I am an office-bearer, too, so I am pushing for Kerala as a Partner State for the 2017 edition. I am telling them Delhi is not India. They have committed to us that if this year we become a Partner State, then in 2018 Kerala can host the event. GoI will as always fund it and we will have the unique opportunity to host 500 international delegates who will visit Kerala and the hospitals here.

But we know the Kerala Government has a very skeptical approach towards private healthcare.

Dr. Harish: Healthcare is beyond ideology, it’s a fundamental right of every citizen. Private healthcare exists because of the vacuum in public health services. We are complementary. We are regulated by government agencies. We have to ask loudly, with the disease incidence and growing demand-supply gap, how does the State plan to address universal healthcare?

We are the No. 1 State for diabetes and geriatric problems. In NCD we are in top 5. So if you say only public sector can address this, we live in a fairy tale world. We have to have an ecosystem to exchange ideas and collaborate towards win-win outcomes. We can agree to disagree but there has to be a dialogue.

What is the industry doing to address the need for foreign language facilitation?

Abdulla: We are getting patients from Arab countries and even Europe and the US. But how many of our doctors and nurses can speak their language? Training our people to speak their languages is much needed if MVT has to succeed in our State.

Dr. Harish: Abdulla raised a valid point. If you look at Bumrungrad Hospital Bangkok, they are able to attract MVT beyond SEA. They get patients from Central & South Asia and Africa because of their destination brand and their people’s ability to speak multiple languages. Malayalis can pick up multiple tongues easily because we are academically inclined. It’s a job creation opportunity under Skilling India.

How challenging is it for single unit hospitals like yours to grow especially with large network hospitals around?

Ashok: We started in 1982. MVT visitors from Maldives began coming to Thiruvananthapuram because of us which was the beginning of MVT in Kerala. Later, KIMS came into the scene. We are now NABH SAFE and Green OT-certified. We will go for NABH, and later, JCI accreditations.

Dr. Harish: In a healthy ecosystem different price points will coexist. So you cannot say only large hospitals will thrive. Ashok is bang on when he says they are focusing on quality. Segmentation will take place in the market as it expands and matures.

Neelakannan: Of the 42 large hospitals in Kerala, 23 are already NABH-certified. So the quality consciousness is there among industry players.

Krishnakumar: NABH is exhaustive enough but JCI is more accepted internationally and hence, important for the growth of MVT market. Kerala hospitals should focus on that.

How attainable is it for standalone hospitals?

Dr. Harish: The accreditation fee is manageable but the bigger cost is replacing ageing infrastructure. Compliance with government regulations is not an issue as in Kerala those matters are quite strict. Our manpower is also well trained. Empirical data shows that Kerala leads in medical litigation. NABH hospitals have very low levels of litigation issues. So, if a hospital is not NABH-certified in Kerala, it is a huge business risk.

How can we raise dental tourism to an organised activity to tap MVT dollars more effectively?

Dr. Prashant: In dental tourism we are already there. We all started very small and grew by word of mouth. Our patients say, when we undergo a procedure in Kerala and stay for a month, and during which time see the State, the overall cost (medical treatment plus vacation) comes up to roughly the treatment cost in the West. So they see the dental treatment in Kerala as being able to offer oneself a free holiday too. In dental, there is super specialization and hence, we cross reference patients.

Concluding remarks

Key markets like Africa are not keen to send MVT traffic to India. They’d rather have us build hospitals there. Maldives demands the same from us. So the MVT revenue we clock today is not sustainable in the long term. But for now, our MVT share of 5 per cent has grown to near 10 per cent this year primarily on the back of BTL activities led by individual hospitals.

On that positive note, of MVT traffic to Kerala touching 10 per cent, Destination Kerala’s fourth CEO Roundtable came to a close.