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India-EU relations in health services: prospects and challenges

India-EU relations in health services: prospects and challenges Background: India and the EU are currently negotiating a Trade and Investment Agreement which also covers services. This paper examines the opportunities for and constraints to India-EU relations in health services in the context of this agreement, focusing on the EU as a market for India’s health services exports and collaboration. The paper provides an overview of key features of health services in the EU and India and their bearing on bilateral relations in this sector. Methods: Twenty six semi-structured, in-person, and telephonic interviews were conducted in 2007-2008 in four Indian cities. The respondents included management and practitioners in a variety of healthcare establishments, health sector representatives in Indian industry associations, health sector officials in the Indian government, and official representatives of selected EU countries and the European Commission based in New Delhi. Secondary sources were used to supplement and corroborate these findings. Results: The interviews revealed that India-EU relations in health services are currently very limited. However, several opportunity segments exist, namely: (i) Telemedicine; (ii) Clinical trials and research in India for EU-based pharmaceutical companies; (iii) Medical transcriptions and back office support; (iv) Medical value travel; and (v) Collaborative ventures in medical education, research, training, staff deployment, and product development. However, various factors constrain India’s exports to the EU. These include data protection regulations; recognition requirements; insurance portability restrictions; discriminatory conditions; and cultural, social, and perception-related barriers. The interviews also revealed several constraints in the Indian health care sector, including disparity in domestic standards and training, absence of clear guidelines and procedures, and inadequate infrastructure. Conclusions: The paper concludes that although there are several promising areas for India-EU relations in health services, it will be difficult to realize these opportunities given the pre-dominance of public healthcare delivery in the EU and sensitivities associated with commercializing healthcare. Hence, a gradual approach based on pilot initiatives and selective collaboration would be advisable initially, which could be expanded once there is demonstrated evidence on outcomes. Overall, the paper makes a contribution to the social science and health literature by adding to the limited primary evidence base on globalization and health, especially from a developing-developed country and regional perspective. Background foreign commercial presence takes place through invest- Health services have become increasingly globalized. ments in the healthcare sector (GATS mode 3); and They are traded through all four modes of services cross border movement of service providers involves the circulation of doctors and nurses among countries delivery as defined under the General Agreement on Trade Services (GATS). Cross-border supply of health- (GATS mode 4) The borderline between GATS modes care takes the form of electronic delivery of healthcare may, however, not always be clear or separable (as in across countries (GATS mode 1); consumption abroad the case of electronic transactions involving modes 1 takes the form of medical value travel (GATS mode 2); and 2) and all market segments may not be covered under the GATS. Globalization of health services has Correspondence: rupa@iimb.ernet.in been facilitated by advancements in information and Professor, Economics and Social Sciences Area, Indian Institute of communication technology, liberalization of foreign Management Bangalore, India © 2011 Chanda; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Chanda Globalization and Health 2011, 7:1 Page 2 of 13 http://www.globalizationandhealth.com/content/7/1/1 investment, greater international mobility of patients amounted to US $1.2 trillion in 2005, with France, and service providers, and demographic dynamics. As a Germany, and the UK constituting the three largest mar- result, today, health services are a subject of discussion kets. The public sector dominates healthcare delivery. in multilateral services negotiations. Public spending constituted 77 percent of total health- The health sector has also come under focus in bilat- care expenditures in 2005 for the EU-27 and close to 90 eral and regional trade and cooperation agreements. One percent in certain EU countries [2]. The large volume of such prospective accord is the India-European Union healthcare spending is indicative of this sector’sstrategic (EU) Trade and Investment Agreement (TIA) currently economic and social importance for the EU, which is under negotiation. The latter is India’s first agreement likely to influence bilateral relations with other countries with a major developed country bloc and extends beyond in this sector. The dominance of public spending in goods into services, investment, and several other issues. healthcare suggests that any bilateral discussions would This agreement could potentially facilitate India’sgrow- be influenced by public sector concerns. In this regard, it ing bilateral trade and investment relations with the EU is worth noting that although the EU has undertaken in services, including health services. ambitious commitments on hospital services in its 1993/ This paper examines the opportunities for and con- 94 GATS schedule, it has reduced the coverage of these straints to India-EU relations in health services. It identi- commitments under its Economic Partnership Agree- fies the various segments where there are opportunities ment with the CARIFORUM to “privately funded ser- for India to export health services to the EU and to colla- vices”, reflecting the sensitivity surrounding commitment borate with the EU. It also identifies numerous regulatory of publicly funded services in a trade agreement. State- and other constraints which impede the development of ments by the European Services Forum (ESF), which this bilateral relationship. The discussion is largely based represents the interests of private sector services entities on in-depth discussions with a variety of stakeholders in in the EU, similarly reflect the recognition of health and India’s health sector and official representatives from a few education services as special sectors where government EU countries, corroborated by secondary evidence. In plays an important role and that public health services doing so, the paper makes a useful contribution to the must not be challenged by trade negotiations. According social science and health literature by not only adding to to the ESF, countries should be free to determine if they the very limited information base available at present on wish to open up their health services sectors to foreign globalization and health, based on primary evidence, but providers. also by providing a North-South cum regional perspective. The EU Member States provide universal or near-uni- The paper has two main conclusions. The first is that versal public coverage for health as part of a wider sys- although India and the EU have very different health sys- tem of ‘social protection’.Thisisextendedtohealth tems in terms of public-private composition, regulatory services that are prescribed by health professionals or frameworks, and policy priorities, several factors make institutions registered with the health insurance system this sector conducive to expanding bilateral commercial or which figure on the country’s positive list of approved relations and collaboration between the two. The EU procedures, drugs, and medical devices. Private insur- member countries with their ageing populations, rising ance offering ‘supplementary’ cover accounts for a small costs, and overburdened public healthcare systems could part of total healthcare financing, extending to services benefit from expanded relations with a country like India such as dental or alternative treatment which are not with its growing private healthcare sector, emergence of covered by the statutory systems, and providing supple- world class corporate hospitals, large pool of medical mentary coverage for elective treatments. The domi- manpower, and young population across a variety of seg- nance of public insurance coverage has an important ments. The second conclusion is that given the nature of bearing on prospects for bilateral relations with non- many of the constraints currently affecting this bilateral member countries through modes such as medical value relationship and given the public good nature of health travel. It implies that issues of insurance coverage and services, it would be best to take a gradual approach to portability are likely to be important and that the scope expanding bilateral engagement in this sector, building for medical value travel would be shaped by the effi- on collaborative efforts selectively and over time moving ciency and availability of health care under public health towards more commercial engagements. systems in the EU, and limited to areas where patients spend out-of-pocket or have limited insurance coverage. Overview of the EU’s Health Services Sector: implications Within the EU, nationals can elect to get treated in for bilateral relations another member country for pre-approved procedures Healthcare is a vital and strategic sector in the EU. On or in cases of undue delay, if they carry a European Health Insurance Card (EHIC), also called the EU Medi- average, the EU spends close to 8 percent of its GDP on cal Card. The latter entitles its holders to receive health [1]. Total healthcare spending in the EU-27 Chanda Globalization and Health 2011, 7:1 Page 3 of 13 http://www.globalizationandhealth.com/content/7/1/1 treatment at reduced cost when visiting European Eco- Health Information (EPHI) and specifies three types of nomic Area (EEA) countries and authorizes reimburse- security safeguards required for administrative, physical, ment by the patient’s home country. It is important to and technical compliance, with security standards and note though that although the European Health Card specifications for each standard [5]. facilitates treatment within the EU, it is subject to One important aspect of the EU’s data protection restrictions. It does not entail treatment on the same directive pertains to data transfers to non-member countries [6,7]. It requires that Member States enact terms as those provided in the patient’s home country laws that prohibit transfer of personal data to countries and instead provides for treatment on the same terms as outside the EU which fail to ensure adequate privacy that provided to nationals of the host country. It also does not cover treatment for conditions existing before protection. The Data Protection Commissions and travel or treatment by private providers and few coun- Member States are required to inform each other in tries pay the full cost of treatment and travel insurance such cases. The data adequacy determination require- still remains necessary. ment and concerns over issues of data privacy and con- There is also an initiative to standardize health cards sumer protection have implications for cross-border across member countries by providing an interoperable electronic delivery of health services to the EU by non- format that would help a patient prove entitlement to member countries such as India and raise issues of level healthcare from different national health services or to playing field vis-à-vis member countries. medical insurance schemes in Member States. Such fra- Regulations concerning standards and eligibility meworks have implications for medical value travel pro- requirements for healthcare providers in the EU are also spects with non-EU countries versus EU member likely to affect bilateral relations in health services with countries. Issues of level playing field between members non member countries. There are requirements pertain- and non-members are likely to feature in the EU’s ing to registration, language certification, and insurance health services negotiations. coverage, as well as compliance requirements with EU- Another important aspect of the EU’s healthcare sys- wide as well as national-level legislation in areas such as tem is the role of IT in healthcare delivery. The e-health telemedicine, clinical trials and research activities. industry in the EU was estimated at US $27.7 billion in Health professionals are regulated at the level of Mem- 2006. Europe could potentially account for one-third of ber States and, to some extent, at the EU level [8]. the global health ICT industry of US $66-79 billion [3]. There are two broad regimes for recognition of qualifi- cations in the EU: (a) the sectoral system, based on Although the extent of IT integration in healthcare common minimum training standards defined in rele- delivery varies across EU member countries, there is a general push in this direction due to ageing populations, vant sectoral directives which lead to automatic recogni- rising operational costs, and the need to improve service tion of the diploma; and (b) the “general system”,which access and quality. Several member countries have may require a case-by-case evaluation of the diploma by launched e-health initiatives. The adoption of IT in national authorities with the option to impose compen- healthcare has implications for cross-border delivery of sation measures [9]. Dentists, medical doctors, midwives, healthcare services to EU member countries, from nurses, pharmacists and veterinarians are covered by the within the region and outside, in areas such as telera- sectoral system; all other health professionals are cov- diology, telediagnostics, medical coding, transcriptions, ered by the general system [10]. These recognition and back-office support functions. requirements include competence assessment, certifica- The EU market for e-health, however, remains frag- tion requirements, specification of minimum training, mented with differences among member countries in and other conditions for the medical profession. Such their approach to IT adoption. There are also concerns regulations are likely to influence the ability of profes- about patient privacy, liability, and consumer safety, as sionals and establishments to supply health services to reflected in very stringent data protection directives and the EU from outside the region as well as the portability regulations, at the EU and national levels [4]. The EU’s ofrecognitionwithintheEU givencountry-specific Privacy Rule establishes regulations for the use and dis- requirements [11]. closure of Protected Health Information (PHI), which Another important issue which is pertinent to the refers to any information about health status, provision EU’s bilateral relations with non-member countries is of healthcare, or payment for healthcare that can be the exclusion of health services from the scope of the EU services directive. Notwithstanding initiatives to pro- linked to an individual. The EU’s General Directive on mote cross-border cooperation and to harmonize inter- Data Protection is based on the principles of legitimacy, nal systems in healthcare among member countries, the finality, transparency, proportionality, confidentiality and security, and control. This is supplemented by a Security latter retain their national legislation and regulatory fra- Rule which deals specifically with Electronic Protected meworks to address concerns of consumer safety, Chanda Globalization and Health 2011, 7:1 Page 4 of 13 http://www.globalizationandhealth.com/content/7/1/1 standards, and accountability. To some extent the failure the economy today. Total national healthcare spending to have a single services market in the health sector stood at 4.1 percent of GDP in 2007 and is projected to reflects the wide variety in funding and delivery double to 8 percent of GDP or $77 billion by 2012. The mechanisms that individual EU member states apply in industry has grown at about 13 per cent annually in their health care sectors and the extent to which compe- recent years and is expected to grow at 23 percent per tition between suppliers and insurers is admitted. This year over the next few years [13]. Growth has been has implications for the extent to which the EU can be mainly driven by rising incomes, growing propensities to considered as a single bloc by third countries which spend on healthcare, shift to lifestyle-related diseases, wish to export to this region and also the extent to and demographic factors. which the European Commission is in a position to The sector comprises many segments. Estimates and negotiate on behalf of the entire Union. The non-applic- projections for the individual segments show promising ability of the services directive to health care reflects a trends in several segments such as clinical trials, diag- deeper problem of incompatibility among member nostics, hospitals, medical devices, and health imaging. states. Hence, negotiations in this sector are likely to be Nevertheless, India’s healthcare sector falls well below difficult and a selective engagement with a few markets international benchmarks for physical infrastructure, within the EU may be more likely. manpower, and existing standards in comparable devel- There are numerous challenges facing the EU’s health- oping countries. It is estimated that investment of $78 care sector which have a bearing on its bilateral rela- billion is required in health infrastructure and an addi- tions with countries like India. In a comprehensive tional 800,000 physicians are required over the next 10 report, the European Observatory on Health pointed out years [14]. Considerable scaling up is required in the several issues facing the region’s healthcare systems, availability and quality of physical infrastructure and including ageing populations and pressures on health- human resources. care spending, limited human resources, the need to One of the most important aspects of India’s health- modernize and redesign national health services and care system is the significant role of the private sector, improve management of the healthcare system, rising which accounts for over 75 percent of India’stotal costs and unsustainable public health expenditures, long healthcare spending. Private players account for 75 per- waiting times, and the need to give patients greater cent of dispensaries, 80 percent of all qualified doctors, choice [12]. Such challenges potentially justify engage- and an estimated 95 percent of new hospital beds in ment through trade and collaborative arrangements recent years. Public health expenditure accounts for less within and outside the EU to alleviate these constraints. than 1 per cent of GDP. Government spending on For example, long waiting times have resulted in healthcare infrastructure (excluding land) is projected to increased pressure from patients in several EU countries rise only marginally, by 0.12 per cent of GDP and the to access services across borders. Sickness funds in private sector is expected to provide 88 per cent of some EU countries have contracted hospitals across investment requirements over the medium term [15]. borders to alleviate this pressure. In addition, there is However, private healthcare delivery is highly fragmen- demand for unauthorized and non-contracted care in ted with over 90 per cent of it being serviced by the other EU countries. In recent years, some EU countries unorganized sector according to a recent report, and have initiated reforms by undertaking quality assurance suffers from huge variation in quality and standards programs, providing guarantees of reduced local waiting [16]. The growing dominance of private providers is sig- times, facilitating intra-EU patient mobility and e-health, nificant for India’s bilateral engagement with the EU. It and initiating efforts to expand their health workforce, suggests that the discussions are likely to be and are but the problems still persist. Hence, there are opportu- already being led on the Indian side by the private sec- nities for providers in non-EU countries through tor directly through industry consultations and delega- outsourcing, medical value travel, movement of health tion visits to these markets as well as being channelled personnel, and educational and research partnerships, through the government, while the counterparts in the which could potentially alleviate these cost and accessi- EU are the governments and national health authorities. bility pressures. Regional agreements and collaboration The latter in turn suggests potential conflicts of interests could be used to facilitate such ties. and concerns given the public-private nature of these discussions. Overview of India’s health services sector: implications for The regulatory environment in India’s healthcare sec- bilateral relations tor also has a bearing on its relations with other coun- The Indian healthcare delivery market was estimated at tries. Regulations in several areas pertinent to trade relations, such as standards for medical establishments, US $34 billion and employed over four million people accreditation of medical professionals, and foreign direct in 2008, making it one of the largest service sectors in Chanda Globalization and Health 2011, 7:1 Page 5 of 13 http://www.globalizationandhealth.com/content/7/1/1 investment are still evolving. Standards are currently India’s cost advantage and the quality of its radiologists being introduced for medical establishments, such as the and specialized technical staff. Telehealth in these areas recently introduced accreditation program for secondary provides a means to address the shortage of physicians and tertiary hospitals by the National Accreditation in the respective segments in the importing countries. Board for Hospitals & Healthcare Providers (NABH) to Independent telemedicine providers, reputed hospitals, improve the quality of healthcare establishments in the and large Indian IT companies are currently providing telemedicine services to the US, Singapore, and several country, and which has also received international South and Central Asian countries. India is also an recognition by ISQua (International Society for Quality attractive market for healthcare business process out- in Health Care). Similar standards have been prescribed for Indian laboratories by the National Accreditation sourcing. Some reputed hospitals are partnering with Board for Laboratories to ensure compulsory registra- US companies for billing, documentation of clinical and tion of all clinical establishments and compliance with administrative records, coding of medical processes, and prescribed minimum standards, periodic inspections and insurance claims processing services. Outsourcing of inquiries, and cancellation of registration or penalties if pathology services to India is another emerging opportu- conditions are not met. These recent efforts to establish nity area for Indian diagnostic labs. regulatory frameworks and better governance mechan- India also has promising prospects in the area of med- isms for healthcare providers are significant as they have ical value travel (mode 2). The medical value travel mar- a bearing on India’s prospective discussions with other ket in India was estimated at $333 million in 2004 and countries on issues of mutual recognition of standards is projected to reach $2.2 billion by 2012 [17]. These and insurance portability. prospects are driven by India’s cost advantage, availabil- Certification of medical professionals is another ity of world-class hospitals, and push factors in client important issue that has a bearing on cross-border rela- markets. The cost of comparable treatment in India is tions. Although India has established regulations at the on average one-eighth to one-fifth of those in the West central and state levels for medicine, dentistry, and nur- and compares favourably with costs in other medical sing with rules for registration, practice, and enforce- value travel destinations such as Thailand [18]. How- ment of standards, there remain shortcomings. National ever, these exports remain constrained by lack of insur- level regulatory bodies and norms are lacking in areas ance portability and lack of accreditation of Indian such as paramedical services, standards and training healthcare providers by overseas health insurance trusts and private insurance companies. tend to be non-uniform across educational establish- Other segments where India is seeing growing oppor- ments within the country, and there are no mutual recognition agreements with developed countries for tunities are medical devices and clinical research and qualifications of healthcare professionals. Such issues are trials (in part facilitated by investments by overseas likely to feature importantly in any efforts to develop companies in India’s health services and health products bilateral relations with the EU in healthcare. market). Many foreign companies are entering the The globalization of India’s healthcare sector in recent Indian market through joint ventures and tie-ups in years has significance for India’s cross-border engage- medical devices production and testing, training, and ments in health services, including with the EU. Rapid research. Some foreign companies conduct the first sur- growth as well as the emergence of international quality geries in India after the approval of a medical device or private players in India’s healthcare sector has created surgical treatment by their home authorities. The clini- opportunities for trade, investment, and collaboration, cal research and trials segment has grown significantly cutting across all four GATS modes of delivery. Accord- with projected revenues of $1-2 billion by 2010 [19]. ing to secondary sources and discussions with industry Some Indian research labs and Contract Research Orga- experts, there are many existing and prospective oppor- nizations (CROs) provide sophisticated tests like mole- tunity segments for India to trade health services. With cular diagnostics for autoimmune disorders, cytogenetics regard to mode 1, India has prospects in many aspects and diseases related to abnormalities and also conduct of e-health, including teleradiology, telediagnostics, tele- bioequivalence studies. Some laboratories offer a wide pathology, intensive care (or remote monitoring via tele- menu of tests under one roof to foreign companies. ICU), ophthalmology (remote diagnosis of eye pro- Leading healthcare providers have received approval blems), dermatology (remote diagnosis of skin pro- from overseas authorities to conduct clinical trials, including fast-track clinical trials. blems), tele-psychiatry (using videoconferencing, TV India is also an established exporter of healthcare work- cameras, and microphones to connect patients and psy- ers including doctors, nurses, and technicians (mode 4). chiatrists for diagnosis, assessment, medication manage- ment and second opinions) and continuous online Although much of this movement has been in the form of remote monitoring. These prospects are driven by permanent migration, there are growing prospects for Chanda Globalization and Health 2011, 7:1 Page 6 of 13 http://www.globalizationandhealth.com/content/7/1/1 temporary movement of healthcare workers through insti- medico-legal expert. Semi-structured and customized tutional tie-ups with overseas establishments, to leverage discussion guides were used for all interviews. The find- India’s cost advantage and manpower availability and also ings were presented at stakeholder consultations orga- address the pressures of ageing populations and shortage nized in New Delhi and Bangalore in February 2008 and of healthcare workers in developed countries. Non-unifor- 2009, respectively, and were strongly validated by parti- mity of domestic standards of medical training, lack of cipants. Further insights were also obtained at these mutual recognition, and immigration restrictions, how- consultations and incorporated. Secondary research was used to gather background ever, constrain such prospects at present. information on health services in India and the EU to Methods understand key characteristics of this sector and their Thereislittleornoevidenceonthe current status of bearing on trade, investment, and collaboration opportu- trade and investment flows between India and specific nities between the two, as outlined in the preceding partner countries or regions such as the EU. The aca- background section, and to corroborate the interview demic literature on bilateral relations in health care findings. Several health and economic databases (OECD between India and specific countries is very limited, and Eurostat) were also searched. Secondary information mostly consisting of industry and consulting firm on India was primarily obtained from reports by indus- reports with focus on specific segments. try associations, international agencies, researchers, con- This study relies on primary research, supplemented sulting firms, and the popular media. The literature by secondary sources to understand the nature and search focused on the post 2000 period. extent of relations between India and the EU in health services. The primary survey consisted of 26 semi-struc- Results tured interviews of a variety of stakeholders, including This section provides an overview of the interview find- Indian health services firms, practitioners, government ings on the prospects and challenges concerning India- officials, and industry experts over the 2007-2008 per- EU relations in health services and the general factors iod. The interviews were conducted in person and over likely to shape this relationship. the phone. The cities of Bangalore, Delhi, Kolkata, and Mumbai where major health service providers are Overview of opportunities and constraints in the EU located were covered. The interviews indicated that bilateral commercial and The sample of healthcare establishments included lead- other relations in this sector are very limited at present, ing Indian hospitals, telemedicine firms, clinical and spe- also corroborated by the absence of data and studies in cialized research firms, business process outsourcing firms this regard. However, they also indicated several nascent in healthcare management, and medical equipment and and promising opportunity segments where bilateral technology firms. The practitioners covered include doc- engagement in the health sector could be developed. tors, researchers, radiologists, biotechnologists, and senior These were: management at health services firms. The segments and stakeholders were selected based on initial discussions 1. Telemedicine, most importantly teleradiology fol- with industry experts, other academics, and reading of sec- lowed by telediagnostics, telpathology, bioinfor- ondary literature which helped identify both existing and matics, and continual remote monitoring; prospective areas for India’s trade in health services, not 2. Clinical trials and research in India for EU-based only with the EU but more generally. The interviews then pharmaceutical companies and CROs; specifically addressed the opportunities and challenges 3. Medical transcriptions, revenue cycle manage- with respect to the EU. The aim of these discussions was ment, and other back-office support functions; to understand the range of services currently being pro- 4. Medical value travel, especially for elective and vided by Indian providers to EU-based clients, the oppor- out-of-pocket expenditures and alternative therapies tunities realized or perceived by them in the EU market, and treatments; and the main barriers to doing business with the EU, 5. Collaborative ventures between universities, hospi- including how the EU compared as a trading partner in tals, and research centres on medical education, this sector vies-a-vies other countries. research, training, staff deployment (especially In order to validate these findings and to get alternate nurses) and exchange, and product development perspectives, views were also solicited from representa- under establishment-establishment arrangements tives in Indian industry associations, economic counsel- and intergovernmental agreements lors of the German and French embassies and the European Commission, and experts at the British High Broadly, two issues emerged regarding opportunities. Commission based in New Delhi, and a UK-based First, respondents were generally more optimistic about Chanda Globalization and Health 2011, 7:1 Page 7 of 13 http://www.globalizationandhealth.com/content/7/1/1 expanding bilateral relations in non-intrusive areas and it is often the associated administrative processes in the those with minimal patient contact and interface, i.e., EU that create impediments as they are very cumber- the telemedicine, clinical trials and research, and back- some and time consuming, with approvals required office segments. Views were mixed regarding prospects from multiple institutions and regulatory authorities, in segments such as medical value travel or medical and compliance requirements at the EU and country staffing as these were seen as directly subject to public levels. The findings also highlighted the significance of social, linguistic, cultural, and perception-related factors perception and political, social, cultural factors that in shaping the prospects for India-EU relations in health would be difficult to overcome in the EU. services, given the human resource-intensive and custo- Second, the discussion revealed that markets of inter- est to Indian healthcare providers vary within the EU mer-service oriented nature of healthcare delivery. Both depending on the opportunity segment in question. In Indian and foreign respondents further highlighted regu- telemedicine, the UK’s National Health Service (NHS) latory, institutional, and infrastructural factors in India was identified as the main client market for telemedicine as constraining India’s exports of health services to the exports from India while in the clinical trials and EU market and the world market at large. research segment, Germany and the Scandinavian coun- Broadly, two general factors emerged as key to shap- tries were seen as important prospective markets due to ing India-EU relations in health services. The first was their pharmaceutical base, inclination towards research awareness. Most Indian respondents noted that Indian and development, and acknowledgment of Indian exper- healthcare providers have limited understanding about tise. In the area of personnel staffing and exchange, the the healthcare sector in most EU countries excepting UK (particularly the NHS) was identified as the main the UK’s NHS. Since each EU country has its own com- market, though potential was also perceived in the plex and evolved healthcare system, according to the English language-inclined countries of Scandinavia, Ger- respondents, this lack of awareness within the Indian many, and the Netherlands. In medical value travel, health provider community automatically constrains the apart from the UK, countries such as Germany, France, scope for providing healthcare services to the EU market and the Scandinavian countries were seen as potential at large. Likewise, Indian respondents also pointed out source markets given their inclination towards rehabili- that apart from the UK, there is limited awareness in tative and alternative treatments and tourist interest in the EU about the quality and capabilities of Indian India. In general, the UK was seen as the main market health services providers. The second factor that emerged as critical for shaping for language and culture-dependent areas and emerged bilateral relations in health care was linguistic, social, as the main market within the EU across almost all opportunity segments. and cultural affinity. Lack of such affinity between India The interviews also revealed a variety of constraints and most EU countries was seen as a major constraint faced by Indian healthcare providers in providing health to India’s delivery of healthcare and related services to services to the EU market. These pertained to regulation the EU market. Respondents noted that healthcare is a in EU Member States or at the EU-wide level, which highly personalized service where perceptions, attitudes, included: (1) restrictions on outsourcing certain kinds of and social and linguistic ties play an important role. health services to providers outside the EU territory; Thus, India’s prospects were perceived to be limited to (2) data protection and data exclusivity laws; (3) accredi- the UK market and a few EU countries that have Eng- tation and certification requirements for healthcare lish-speaking capabilities. establishments and compliance issues with international or EU standards and guidelines; (4) insurance portability Discussion restrictions and coverage issues; (5) recognition of This section provides a detailed discussion of the survey professional qualifications and registration requirements; findings for each of the identified opportunity segments. (6) immigration and visa regulations affecting mobility It highlights the existing status and prospects for bilat- of providers; and (7) national treatment restrictions and eral engagement in each segment and associated con- discriminatory treatment which put Indian healthcare straints in the EU and in India. providers onanunevenplaying fieldwith EU-based providers and undermined their market access vis-à-vis Prospects in Telemedicine competitor countries in the EU. The interviews with Indian and EU respondents high- However, respondents made a distinction between lighted telemedicine, especially tele-radiology as one of constraints and barriers, clearly accepting that some the most promising areas for expanding bilateral rela- regulations and requirements are warranted on public tions, the key driver being the shortage of qualified per- policy grounds such as protecting consumers, ensuring sons and the launching of e-health initiatives in several patient safety, and maintaining standards. In their view, EU countries. At present Indian firms do not provide Chanda Globalization and Health 2011, 7:1 Page 8 of 13 http://www.globalizationandhealth.com/content/7/1/1 telemedicine to the EU market as EU authorities do not build their image and credibility. Although secondary deem India to be a data secure country. Hence, they do data were not readily available to estimate the magni- not permit outsourcing of patient data to India for tele- tude of this business with the EU, experts who were medicine purposes. But discussions with management interviewed estimated that Indian companies were doing and practitioners at two leading Indian telemedicine only some $100 million worth of clinical trials work for establishments revealed that these data protection the EU compared to around $3 billion of work being restrictions are expected to be removed eventually by done by the Eastern European countries. the EU authorities once there is greater awareness of However, as in the case of telemedicine, the interviews Indian providers and their capabilities and the cost revealed that Indian companies are taking a long term advantages of outsourcing telemedicine become evident. view of the European market and plan to expand their This view was corroborated by secondary sources which business in the EU. Some Indian CROs are holding dis- indicated that several Trade Commissions from EU cussions with companies in the UK, Germany, and Italy. member countries have in recent years shown interest There has also been interest by Swedish, Danish, Ger- in outsourcing telemedicine work to India. man, and Finnish companies about conducting clinical The interviews further revealed that some Indian research and trials in India for faster turnaround. Some firms are taking a long-term perspective and are adopt- areas of interest for European companies are Phase I ing different strategies to circumvent these restrictions, and II studies on diabetes, oncology, neuropsychiatry, for example, by establishing subsidiaries and partner- gastroenterology, and stem cell research. Respondents ships within the EU in order to serve the EU market also noted that there are ongoing discussions with Eur- from within. Such commercial presence enables them to opean biopharma companies for proof of concept for bid for teleradiology contracts that are being outsourced new drugs. European countries with the strongest phar- by some EU governments as their European subsidiaries maceutical sectors, namely the UK and Germany, were are not subject to outsourcing restrictions on patient seen as the most important markets in the EU. Indian data. One leading Indian teleradiology firm confirmed firms also noted the scope for research in experimental that it has incorporated a subsidiary in the EU to therapies that could be conducted by Indian companies undertake such work from within the EU and is also or research centres in collaboration with European insti- investing in a dedicated section at its India office to tutions and universities and for potential partnerships cater to prospective clients in the EU and gain a first- between Indian and EU laboratories to get international mover advantage in that market. Another leading Indian certification for evaluation and testing. telemedicine provider has similarly used its overseas According to respondents, the driving force for presence in the UK to tap the emerging business in tel- expanding India-EU relations in the clinical trials and emedicine. It has a subcontract from a private consor- research segment would be the high drug development tium that has obtained a NHS contract for radiology costs, the limited patient pool, and slow recruitment reporting within the UK. The Indian firm has set up a rate of patients for clinical trials in the EU. It was noted local office in the UK staffed by Indian radiologists who that India is cost-effective for conducting clinical trials are sent from India on a rotational basis to do the given its huge population, diverse genetic pool, wide reporting work. range of diseases, drug-naïve population, trained medical However, Indian providers noted four major con- and technical manpower, and good hospitals for under- straints to providing telemedicine services for the EU, taking such trials. According to these respondents, namely, data protection regulations, lack of recognition Indian CROs can help EU-based pharmaceutical compa- of the qualifications of Indian providers, contractual nies lower their costs and the time to market drugs. issues, and perceptions regarding India as a healthcare Several constraints were also highlighted, though these provider. The key aspects of these barriers and how they were often seen as necessary regulations and not bar- affect telemedicine exports from India to the EU are riers per se. These constraints mostly pertained to data summarized in Table 1. exclusivity requirements, accreditation and certification requirements for laboratories and organizations con- Prospects in clinical research and trials ducting the trials, and contractual obligations. The inter- This segment, though nascent, was seen to be very pro- views also revealed perception-related barriers due to mising for expanding commercial relations and colla- the lack of awareness in the EU about India’s capability boration between India and the EU. Some Indian as a destination for clinical trials and research. There companies are conducting clinical trials for European were also concerns expressed by EU officials on ethical pharmaceutical companies. Some Indian CROs have set grounds. Table 2 summarizes the main constraints that emerged with regard to clinical trials and research, and up marketing offices in a few EU countries, while others their resulting implications for Indian companies. are acquiring companies in the EU and elsewhere to Chanda Globalization and Health 2011, 7:1 Page 9 of 13 http://www.globalizationandhealth.com/content/7/1/1 Table 1 Barriers affecting India’s Telemedicine Exports to the EU Constraint Features and Implications Data protection, privacy, and information � Bureaucratic EU data protection laws security issues [21] � Cumbersome database registration requirement with data protection authorities � Data on EU patients cannot be sent outside the EU unless legal basis for transfer, i.e., official adequacy finding to determine country has national laws to provide adequate level of data protection � India has not received adequacy determination from EU authorities, so needs to legalize data transfer � Lack of harmonization in data protection legislation among members creates additional compliance costs of security audits, fines, registration in signing contracts with clients in different EU member countries � Stringent national level legislations on data and information security and data privacy relating to disclosure and use of Protected Health Information create additional administrative, physical, technical, and organizational compliance costs (e.g., need to adopt information security standards along the lines of the British Standard for Information Security management, BS-7799) � Firms may need to set up commercial presence in EU and provide telemedicine from within EU to overcome the absence of data adequacy determination for Indian providers based in India Recognition and accreditation � Very expensive and time-consuming (as long as one year per provider) certification process requirements � Multiple levels of verification with various professional bodies � Stringent certification requirements for teleradiology companies and providers � Registration required with each country’s healthcare commission and concerned authorities � Compliance with EU directives on data protection, consumer safety, etc. � Indemnity/insurance requirement � Cumbersome evaluation and documentation requirements � Competence determination tests � Language requirements � Residency requirements � Requirement to appear in person for registration � Recertification, revalidation, re-licensure, regular appraisal requirements � Lack of harmonization within EU � Implicit discrimination against non-EU providers Contractual issues � Practical problems with malpractice insurance and liability policies in EU countries � Handling of breach of contract and jurisdictional issues in enforcing compliance � Costs imposed due to service line agreement clauses on prior consent, indemnity, non-disclosure, liability � Delays in executing contracts Perception, attitudes, and stakeholder � Resistance to electronic delivery of healthcare in EU resistance � Cultural and social barriers � Linguistic barriers, translation requirements for reports � Resistance from professional associations in EU due to concerns over employment losses Source: Based on interviews. Prospects in Medical Value Travel about the prospects for expanding medical value travel To date, India’s medical value travel exports are mostly from several EU countries, especially the UK, given the to developing countries in South Asia, Africa, and the latter’s colonial, linguistic, and social ties with India. Middle East. Interviews with practitioners and manage- This view was corroborated by secondary sources where ment at leading Indian hospitals indicated that there are according to a survey conducted by the Treatment very few medical value travellers from the EU to India. Abroad website in 2007, over 70,000 British citizens The latter are limited to out-of-pocket patients and elec- who travelled abroad for medical treatment noted India tive treatments. However, respondents were optimistic as a destination of choice [20]. Table 2 Constraints affecting clinical trials and research Problem Features and Implications Standards and Accreditation � Requirement to conform with client country guidelines often cumbersome � Accreditation of Indian labs required even if they conform to accepted global standards � Compliance costs of meeting documentation, audit, infrastructure, qualification, training requirements Norms for clinical trials � Stringent requirements for informed consent, transparency, adherence to prescribed norms Data Protection � India not perceived as data-secure � Data exclusivity contracts have to be signed � Detailed audits required � Costs of litigation Manpower mobility � Problems in getting visas for technical persons sent by Indian CROs to clients in EU– short duration, single entry Source: Based on interviews. Chanda Globalization and Health 2011, 7:1 Page 10 of 13 http://www.globalizationandhealth.com/content/7/1/1 Some Indian practitioners also cited prospects in cer- the importance of perception given the fact that medical tain countries of Eastern Europe, such as Poland, which value travel involves a close interface between the doc- face challenges in their healthcare system following their tor and the patient. In their view, attitudinal factors and transition from socialism. They pointed to possibilities India’s lack of credibility as a medical value travel desti- in the form of commercial presence by Indian hospitals nation is likely to remain a constraint to such exports to or tie-ups with institutions in these countries, given the the EU. Table 3 summarizes the main constraints to expanding medical value travel from the EU to India. latter’s need for affordable healthcare, lack of quality medical infrastructure, exodus of medical personnel to Western Europe following accession, and possible affi- Prospects for back-office support services nity to India due to good political relations in the past. One interesting opportunity segment that emerged from However, the general view was that developing and the in-depth discussions was back-office business pro- least developed countries rather than developed regions cess and support services in healthcare delivery and such as the EU would continue to be the main sources administration. The interviews highlighted the existence for medical value travellers to India. There was also gen- of such exports by Indian firms for the US market and erally much greater optimism among all respondents similar prospects for doing high-end, back-office work about the prospects in alternative medicine and thera- in healthcare for the EU market. pies given growing interest in the West for treatment of One specific activity that was cited was revenue cycle chronic disorders where allopathy fails to deliver. management, which involves taking patient bills and Respondents noted that India has the potential to pro- records for processing reimbursements from insurance vide various streams of alternative medicine, including companies. Respondents noted that such services involve panchkarma, ayurveda, unani, siddha, and homeopathy. specialized expertise and that Germany has recently This finding was corroborated by rough estimates pro- expressed an interest in outsourcing medical transcrip- vided by some respondents on the share of European tion as well as other IT-enabled services to India to over- patients seeking treatment at traditional allopathic ver- come its high costs and labour shortages in healthcare. sus alternative treatment facilities. The share of Eur- Another activity where Indian firms could provide spe- opean patients at alternative treatment facilities was cialized business process support services was medical over 50 percent in some cases while in all the traditional coding and analysis of patient charts to ease reimburse- corporate hospitals that were covered by this survey, this ment-related analysis by insurance companies. The inter- share was less than 10 percent. views highlighted the prospects for providing such The in-depth discussions also pointed out various fac- coding services to the EU for data analysis and diagnostic tors which limit and will probably continue to limit med- purposes, based on the European Procedural Terminol- ical value travel from the EU to India. These related to: ogy. However, the discussions also highlighted several constraints to India’s exports of back office health sup- (i) Restrictions on reimbursement of patients from port services to the EU, several of them common to the EU if travel to the exporting country exceeds a certain duration, effectively affecting India’s attrac- Table 3 Constraints to India’s Medical Value Travel tiveness as a medical destination; Exports to the EU (ii) The relatively low share of non-insured and out- Problem Features and Implications of-pocket paying patients in the EU that automati- Insurance portability � State insurance trusts and private insurance cally limits the pool of patients who would opt for regulations companies do not accept treatment in India for treatment in India; reimbursement � Flight time restrictions for UK patients (limited (iii) Dominance of the public sector as a provider of to 3 hours) for reimbursement from NHS insurance which creates problems of political accept- � Restrictions on reimbursement of alternative ability in allowing medical value travel to India and medicines and therapies for lack of scientific evidence and registration getting reimbursed by the national health insurance Growing competition � India at disadvantage relative to Eastern trusts in EU countries; European countries on qualification, e-health (iv) Lack of accreditation of Indian hospitals and the delivery, movement of persons, insurance lack of recognition of Indian medical qualifications portability which affect the scope for reimbursement for treat- Perceptions � Nationally sensitive issue, resistance to medical value travel by national health providers ment in India. � Cultural, social, linguistic perceptions about India In addition, respondents noted the role of linguistic, � Perceptions about India as a suitable destination for medical value travel cultural, and social differences in limiting India’smedi- cal value travel exports to the EU. They also stressed Source: Based on interviews. Chanda Globalization and Health 2011, 7:1 Page 11 of 13 http://www.globalizationandhealth.com/content/7/1/1 other opportunity segments. These constraints and their such as design and production of medical devices and implications are summarized in Table 4. testing of medical equipment. Companies such as Sie- mens and Philips in India for the design, production, Prospects for collaboration in training, research, and and testing of medical equipment, as a global delivery staffing centre, and as a market for such products. According to The interviews also indicated several areas for India-EU the respondents, the entry of large multinationals into collaboration in health services. Given the shortage of India in the medical devices segment as well as the emergence of world class corporate hospitals in India personnel in several EU countries, respondents noted where such tests can be carried out are likely to drive that India could export medical personnel on a tempor- ary basis to staff the national health systems of those these outsourcing possibilities. In this regard, the pre- countries, particularly for nursing and paramedical ser- sence of bilateral investment treaties (BITS) between vices. The UK was cited as the most important prospec- India and several EU member states (UK, France, Ger- tive market for deployment of health personnel. many, Austria, Belgium, Denmark, Italy, Sweden, Another potential area for collaboration, highlighted Poland, and Spain) could have a bearing on foreign by the interviews was medical education and training. direct investment and research and development related While the EU countries have thus far shown little inter- collaborations in the health care sector. est in entering India’s medical education segment, both But collaboration was once again seen to be con- Indian and EU respondents noted that there are possibi- strained by various factors. Linguistic differences and lities for collaboration through technical tie-ups, dual lack of mutual recognition constrain possibilities for degrees, and twinning programs, which could be com- staff exchange and deployment. Ethical regulations, liabi- bined with a period of deployment and practical training lity and compensation-related concerns, and lack of in the EU following coursework. Indian respondents also international standards for registration of medical highlighted the fact that since the EU has excellent hos- devices and technologies in India affect the scope for pitals with trained personnel and established processes development and testing services for medical equipment in subspecialty care, collaboration in post-graduate and devices. There was also a general view that the EU training would help raise Indian standards while also has not been open to collaboration with India in the addressing labour shortages in those countries. Danish healthcare sector. Table 5 highlights constraints affect- authorities have expressed interest in such collaboration. ing specific areas where there are India-EU collaboration EU companies engaged in the development and produc- prospects. tion of medical equipment and devices could potentially be part of this collaboration by partnering with aca- Constraints in India demic institutions and healthcare providers in India for The primary research also revealed the presence of research and development and training services. domestic constraints in India, which affect its exports of The interviews also indicated possibilities for colla- health services to the EU and also other developed boration in knowledge process outsourcing of specia- country markets. These pertained to the lack of domes- lized and technical services for the healthcare industry, tic regulatory frameworks or lack of enforcement of necessary regulations in India’s health sector, particu- larly with regard to standards and accreditation of estab- Table 4 Constrains to India’s provision of support lishments and health personnel. Table 6 summarizes the services in healthcare to the EU main constraints within India that were highlighted by Problem Features and Implications the interviews. Accreditation � Certification required by concerned regulatory bodies in various Table 5 Constraints to collaboration in healthcare segments (medical coding, analysis) � Additional requirements of between India and the EU continuing certification and Problem Features and Implications evaluation Political and social � Affect staffing and temporary movement of Data privacy and restrictions on � India is not empanelled as a data- sensitivities health personnel from India to EU countries international data transfer secure by EU authorities � Restricts scope for data transfer and Recognition of � Qualifications and experience of Indian health related outsourcing qualifications personnel not recognized in EU member � Compliance costs of meeting EU countries and individual countries’ data � Re-certification and registration requirements protection legislation impose additional costs on Indian doctors Limited scope of the EU � Resistance to outsourcing of back- Other regulatory � Regulatory differences between India and the office functions in the EU issues EU on ethics, liability, and production and testing Source: Based on interviews. Source: Based on interviews. Chanda Globalization and Health 2011, 7:1 Page 12 of 13 http://www.globalizationandhealth.com/content/7/1/1 Table 6 Domestic Constraints to India’s Health Services Exports to the EU Constraint Features and Implications Accreditation and � Absence of mutual recognition agreements with key markets, requiring Indian providers to undergo cumbersome standards certification and registration processes � Lack of recognition prevents Indian companies from drawing on overseas pool of medical manpower � Lack of standardization in medical and nursing training in India � No regulatory body in some areas (paramedics) � Authentication systems not perceived to be credible � Lack of international accreditation by most Indian healthcare establishments, preventing medical value travel, insurance portability, clinical trials outsourcing � Lack of registration, standardization and overseas recognition of alternative medicines and therapies � Lack of central laboratory accreditation that is recognized internationally (CAP) Legal and regulatory � Bureaucracy and delays in approval process for clinical trials framework � Delays in clearance for drug and sample shipments for testing � Multiple clearances required by CROs for undertaking clinical trials (from multiple Ministries) � Ethics approval process cumbersome as multiple committees involved � Absence of legislation in certain areas (movement of drugs within India, lack of procedural controls on use of medical devices) � Poor enforcement of registration for clinical trials � Slow regulatory clearances for bioequivalence studies � Lack of clarity in guidelines for biotechnology products � Jurisdictional issues about dispute resolution as lack of credible and efficient legal system in India � Gaps between India’s clinical trials legislation and that of EU countries (e.g., requirement for pharmaceutical person for issuing drugs in the EU, not in India) � Concerns over violation of ethics by Indian CROs Data protection � Concerns over possible breach of data confidentiality after data submission to Indian regulatory body � Lack of strict firewalls for data leakage, guidelines on data exclusivity lacking, not strictly enforced Insurance and litigation � Lack of insurance portability, public or private from EU (related to lack of recognition of Indian qualifications and establishments) � Malpractice liability issues: concerns over dispute resolution, jurisdiction, appropriate compensation � Absence of insurance in India in emerging areas: clinical trials requiring insurance abroad at high cost Other � VAT and service tax charged on services of consultants monitoring clinical trials and reporting to client (export-oriented services usually exempt from service tax) � Delays in getting multiple entry visas for consultants monitoring clinical trials, short duration visas typical � Delays in bringing certain medical devices into India affecting medical device testing, research-related outsourcing Source: Based on interviews. According to Indian and EU respondents, India needs trainees, research collaboration, cooperation on to adopt a variety of regulatory measures and to align standards and recognition issues, and launching of joint its own standards and regulations to international ones. programs and pilot projects between India and EU This would enable India to leverage its capabilities in countries. Some specific areas for joint initiatives could include: health services for exporting to and entering into colla- borative arrangements with EU member countries as well as other developed regions. � Institutional tie-ups to facilitate telemedicine and medical value travel Conclusions � Partnerships and affiliations among labs and Certain broad policy directions emerge from the find- research centres to facilitate work in the area of clin- ings of this survey. Given the exclusion of health ser- ical trials, and global recognition and certification of vices from the EU’s services directive, this is a Indian labs challenging sector to discuss in any trade agreement � Reciprocal health agreements with selected markets with the EU. Moreover, given the sensitivities associated in the EU, along the lines of the agreements some of with commercialization of health care, and the likely dif- these countries have with non-member nations for ficulties in addressing issues such as recognition, data treatments required during visits on emergency protection, or public attitudes in the EU in the short grounds term, a cross-cutting approach based on cooperation � Provisions to facilitate partnerships and collabora- might be more appropriate. Such collaboration would tion among medical education and research institu- need to be on a selective basis, between selected institu- tions in India and the EU tions on both sides, between India and specific countries � Pilot programs for staff deployment and exchange in the EU, and in selected opportunity segments. or medical value travel between select institutions India-EU cooperation in healthcare could involve on both sides, supported by collaborative programs institutional tie-ups, exchange of faculty, students, and in education, research, and training between selected Chanda Globalization and Health 2011, 7:1 Page 13 of 13 http://www.globalizationandhealth.com/content/7/1/1 Received: 1 October 2010 Accepted: 10 February 2011 prestigious hospitals, medical colleges, and centres in Published: 10 February 2011 India and the EU � Tie-ups between Indian hospitals/research centres References and EU companies such as Siemens and Philips that 1. Health expenditure and economy: [http://www.euractiv.com/en/health/ health-expenditure-economy/article-153271]. develop medical devices and equipment, for com- 2. Hawe E: Compendium of Health Statistics. Radcliffe Publishers. UK; 2008. mercial and academic reasons, also enabling Indian 3. OECD: Health at a Glance. Paris; 2007. companies, research centres, and labs to partner in 4. Eur-Lex: Directive 2000/31/EC of The European Parliament and of The Council of 8 June 2000 on certain legal aspects of information society the engineering and design services work for the services, in particular electronic commerce, in the Internal Market development of medical equipment (Directive on electronic commerce). Official Journal of the European Union, L 178/11 Brussels; 2000. 5. European Commission: Accelerating the Development of the E-Health Over time, the demonstrated outcomes of such Market in Europe. E-Health Taskforce Report Luxembourg Office; 2007. arrangements could provide the basis for expanding the 6. Eur-Lex: Directive 95/46/EC of the European Parliament and of The bilateral relationship to include more providers and Council of 24 October 1995 on the protection of individuals with regard to the processing of personal data and on the free movement of such more EU member countries, and to cover more com- data. Official Journal of the European Union, L 281/31 Brussels; 1995. mercially-oriented opportunities. Collaboration could 7. Johnson E: Data Protection Law in the European Union. The Federal also help address longer term goals such as mutual Lawyer Arlington, Virginia; 2007, 44-48. 8. Eur-Lex: Directive 2005/36/EC of The European Parliament and of The recognition and changing public perceptions in the EU. Council of 7 September 2005 on the Recognition of Professional For example, twinning programs, educational partner- Qualifications. Official Journal of the European Union, L 255/22 Brussels; ships, and affiliations between institutions on both sides 9. Eur-Lex: Medicine: Mutual Recognition of Qualifications. Official Journal of could help provide the basis for future discussions on the European Union Brussels; 2007, Council Directive 93/16/EEC of 5 April equivalence of qualifications and mutual recognition. 1993 to facilitate the free movement of doctors and the mutual Likewise, tie-ups in the area of telemedicine could pro- recognition of their diplomas, certificates and other evidence of formal qualifications. vide the basis for discussing the removal of outsourcing 10. Polak G: Labour Mobility of Medical Physicians in EU Countries. Hospital restrictions on patient data. Post Europe, 06/2007, 31 GIT VERLAG, Germany; 2007. In parallel, the discussions would also need to focus 11. Gerlinger T, Schmucker R: Transnational Migration of Health Professionals in the European Union. In Cadernos de Saude Publica. Volume 23. Rio De on streamlining administrative procedures in the EU Janeiro; 2007:(2):S184-S192. which act as impediments to Indian healthcare providers 12. Commission of the European Communities: Together for Health: A and to address specific issues such as data adequacy Strategic Approach for the EU 2008-13. White Paper Brussels; 2007. 13. Healthcare to become $77-bn sector in India by 2012: Report - in The determination for India by EU data protection authori- Economic Times. [http://economictimes.indiatimes.com/news/news-by- ties. Attention would also be required on domestic mea- industry/healthcare/biotech/healthcare/Healthcare-to-become-77-bn-sector- sures concerning standards and data protection for in-India-by-2012-Report/articleshow/5268848.cms]. 14. FICCI-Ernst and Young: Opportunities in Healthcare Destination India. India to effectively exploit its potential in health services New Delhi; 2007. exports, not only to the EU but more generally. It 15. Indian Brand Equity Foundation (IBEF): Going Global - India Inc. in the EU, would also be important to link India’s potential as an Executive Summary. Gurgaon; 2006 [http://www.ibef.org/download/ GoingGlobalIn_ExecutiveSummary.pdf]. exporter of health services to its potential as a consumer 16. Technopak: Healthcare Outlook. In Quarterly report. Volume 1. India; of health care, such as for medical devices, drugs, diag- 2007:17. nostic equipment, and as a market for foreign invest- 17. Gopalan, “India Emerging as International Medical Tourism Hub”: Health Watch. 2008 [http://www.medindia.net/news/healthwatch/India-Emerging- ment by EU companies and hence the win-win as-International-Medical Tourism-Hub-42144-1.htm]. possibilities. Greater awareness would also need to be 18. Economic and Social Commission for Asia and the Pacific: Medical created on both sides about the competencies in each Tourism, Asia’s Growth Industry. Medical Travel in Asia and the Pacific: Challenges and Opportunities. Bangkok; 2007 [http://www.unescap.org/ other’s markets. ESID/hds/lastestadd/MedicalTourismReport09.pdf]. 19. Thaindian News, “India a Popular Destination for Clinical Research”: Bangkok; 2008 [http://www.thaindian.com/newsportal/sci-tech/india-a- Acknowledgements popular-destination-for-clinical-research_10034246.html]. This study was funded by the Indian Council for Research on International 20. Business Standard: Britons oppose sending NHS patients to India. 2008, Economic Relations, New Delhi. Research assistance was provided by Sasidaran Gopalan. 21. Johnson E: Data Protection Law in the European Union. The Federal Lawyer Arlington, Virginia; 2007, 44-48. Authors’ contributions The author carried out the entire study. She conceived and designed the doi:10.1186/1744-8603-7-1 interviews and their customization for different respondents. She did the Cite this article as: Chanda: India-EU relations in health services: entire data collection, analysis, and interpretation of findings. She drafted the prospects and challenges. Globalization and Health 2011 7:1. entire manuscript and subsequent revisions. Competing interests The author declares that they have no competing interests. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Globalization and Health Springer Journals

India-EU relations in health services: prospects and challenges

Globalization and Health , Volume 7 (1) – Feb 10, 2011

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Springer Journals
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Copyright © 2011 by Chanda; licensee BioMed Central Ltd.
Subject
Medicine & Public Health; Public Health; Development Economics; Social Policy; Quality of Life Research; Epidemiology
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1744-8603
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10.1186/1744-8603-7-1
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21310041
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Abstract

Background: India and the EU are currently negotiating a Trade and Investment Agreement which also covers services. This paper examines the opportunities for and constraints to India-EU relations in health services in the context of this agreement, focusing on the EU as a market for India’s health services exports and collaboration. The paper provides an overview of key features of health services in the EU and India and their bearing on bilateral relations in this sector. Methods: Twenty six semi-structured, in-person, and telephonic interviews were conducted in 2007-2008 in four Indian cities. The respondents included management and practitioners in a variety of healthcare establishments, health sector representatives in Indian industry associations, health sector officials in the Indian government, and official representatives of selected EU countries and the European Commission based in New Delhi. Secondary sources were used to supplement and corroborate these findings. Results: The interviews revealed that India-EU relations in health services are currently very limited. However, several opportunity segments exist, namely: (i) Telemedicine; (ii) Clinical trials and research in India for EU-based pharmaceutical companies; (iii) Medical transcriptions and back office support; (iv) Medical value travel; and (v) Collaborative ventures in medical education, research, training, staff deployment, and product development. However, various factors constrain India’s exports to the EU. These include data protection regulations; recognition requirements; insurance portability restrictions; discriminatory conditions; and cultural, social, and perception-related barriers. The interviews also revealed several constraints in the Indian health care sector, including disparity in domestic standards and training, absence of clear guidelines and procedures, and inadequate infrastructure. Conclusions: The paper concludes that although there are several promising areas for India-EU relations in health services, it will be difficult to realize these opportunities given the pre-dominance of public healthcare delivery in the EU and sensitivities associated with commercializing healthcare. Hence, a gradual approach based on pilot initiatives and selective collaboration would be advisable initially, which could be expanded once there is demonstrated evidence on outcomes. Overall, the paper makes a contribution to the social science and health literature by adding to the limited primary evidence base on globalization and health, especially from a developing-developed country and regional perspective. Background foreign commercial presence takes place through invest- Health services have become increasingly globalized. ments in the healthcare sector (GATS mode 3); and They are traded through all four modes of services cross border movement of service providers involves the circulation of doctors and nurses among countries delivery as defined under the General Agreement on Trade Services (GATS). Cross-border supply of health- (GATS mode 4) The borderline between GATS modes care takes the form of electronic delivery of healthcare may, however, not always be clear or separable (as in across countries (GATS mode 1); consumption abroad the case of electronic transactions involving modes 1 takes the form of medical value travel (GATS mode 2); and 2) and all market segments may not be covered under the GATS. Globalization of health services has Correspondence: rupa@iimb.ernet.in been facilitated by advancements in information and Professor, Economics and Social Sciences Area, Indian Institute of communication technology, liberalization of foreign Management Bangalore, India © 2011 Chanda; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Chanda Globalization and Health 2011, 7:1 Page 2 of 13 http://www.globalizationandhealth.com/content/7/1/1 investment, greater international mobility of patients amounted to US $1.2 trillion in 2005, with France, and service providers, and demographic dynamics. As a Germany, and the UK constituting the three largest mar- result, today, health services are a subject of discussion kets. The public sector dominates healthcare delivery. in multilateral services negotiations. Public spending constituted 77 percent of total health- The health sector has also come under focus in bilat- care expenditures in 2005 for the EU-27 and close to 90 eral and regional trade and cooperation agreements. One percent in certain EU countries [2]. The large volume of such prospective accord is the India-European Union healthcare spending is indicative of this sector’sstrategic (EU) Trade and Investment Agreement (TIA) currently economic and social importance for the EU, which is under negotiation. The latter is India’s first agreement likely to influence bilateral relations with other countries with a major developed country bloc and extends beyond in this sector. The dominance of public spending in goods into services, investment, and several other issues. healthcare suggests that any bilateral discussions would This agreement could potentially facilitate India’sgrow- be influenced by public sector concerns. In this regard, it ing bilateral trade and investment relations with the EU is worth noting that although the EU has undertaken in services, including health services. ambitious commitments on hospital services in its 1993/ This paper examines the opportunities for and con- 94 GATS schedule, it has reduced the coverage of these straints to India-EU relations in health services. It identi- commitments under its Economic Partnership Agree- fies the various segments where there are opportunities ment with the CARIFORUM to “privately funded ser- for India to export health services to the EU and to colla- vices”, reflecting the sensitivity surrounding commitment borate with the EU. It also identifies numerous regulatory of publicly funded services in a trade agreement. State- and other constraints which impede the development of ments by the European Services Forum (ESF), which this bilateral relationship. The discussion is largely based represents the interests of private sector services entities on in-depth discussions with a variety of stakeholders in in the EU, similarly reflect the recognition of health and India’s health sector and official representatives from a few education services as special sectors where government EU countries, corroborated by secondary evidence. In plays an important role and that public health services doing so, the paper makes a useful contribution to the must not be challenged by trade negotiations. According social science and health literature by not only adding to to the ESF, countries should be free to determine if they the very limited information base available at present on wish to open up their health services sectors to foreign globalization and health, based on primary evidence, but providers. also by providing a North-South cum regional perspective. The EU Member States provide universal or near-uni- The paper has two main conclusions. The first is that versal public coverage for health as part of a wider sys- although India and the EU have very different health sys- tem of ‘social protection’.Thisisextendedtohealth tems in terms of public-private composition, regulatory services that are prescribed by health professionals or frameworks, and policy priorities, several factors make institutions registered with the health insurance system this sector conducive to expanding bilateral commercial or which figure on the country’s positive list of approved relations and collaboration between the two. The EU procedures, drugs, and medical devices. Private insur- member countries with their ageing populations, rising ance offering ‘supplementary’ cover accounts for a small costs, and overburdened public healthcare systems could part of total healthcare financing, extending to services benefit from expanded relations with a country like India such as dental or alternative treatment which are not with its growing private healthcare sector, emergence of covered by the statutory systems, and providing supple- world class corporate hospitals, large pool of medical mentary coverage for elective treatments. The domi- manpower, and young population across a variety of seg- nance of public insurance coverage has an important ments. The second conclusion is that given the nature of bearing on prospects for bilateral relations with non- many of the constraints currently affecting this bilateral member countries through modes such as medical value relationship and given the public good nature of health travel. It implies that issues of insurance coverage and services, it would be best to take a gradual approach to portability are likely to be important and that the scope expanding bilateral engagement in this sector, building for medical value travel would be shaped by the effi- on collaborative efforts selectively and over time moving ciency and availability of health care under public health towards more commercial engagements. systems in the EU, and limited to areas where patients spend out-of-pocket or have limited insurance coverage. Overview of the EU’s Health Services Sector: implications Within the EU, nationals can elect to get treated in for bilateral relations another member country for pre-approved procedures Healthcare is a vital and strategic sector in the EU. On or in cases of undue delay, if they carry a European Health Insurance Card (EHIC), also called the EU Medi- average, the EU spends close to 8 percent of its GDP on cal Card. The latter entitles its holders to receive health [1]. Total healthcare spending in the EU-27 Chanda Globalization and Health 2011, 7:1 Page 3 of 13 http://www.globalizationandhealth.com/content/7/1/1 treatment at reduced cost when visiting European Eco- Health Information (EPHI) and specifies three types of nomic Area (EEA) countries and authorizes reimburse- security safeguards required for administrative, physical, ment by the patient’s home country. It is important to and technical compliance, with security standards and note though that although the European Health Card specifications for each standard [5]. facilitates treatment within the EU, it is subject to One important aspect of the EU’s data protection restrictions. It does not entail treatment on the same directive pertains to data transfers to non-member countries [6,7]. It requires that Member States enact terms as those provided in the patient’s home country laws that prohibit transfer of personal data to countries and instead provides for treatment on the same terms as outside the EU which fail to ensure adequate privacy that provided to nationals of the host country. It also does not cover treatment for conditions existing before protection. The Data Protection Commissions and travel or treatment by private providers and few coun- Member States are required to inform each other in tries pay the full cost of treatment and travel insurance such cases. The data adequacy determination require- still remains necessary. ment and concerns over issues of data privacy and con- There is also an initiative to standardize health cards sumer protection have implications for cross-border across member countries by providing an interoperable electronic delivery of health services to the EU by non- format that would help a patient prove entitlement to member countries such as India and raise issues of level healthcare from different national health services or to playing field vis-à-vis member countries. medical insurance schemes in Member States. Such fra- Regulations concerning standards and eligibility meworks have implications for medical value travel pro- requirements for healthcare providers in the EU are also spects with non-EU countries versus EU member likely to affect bilateral relations in health services with countries. Issues of level playing field between members non member countries. There are requirements pertain- and non-members are likely to feature in the EU’s ing to registration, language certification, and insurance health services negotiations. coverage, as well as compliance requirements with EU- Another important aspect of the EU’s healthcare sys- wide as well as national-level legislation in areas such as tem is the role of IT in healthcare delivery. The e-health telemedicine, clinical trials and research activities. industry in the EU was estimated at US $27.7 billion in Health professionals are regulated at the level of Mem- 2006. Europe could potentially account for one-third of ber States and, to some extent, at the EU level [8]. the global health ICT industry of US $66-79 billion [3]. There are two broad regimes for recognition of qualifi- cations in the EU: (a) the sectoral system, based on Although the extent of IT integration in healthcare common minimum training standards defined in rele- delivery varies across EU member countries, there is a general push in this direction due to ageing populations, vant sectoral directives which lead to automatic recogni- rising operational costs, and the need to improve service tion of the diploma; and (b) the “general system”,which access and quality. Several member countries have may require a case-by-case evaluation of the diploma by launched e-health initiatives. The adoption of IT in national authorities with the option to impose compen- healthcare has implications for cross-border delivery of sation measures [9]. Dentists, medical doctors, midwives, healthcare services to EU member countries, from nurses, pharmacists and veterinarians are covered by the within the region and outside, in areas such as telera- sectoral system; all other health professionals are cov- diology, telediagnostics, medical coding, transcriptions, ered by the general system [10]. These recognition and back-office support functions. requirements include competence assessment, certifica- The EU market for e-health, however, remains frag- tion requirements, specification of minimum training, mented with differences among member countries in and other conditions for the medical profession. Such their approach to IT adoption. There are also concerns regulations are likely to influence the ability of profes- about patient privacy, liability, and consumer safety, as sionals and establishments to supply health services to reflected in very stringent data protection directives and the EU from outside the region as well as the portability regulations, at the EU and national levels [4]. The EU’s ofrecognitionwithintheEU givencountry-specific Privacy Rule establishes regulations for the use and dis- requirements [11]. closure of Protected Health Information (PHI), which Another important issue which is pertinent to the refers to any information about health status, provision EU’s bilateral relations with non-member countries is of healthcare, or payment for healthcare that can be the exclusion of health services from the scope of the EU services directive. Notwithstanding initiatives to pro- linked to an individual. The EU’s General Directive on mote cross-border cooperation and to harmonize inter- Data Protection is based on the principles of legitimacy, nal systems in healthcare among member countries, the finality, transparency, proportionality, confidentiality and security, and control. This is supplemented by a Security latter retain their national legislation and regulatory fra- Rule which deals specifically with Electronic Protected meworks to address concerns of consumer safety, Chanda Globalization and Health 2011, 7:1 Page 4 of 13 http://www.globalizationandhealth.com/content/7/1/1 standards, and accountability. To some extent the failure the economy today. Total national healthcare spending to have a single services market in the health sector stood at 4.1 percent of GDP in 2007 and is projected to reflects the wide variety in funding and delivery double to 8 percent of GDP or $77 billion by 2012. The mechanisms that individual EU member states apply in industry has grown at about 13 per cent annually in their health care sectors and the extent to which compe- recent years and is expected to grow at 23 percent per tition between suppliers and insurers is admitted. This year over the next few years [13]. Growth has been has implications for the extent to which the EU can be mainly driven by rising incomes, growing propensities to considered as a single bloc by third countries which spend on healthcare, shift to lifestyle-related diseases, wish to export to this region and also the extent to and demographic factors. which the European Commission is in a position to The sector comprises many segments. Estimates and negotiate on behalf of the entire Union. The non-applic- projections for the individual segments show promising ability of the services directive to health care reflects a trends in several segments such as clinical trials, diag- deeper problem of incompatibility among member nostics, hospitals, medical devices, and health imaging. states. Hence, negotiations in this sector are likely to be Nevertheless, India’s healthcare sector falls well below difficult and a selective engagement with a few markets international benchmarks for physical infrastructure, within the EU may be more likely. manpower, and existing standards in comparable devel- There are numerous challenges facing the EU’s health- oping countries. It is estimated that investment of $78 care sector which have a bearing on its bilateral rela- billion is required in health infrastructure and an addi- tions with countries like India. In a comprehensive tional 800,000 physicians are required over the next 10 report, the European Observatory on Health pointed out years [14]. Considerable scaling up is required in the several issues facing the region’s healthcare systems, availability and quality of physical infrastructure and including ageing populations and pressures on health- human resources. care spending, limited human resources, the need to One of the most important aspects of India’s health- modernize and redesign national health services and care system is the significant role of the private sector, improve management of the healthcare system, rising which accounts for over 75 percent of India’stotal costs and unsustainable public health expenditures, long healthcare spending. Private players account for 75 per- waiting times, and the need to give patients greater cent of dispensaries, 80 percent of all qualified doctors, choice [12]. Such challenges potentially justify engage- and an estimated 95 percent of new hospital beds in ment through trade and collaborative arrangements recent years. Public health expenditure accounts for less within and outside the EU to alleviate these constraints. than 1 per cent of GDP. Government spending on For example, long waiting times have resulted in healthcare infrastructure (excluding land) is projected to increased pressure from patients in several EU countries rise only marginally, by 0.12 per cent of GDP and the to access services across borders. Sickness funds in private sector is expected to provide 88 per cent of some EU countries have contracted hospitals across investment requirements over the medium term [15]. borders to alleviate this pressure. In addition, there is However, private healthcare delivery is highly fragmen- demand for unauthorized and non-contracted care in ted with over 90 per cent of it being serviced by the other EU countries. In recent years, some EU countries unorganized sector according to a recent report, and have initiated reforms by undertaking quality assurance suffers from huge variation in quality and standards programs, providing guarantees of reduced local waiting [16]. The growing dominance of private providers is sig- times, facilitating intra-EU patient mobility and e-health, nificant for India’s bilateral engagement with the EU. It and initiating efforts to expand their health workforce, suggests that the discussions are likely to be and are but the problems still persist. Hence, there are opportu- already being led on the Indian side by the private sec- nities for providers in non-EU countries through tor directly through industry consultations and delega- outsourcing, medical value travel, movement of health tion visits to these markets as well as being channelled personnel, and educational and research partnerships, through the government, while the counterparts in the which could potentially alleviate these cost and accessi- EU are the governments and national health authorities. bility pressures. Regional agreements and collaboration The latter in turn suggests potential conflicts of interests could be used to facilitate such ties. and concerns given the public-private nature of these discussions. Overview of India’s health services sector: implications for The regulatory environment in India’s healthcare sec- bilateral relations tor also has a bearing on its relations with other coun- The Indian healthcare delivery market was estimated at tries. Regulations in several areas pertinent to trade relations, such as standards for medical establishments, US $34 billion and employed over four million people accreditation of medical professionals, and foreign direct in 2008, making it one of the largest service sectors in Chanda Globalization and Health 2011, 7:1 Page 5 of 13 http://www.globalizationandhealth.com/content/7/1/1 investment are still evolving. Standards are currently India’s cost advantage and the quality of its radiologists being introduced for medical establishments, such as the and specialized technical staff. Telehealth in these areas recently introduced accreditation program for secondary provides a means to address the shortage of physicians and tertiary hospitals by the National Accreditation in the respective segments in the importing countries. Board for Hospitals & Healthcare Providers (NABH) to Independent telemedicine providers, reputed hospitals, improve the quality of healthcare establishments in the and large Indian IT companies are currently providing telemedicine services to the US, Singapore, and several country, and which has also received international South and Central Asian countries. India is also an recognition by ISQua (International Society for Quality attractive market for healthcare business process out- in Health Care). Similar standards have been prescribed for Indian laboratories by the National Accreditation sourcing. Some reputed hospitals are partnering with Board for Laboratories to ensure compulsory registra- US companies for billing, documentation of clinical and tion of all clinical establishments and compliance with administrative records, coding of medical processes, and prescribed minimum standards, periodic inspections and insurance claims processing services. Outsourcing of inquiries, and cancellation of registration or penalties if pathology services to India is another emerging opportu- conditions are not met. These recent efforts to establish nity area for Indian diagnostic labs. regulatory frameworks and better governance mechan- India also has promising prospects in the area of med- isms for healthcare providers are significant as they have ical value travel (mode 2). The medical value travel mar- a bearing on India’s prospective discussions with other ket in India was estimated at $333 million in 2004 and countries on issues of mutual recognition of standards is projected to reach $2.2 billion by 2012 [17]. These and insurance portability. prospects are driven by India’s cost advantage, availabil- Certification of medical professionals is another ity of world-class hospitals, and push factors in client important issue that has a bearing on cross-border rela- markets. The cost of comparable treatment in India is tions. Although India has established regulations at the on average one-eighth to one-fifth of those in the West central and state levels for medicine, dentistry, and nur- and compares favourably with costs in other medical sing with rules for registration, practice, and enforce- value travel destinations such as Thailand [18]. How- ment of standards, there remain shortcomings. National ever, these exports remain constrained by lack of insur- level regulatory bodies and norms are lacking in areas ance portability and lack of accreditation of Indian such as paramedical services, standards and training healthcare providers by overseas health insurance trusts and private insurance companies. tend to be non-uniform across educational establish- Other segments where India is seeing growing oppor- ments within the country, and there are no mutual recognition agreements with developed countries for tunities are medical devices and clinical research and qualifications of healthcare professionals. Such issues are trials (in part facilitated by investments by overseas likely to feature importantly in any efforts to develop companies in India’s health services and health products bilateral relations with the EU in healthcare. market). Many foreign companies are entering the The globalization of India’s healthcare sector in recent Indian market through joint ventures and tie-ups in years has significance for India’s cross-border engage- medical devices production and testing, training, and ments in health services, including with the EU. Rapid research. Some foreign companies conduct the first sur- growth as well as the emergence of international quality geries in India after the approval of a medical device or private players in India’s healthcare sector has created surgical treatment by their home authorities. The clini- opportunities for trade, investment, and collaboration, cal research and trials segment has grown significantly cutting across all four GATS modes of delivery. Accord- with projected revenues of $1-2 billion by 2010 [19]. ing to secondary sources and discussions with industry Some Indian research labs and Contract Research Orga- experts, there are many existing and prospective oppor- nizations (CROs) provide sophisticated tests like mole- tunity segments for India to trade health services. With cular diagnostics for autoimmune disorders, cytogenetics regard to mode 1, India has prospects in many aspects and diseases related to abnormalities and also conduct of e-health, including teleradiology, telediagnostics, tele- bioequivalence studies. Some laboratories offer a wide pathology, intensive care (or remote monitoring via tele- menu of tests under one roof to foreign companies. ICU), ophthalmology (remote diagnosis of eye pro- Leading healthcare providers have received approval blems), dermatology (remote diagnosis of skin pro- from overseas authorities to conduct clinical trials, including fast-track clinical trials. blems), tele-psychiatry (using videoconferencing, TV India is also an established exporter of healthcare work- cameras, and microphones to connect patients and psy- ers including doctors, nurses, and technicians (mode 4). chiatrists for diagnosis, assessment, medication manage- ment and second opinions) and continuous online Although much of this movement has been in the form of remote monitoring. These prospects are driven by permanent migration, there are growing prospects for Chanda Globalization and Health 2011, 7:1 Page 6 of 13 http://www.globalizationandhealth.com/content/7/1/1 temporary movement of healthcare workers through insti- medico-legal expert. Semi-structured and customized tutional tie-ups with overseas establishments, to leverage discussion guides were used for all interviews. The find- India’s cost advantage and manpower availability and also ings were presented at stakeholder consultations orga- address the pressures of ageing populations and shortage nized in New Delhi and Bangalore in February 2008 and of healthcare workers in developed countries. Non-unifor- 2009, respectively, and were strongly validated by parti- mity of domestic standards of medical training, lack of cipants. Further insights were also obtained at these mutual recognition, and immigration restrictions, how- consultations and incorporated. Secondary research was used to gather background ever, constrain such prospects at present. information on health services in India and the EU to Methods understand key characteristics of this sector and their Thereislittleornoevidenceonthe current status of bearing on trade, investment, and collaboration opportu- trade and investment flows between India and specific nities between the two, as outlined in the preceding partner countries or regions such as the EU. The aca- background section, and to corroborate the interview demic literature on bilateral relations in health care findings. Several health and economic databases (OECD between India and specific countries is very limited, and Eurostat) were also searched. Secondary information mostly consisting of industry and consulting firm on India was primarily obtained from reports by indus- reports with focus on specific segments. try associations, international agencies, researchers, con- This study relies on primary research, supplemented sulting firms, and the popular media. The literature by secondary sources to understand the nature and search focused on the post 2000 period. extent of relations between India and the EU in health services. The primary survey consisted of 26 semi-struc- Results tured interviews of a variety of stakeholders, including This section provides an overview of the interview find- Indian health services firms, practitioners, government ings on the prospects and challenges concerning India- officials, and industry experts over the 2007-2008 per- EU relations in health services and the general factors iod. The interviews were conducted in person and over likely to shape this relationship. the phone. The cities of Bangalore, Delhi, Kolkata, and Mumbai where major health service providers are Overview of opportunities and constraints in the EU located were covered. The interviews indicated that bilateral commercial and The sample of healthcare establishments included lead- other relations in this sector are very limited at present, ing Indian hospitals, telemedicine firms, clinical and spe- also corroborated by the absence of data and studies in cialized research firms, business process outsourcing firms this regard. However, they also indicated several nascent in healthcare management, and medical equipment and and promising opportunity segments where bilateral technology firms. The practitioners covered include doc- engagement in the health sector could be developed. tors, researchers, radiologists, biotechnologists, and senior These were: management at health services firms. The segments and stakeholders were selected based on initial discussions 1. Telemedicine, most importantly teleradiology fol- with industry experts, other academics, and reading of sec- lowed by telediagnostics, telpathology, bioinfor- ondary literature which helped identify both existing and matics, and continual remote monitoring; prospective areas for India’s trade in health services, not 2. Clinical trials and research in India for EU-based only with the EU but more generally. The interviews then pharmaceutical companies and CROs; specifically addressed the opportunities and challenges 3. Medical transcriptions, revenue cycle manage- with respect to the EU. The aim of these discussions was ment, and other back-office support functions; to understand the range of services currently being pro- 4. Medical value travel, especially for elective and vided by Indian providers to EU-based clients, the oppor- out-of-pocket expenditures and alternative therapies tunities realized or perceived by them in the EU market, and treatments; and the main barriers to doing business with the EU, 5. Collaborative ventures between universities, hospi- including how the EU compared as a trading partner in tals, and research centres on medical education, this sector vies-a-vies other countries. research, training, staff deployment (especially In order to validate these findings and to get alternate nurses) and exchange, and product development perspectives, views were also solicited from representa- under establishment-establishment arrangements tives in Indian industry associations, economic counsel- and intergovernmental agreements lors of the German and French embassies and the European Commission, and experts at the British High Broadly, two issues emerged regarding opportunities. Commission based in New Delhi, and a UK-based First, respondents were generally more optimistic about Chanda Globalization and Health 2011, 7:1 Page 7 of 13 http://www.globalizationandhealth.com/content/7/1/1 expanding bilateral relations in non-intrusive areas and it is often the associated administrative processes in the those with minimal patient contact and interface, i.e., EU that create impediments as they are very cumber- the telemedicine, clinical trials and research, and back- some and time consuming, with approvals required office segments. Views were mixed regarding prospects from multiple institutions and regulatory authorities, in segments such as medical value travel or medical and compliance requirements at the EU and country staffing as these were seen as directly subject to public levels. The findings also highlighted the significance of social, linguistic, cultural, and perception-related factors perception and political, social, cultural factors that in shaping the prospects for India-EU relations in health would be difficult to overcome in the EU. services, given the human resource-intensive and custo- Second, the discussion revealed that markets of inter- est to Indian healthcare providers vary within the EU mer-service oriented nature of healthcare delivery. Both depending on the opportunity segment in question. In Indian and foreign respondents further highlighted regu- telemedicine, the UK’s National Health Service (NHS) latory, institutional, and infrastructural factors in India was identified as the main client market for telemedicine as constraining India’s exports of health services to the exports from India while in the clinical trials and EU market and the world market at large. research segment, Germany and the Scandinavian coun- Broadly, two general factors emerged as key to shap- tries were seen as important prospective markets due to ing India-EU relations in health services. The first was their pharmaceutical base, inclination towards research awareness. Most Indian respondents noted that Indian and development, and acknowledgment of Indian exper- healthcare providers have limited understanding about tise. In the area of personnel staffing and exchange, the the healthcare sector in most EU countries excepting UK (particularly the NHS) was identified as the main the UK’s NHS. Since each EU country has its own com- market, though potential was also perceived in the plex and evolved healthcare system, according to the English language-inclined countries of Scandinavia, Ger- respondents, this lack of awareness within the Indian many, and the Netherlands. In medical value travel, health provider community automatically constrains the apart from the UK, countries such as Germany, France, scope for providing healthcare services to the EU market and the Scandinavian countries were seen as potential at large. Likewise, Indian respondents also pointed out source markets given their inclination towards rehabili- that apart from the UK, there is limited awareness in tative and alternative treatments and tourist interest in the EU about the quality and capabilities of Indian India. In general, the UK was seen as the main market health services providers. The second factor that emerged as critical for shaping for language and culture-dependent areas and emerged bilateral relations in health care was linguistic, social, as the main market within the EU across almost all opportunity segments. and cultural affinity. Lack of such affinity between India The interviews also revealed a variety of constraints and most EU countries was seen as a major constraint faced by Indian healthcare providers in providing health to India’s delivery of healthcare and related services to services to the EU market. These pertained to regulation the EU market. Respondents noted that healthcare is a in EU Member States or at the EU-wide level, which highly personalized service where perceptions, attitudes, included: (1) restrictions on outsourcing certain kinds of and social and linguistic ties play an important role. health services to providers outside the EU territory; Thus, India’s prospects were perceived to be limited to (2) data protection and data exclusivity laws; (3) accredi- the UK market and a few EU countries that have Eng- tation and certification requirements for healthcare lish-speaking capabilities. establishments and compliance issues with international or EU standards and guidelines; (4) insurance portability Discussion restrictions and coverage issues; (5) recognition of This section provides a detailed discussion of the survey professional qualifications and registration requirements; findings for each of the identified opportunity segments. (6) immigration and visa regulations affecting mobility It highlights the existing status and prospects for bilat- of providers; and (7) national treatment restrictions and eral engagement in each segment and associated con- discriminatory treatment which put Indian healthcare straints in the EU and in India. providers onanunevenplaying fieldwith EU-based providers and undermined their market access vis-à-vis Prospects in Telemedicine competitor countries in the EU. The interviews with Indian and EU respondents high- However, respondents made a distinction between lighted telemedicine, especially tele-radiology as one of constraints and barriers, clearly accepting that some the most promising areas for expanding bilateral rela- regulations and requirements are warranted on public tions, the key driver being the shortage of qualified per- policy grounds such as protecting consumers, ensuring sons and the launching of e-health initiatives in several patient safety, and maintaining standards. In their view, EU countries. At present Indian firms do not provide Chanda Globalization and Health 2011, 7:1 Page 8 of 13 http://www.globalizationandhealth.com/content/7/1/1 telemedicine to the EU market as EU authorities do not build their image and credibility. Although secondary deem India to be a data secure country. Hence, they do data were not readily available to estimate the magni- not permit outsourcing of patient data to India for tele- tude of this business with the EU, experts who were medicine purposes. But discussions with management interviewed estimated that Indian companies were doing and practitioners at two leading Indian telemedicine only some $100 million worth of clinical trials work for establishments revealed that these data protection the EU compared to around $3 billion of work being restrictions are expected to be removed eventually by done by the Eastern European countries. the EU authorities once there is greater awareness of However, as in the case of telemedicine, the interviews Indian providers and their capabilities and the cost revealed that Indian companies are taking a long term advantages of outsourcing telemedicine become evident. view of the European market and plan to expand their This view was corroborated by secondary sources which business in the EU. Some Indian CROs are holding dis- indicated that several Trade Commissions from EU cussions with companies in the UK, Germany, and Italy. member countries have in recent years shown interest There has also been interest by Swedish, Danish, Ger- in outsourcing telemedicine work to India. man, and Finnish companies about conducting clinical The interviews further revealed that some Indian research and trials in India for faster turnaround. Some firms are taking a long-term perspective and are adopt- areas of interest for European companies are Phase I ing different strategies to circumvent these restrictions, and II studies on diabetes, oncology, neuropsychiatry, for example, by establishing subsidiaries and partner- gastroenterology, and stem cell research. Respondents ships within the EU in order to serve the EU market also noted that there are ongoing discussions with Eur- from within. Such commercial presence enables them to opean biopharma companies for proof of concept for bid for teleradiology contracts that are being outsourced new drugs. European countries with the strongest phar- by some EU governments as their European subsidiaries maceutical sectors, namely the UK and Germany, were are not subject to outsourcing restrictions on patient seen as the most important markets in the EU. Indian data. One leading Indian teleradiology firm confirmed firms also noted the scope for research in experimental that it has incorporated a subsidiary in the EU to therapies that could be conducted by Indian companies undertake such work from within the EU and is also or research centres in collaboration with European insti- investing in a dedicated section at its India office to tutions and universities and for potential partnerships cater to prospective clients in the EU and gain a first- between Indian and EU laboratories to get international mover advantage in that market. Another leading Indian certification for evaluation and testing. telemedicine provider has similarly used its overseas According to respondents, the driving force for presence in the UK to tap the emerging business in tel- expanding India-EU relations in the clinical trials and emedicine. It has a subcontract from a private consor- research segment would be the high drug development tium that has obtained a NHS contract for radiology costs, the limited patient pool, and slow recruitment reporting within the UK. The Indian firm has set up a rate of patients for clinical trials in the EU. It was noted local office in the UK staffed by Indian radiologists who that India is cost-effective for conducting clinical trials are sent from India on a rotational basis to do the given its huge population, diverse genetic pool, wide reporting work. range of diseases, drug-naïve population, trained medical However, Indian providers noted four major con- and technical manpower, and good hospitals for under- straints to providing telemedicine services for the EU, taking such trials. According to these respondents, namely, data protection regulations, lack of recognition Indian CROs can help EU-based pharmaceutical compa- of the qualifications of Indian providers, contractual nies lower their costs and the time to market drugs. issues, and perceptions regarding India as a healthcare Several constraints were also highlighted, though these provider. The key aspects of these barriers and how they were often seen as necessary regulations and not bar- affect telemedicine exports from India to the EU are riers per se. These constraints mostly pertained to data summarized in Table 1. exclusivity requirements, accreditation and certification requirements for laboratories and organizations con- Prospects in clinical research and trials ducting the trials, and contractual obligations. The inter- This segment, though nascent, was seen to be very pro- views also revealed perception-related barriers due to mising for expanding commercial relations and colla- the lack of awareness in the EU about India’s capability boration between India and the EU. Some Indian as a destination for clinical trials and research. There companies are conducting clinical trials for European were also concerns expressed by EU officials on ethical pharmaceutical companies. Some Indian CROs have set grounds. Table 2 summarizes the main constraints that emerged with regard to clinical trials and research, and up marketing offices in a few EU countries, while others their resulting implications for Indian companies. are acquiring companies in the EU and elsewhere to Chanda Globalization and Health 2011, 7:1 Page 9 of 13 http://www.globalizationandhealth.com/content/7/1/1 Table 1 Barriers affecting India’s Telemedicine Exports to the EU Constraint Features and Implications Data protection, privacy, and information � Bureaucratic EU data protection laws security issues [21] � Cumbersome database registration requirement with data protection authorities � Data on EU patients cannot be sent outside the EU unless legal basis for transfer, i.e., official adequacy finding to determine country has national laws to provide adequate level of data protection � India has not received adequacy determination from EU authorities, so needs to legalize data transfer � Lack of harmonization in data protection legislation among members creates additional compliance costs of security audits, fines, registration in signing contracts with clients in different EU member countries � Stringent national level legislations on data and information security and data privacy relating to disclosure and use of Protected Health Information create additional administrative, physical, technical, and organizational compliance costs (e.g., need to adopt information security standards along the lines of the British Standard for Information Security management, BS-7799) � Firms may need to set up commercial presence in EU and provide telemedicine from within EU to overcome the absence of data adequacy determination for Indian providers based in India Recognition and accreditation � Very expensive and time-consuming (as long as one year per provider) certification process requirements � Multiple levels of verification with various professional bodies � Stringent certification requirements for teleradiology companies and providers � Registration required with each country’s healthcare commission and concerned authorities � Compliance with EU directives on data protection, consumer safety, etc. � Indemnity/insurance requirement � Cumbersome evaluation and documentation requirements � Competence determination tests � Language requirements � Residency requirements � Requirement to appear in person for registration � Recertification, revalidation, re-licensure, regular appraisal requirements � Lack of harmonization within EU � Implicit discrimination against non-EU providers Contractual issues � Practical problems with malpractice insurance and liability policies in EU countries � Handling of breach of contract and jurisdictional issues in enforcing compliance � Costs imposed due to service line agreement clauses on prior consent, indemnity, non-disclosure, liability � Delays in executing contracts Perception, attitudes, and stakeholder � Resistance to electronic delivery of healthcare in EU resistance � Cultural and social barriers � Linguistic barriers, translation requirements for reports � Resistance from professional associations in EU due to concerns over employment losses Source: Based on interviews. Prospects in Medical Value Travel about the prospects for expanding medical value travel To date, India’s medical value travel exports are mostly from several EU countries, especially the UK, given the to developing countries in South Asia, Africa, and the latter’s colonial, linguistic, and social ties with India. Middle East. Interviews with practitioners and manage- This view was corroborated by secondary sources where ment at leading Indian hospitals indicated that there are according to a survey conducted by the Treatment very few medical value travellers from the EU to India. Abroad website in 2007, over 70,000 British citizens The latter are limited to out-of-pocket patients and elec- who travelled abroad for medical treatment noted India tive treatments. However, respondents were optimistic as a destination of choice [20]. Table 2 Constraints affecting clinical trials and research Problem Features and Implications Standards and Accreditation � Requirement to conform with client country guidelines often cumbersome � Accreditation of Indian labs required even if they conform to accepted global standards � Compliance costs of meeting documentation, audit, infrastructure, qualification, training requirements Norms for clinical trials � Stringent requirements for informed consent, transparency, adherence to prescribed norms Data Protection � India not perceived as data-secure � Data exclusivity contracts have to be signed � Detailed audits required � Costs of litigation Manpower mobility � Problems in getting visas for technical persons sent by Indian CROs to clients in EU– short duration, single entry Source: Based on interviews. Chanda Globalization and Health 2011, 7:1 Page 10 of 13 http://www.globalizationandhealth.com/content/7/1/1 Some Indian practitioners also cited prospects in cer- the importance of perception given the fact that medical tain countries of Eastern Europe, such as Poland, which value travel involves a close interface between the doc- face challenges in their healthcare system following their tor and the patient. In their view, attitudinal factors and transition from socialism. They pointed to possibilities India’s lack of credibility as a medical value travel desti- in the form of commercial presence by Indian hospitals nation is likely to remain a constraint to such exports to or tie-ups with institutions in these countries, given the the EU. Table 3 summarizes the main constraints to expanding medical value travel from the EU to India. latter’s need for affordable healthcare, lack of quality medical infrastructure, exodus of medical personnel to Western Europe following accession, and possible affi- Prospects for back-office support services nity to India due to good political relations in the past. One interesting opportunity segment that emerged from However, the general view was that developing and the in-depth discussions was back-office business pro- least developed countries rather than developed regions cess and support services in healthcare delivery and such as the EU would continue to be the main sources administration. The interviews highlighted the existence for medical value travellers to India. There was also gen- of such exports by Indian firms for the US market and erally much greater optimism among all respondents similar prospects for doing high-end, back-office work about the prospects in alternative medicine and thera- in healthcare for the EU market. pies given growing interest in the West for treatment of One specific activity that was cited was revenue cycle chronic disorders where allopathy fails to deliver. management, which involves taking patient bills and Respondents noted that India has the potential to pro- records for processing reimbursements from insurance vide various streams of alternative medicine, including companies. Respondents noted that such services involve panchkarma, ayurveda, unani, siddha, and homeopathy. specialized expertise and that Germany has recently This finding was corroborated by rough estimates pro- expressed an interest in outsourcing medical transcrip- vided by some respondents on the share of European tion as well as other IT-enabled services to India to over- patients seeking treatment at traditional allopathic ver- come its high costs and labour shortages in healthcare. sus alternative treatment facilities. The share of Eur- Another activity where Indian firms could provide spe- opean patients at alternative treatment facilities was cialized business process support services was medical over 50 percent in some cases while in all the traditional coding and analysis of patient charts to ease reimburse- corporate hospitals that were covered by this survey, this ment-related analysis by insurance companies. The inter- share was less than 10 percent. views highlighted the prospects for providing such The in-depth discussions also pointed out various fac- coding services to the EU for data analysis and diagnostic tors which limit and will probably continue to limit med- purposes, based on the European Procedural Terminol- ical value travel from the EU to India. These related to: ogy. However, the discussions also highlighted several constraints to India’s exports of back office health sup- (i) Restrictions on reimbursement of patients from port services to the EU, several of them common to the EU if travel to the exporting country exceeds a certain duration, effectively affecting India’s attrac- Table 3 Constraints to India’s Medical Value Travel tiveness as a medical destination; Exports to the EU (ii) The relatively low share of non-insured and out- Problem Features and Implications of-pocket paying patients in the EU that automati- Insurance portability � State insurance trusts and private insurance cally limits the pool of patients who would opt for regulations companies do not accept treatment in India for treatment in India; reimbursement � Flight time restrictions for UK patients (limited (iii) Dominance of the public sector as a provider of to 3 hours) for reimbursement from NHS insurance which creates problems of political accept- � Restrictions on reimbursement of alternative ability in allowing medical value travel to India and medicines and therapies for lack of scientific evidence and registration getting reimbursed by the national health insurance Growing competition � India at disadvantage relative to Eastern trusts in EU countries; European countries on qualification, e-health (iv) Lack of accreditation of Indian hospitals and the delivery, movement of persons, insurance lack of recognition of Indian medical qualifications portability which affect the scope for reimbursement for treat- Perceptions � Nationally sensitive issue, resistance to medical value travel by national health providers ment in India. � Cultural, social, linguistic perceptions about India In addition, respondents noted the role of linguistic, � Perceptions about India as a suitable destination for medical value travel cultural, and social differences in limiting India’smedi- cal value travel exports to the EU. They also stressed Source: Based on interviews. Chanda Globalization and Health 2011, 7:1 Page 11 of 13 http://www.globalizationandhealth.com/content/7/1/1 other opportunity segments. These constraints and their such as design and production of medical devices and implications are summarized in Table 4. testing of medical equipment. Companies such as Sie- mens and Philips in India for the design, production, Prospects for collaboration in training, research, and and testing of medical equipment, as a global delivery staffing centre, and as a market for such products. According to The interviews also indicated several areas for India-EU the respondents, the entry of large multinationals into collaboration in health services. Given the shortage of India in the medical devices segment as well as the emergence of world class corporate hospitals in India personnel in several EU countries, respondents noted where such tests can be carried out are likely to drive that India could export medical personnel on a tempor- ary basis to staff the national health systems of those these outsourcing possibilities. In this regard, the pre- countries, particularly for nursing and paramedical ser- sence of bilateral investment treaties (BITS) between vices. The UK was cited as the most important prospec- India and several EU member states (UK, France, Ger- tive market for deployment of health personnel. many, Austria, Belgium, Denmark, Italy, Sweden, Another potential area for collaboration, highlighted Poland, and Spain) could have a bearing on foreign by the interviews was medical education and training. direct investment and research and development related While the EU countries have thus far shown little inter- collaborations in the health care sector. est in entering India’s medical education segment, both But collaboration was once again seen to be con- Indian and EU respondents noted that there are possibi- strained by various factors. Linguistic differences and lities for collaboration through technical tie-ups, dual lack of mutual recognition constrain possibilities for degrees, and twinning programs, which could be com- staff exchange and deployment. Ethical regulations, liabi- bined with a period of deployment and practical training lity and compensation-related concerns, and lack of in the EU following coursework. Indian respondents also international standards for registration of medical highlighted the fact that since the EU has excellent hos- devices and technologies in India affect the scope for pitals with trained personnel and established processes development and testing services for medical equipment in subspecialty care, collaboration in post-graduate and devices. There was also a general view that the EU training would help raise Indian standards while also has not been open to collaboration with India in the addressing labour shortages in those countries. Danish healthcare sector. Table 5 highlights constraints affect- authorities have expressed interest in such collaboration. ing specific areas where there are India-EU collaboration EU companies engaged in the development and produc- prospects. tion of medical equipment and devices could potentially be part of this collaboration by partnering with aca- Constraints in India demic institutions and healthcare providers in India for The primary research also revealed the presence of research and development and training services. domestic constraints in India, which affect its exports of The interviews also indicated possibilities for colla- health services to the EU and also other developed boration in knowledge process outsourcing of specia- country markets. These pertained to the lack of domes- lized and technical services for the healthcare industry, tic regulatory frameworks or lack of enforcement of necessary regulations in India’s health sector, particu- larly with regard to standards and accreditation of estab- Table 4 Constrains to India’s provision of support lishments and health personnel. Table 6 summarizes the services in healthcare to the EU main constraints within India that were highlighted by Problem Features and Implications the interviews. Accreditation � Certification required by concerned regulatory bodies in various Table 5 Constraints to collaboration in healthcare segments (medical coding, analysis) � Additional requirements of between India and the EU continuing certification and Problem Features and Implications evaluation Political and social � Affect staffing and temporary movement of Data privacy and restrictions on � India is not empanelled as a data- sensitivities health personnel from India to EU countries international data transfer secure by EU authorities � Restricts scope for data transfer and Recognition of � Qualifications and experience of Indian health related outsourcing qualifications personnel not recognized in EU member � Compliance costs of meeting EU countries and individual countries’ data � Re-certification and registration requirements protection legislation impose additional costs on Indian doctors Limited scope of the EU � Resistance to outsourcing of back- Other regulatory � Regulatory differences between India and the office functions in the EU issues EU on ethics, liability, and production and testing Source: Based on interviews. Source: Based on interviews. Chanda Globalization and Health 2011, 7:1 Page 12 of 13 http://www.globalizationandhealth.com/content/7/1/1 Table 6 Domestic Constraints to India’s Health Services Exports to the EU Constraint Features and Implications Accreditation and � Absence of mutual recognition agreements with key markets, requiring Indian providers to undergo cumbersome standards certification and registration processes � Lack of recognition prevents Indian companies from drawing on overseas pool of medical manpower � Lack of standardization in medical and nursing training in India � No regulatory body in some areas (paramedics) � Authentication systems not perceived to be credible � Lack of international accreditation by most Indian healthcare establishments, preventing medical value travel, insurance portability, clinical trials outsourcing � Lack of registration, standardization and overseas recognition of alternative medicines and therapies � Lack of central laboratory accreditation that is recognized internationally (CAP) Legal and regulatory � Bureaucracy and delays in approval process for clinical trials framework � Delays in clearance for drug and sample shipments for testing � Multiple clearances required by CROs for undertaking clinical trials (from multiple Ministries) � Ethics approval process cumbersome as multiple committees involved � Absence of legislation in certain areas (movement of drugs within India, lack of procedural controls on use of medical devices) � Poor enforcement of registration for clinical trials � Slow regulatory clearances for bioequivalence studies � Lack of clarity in guidelines for biotechnology products � Jurisdictional issues about dispute resolution as lack of credible and efficient legal system in India � Gaps between India’s clinical trials legislation and that of EU countries (e.g., requirement for pharmaceutical person for issuing drugs in the EU, not in India) � Concerns over violation of ethics by Indian CROs Data protection � Concerns over possible breach of data confidentiality after data submission to Indian regulatory body � Lack of strict firewalls for data leakage, guidelines on data exclusivity lacking, not strictly enforced Insurance and litigation � Lack of insurance portability, public or private from EU (related to lack of recognition of Indian qualifications and establishments) � Malpractice liability issues: concerns over dispute resolution, jurisdiction, appropriate compensation � Absence of insurance in India in emerging areas: clinical trials requiring insurance abroad at high cost Other � VAT and service tax charged on services of consultants monitoring clinical trials and reporting to client (export-oriented services usually exempt from service tax) � Delays in getting multiple entry visas for consultants monitoring clinical trials, short duration visas typical � Delays in bringing certain medical devices into India affecting medical device testing, research-related outsourcing Source: Based on interviews. According to Indian and EU respondents, India needs trainees, research collaboration, cooperation on to adopt a variety of regulatory measures and to align standards and recognition issues, and launching of joint its own standards and regulations to international ones. programs and pilot projects between India and EU This would enable India to leverage its capabilities in countries. Some specific areas for joint initiatives could include: health services for exporting to and entering into colla- borative arrangements with EU member countries as well as other developed regions. � Institutional tie-ups to facilitate telemedicine and medical value travel Conclusions � Partnerships and affiliations among labs and Certain broad policy directions emerge from the find- research centres to facilitate work in the area of clin- ings of this survey. Given the exclusion of health ser- ical trials, and global recognition and certification of vices from the EU’s services directive, this is a Indian labs challenging sector to discuss in any trade agreement � Reciprocal health agreements with selected markets with the EU. Moreover, given the sensitivities associated in the EU, along the lines of the agreements some of with commercialization of health care, and the likely dif- these countries have with non-member nations for ficulties in addressing issues such as recognition, data treatments required during visits on emergency protection, or public attitudes in the EU in the short grounds term, a cross-cutting approach based on cooperation � Provisions to facilitate partnerships and collabora- might be more appropriate. Such collaboration would tion among medical education and research institu- need to be on a selective basis, between selected institu- tions in India and the EU tions on both sides, between India and specific countries � Pilot programs for staff deployment and exchange in the EU, and in selected opportunity segments. or medical value travel between select institutions India-EU cooperation in healthcare could involve on both sides, supported by collaborative programs institutional tie-ups, exchange of faculty, students, and in education, research, and training between selected Chanda Globalization and Health 2011, 7:1 Page 13 of 13 http://www.globalizationandhealth.com/content/7/1/1 Received: 1 October 2010 Accepted: 10 February 2011 prestigious hospitals, medical colleges, and centres in Published: 10 February 2011 India and the EU � Tie-ups between Indian hospitals/research centres References and EU companies such as Siemens and Philips that 1. 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She did the Cite this article as: Chanda: India-EU relations in health services: entire data collection, analysis, and interpretation of findings. She drafted the prospects and challenges. Globalization and Health 2011 7:1. entire manuscript and subsequent revisions. Competing interests The author declares that they have no competing interests.

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