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Trade in Health Services
Country Experiences with GATS and Trade in Health Services
Report on cross-border trade (Mode 1) - Findings from Indian e-Health Study
A. Didar Singh, Expert ICTs, Trade & Health
Inter-regional Workshop on Trade and HealthNew Delhi, October 12-13, 2004
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AGENDA
• MODE 1 – e-Health
• PROCESS & METHODOLOGY
• FINDINGS OF THE STUDY
• ANALYSIS OF INDIA’S E-HEALTH ENVIRONMENT
• LESSONS
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Working definition of e-Health
• Telemedicine and e-Health services over the Internet (Mode 1 – cross-border)
• Public Health services over the Internet (e-Government)
• E-Commerce and e-Business practices used for Health management and health systems
Types of transactions• P2C (Provider to Client) (B2C)
• P2P (Provider to Provider) (B2B)
• G2C (Govt. to Client) (eGovernment)
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Mode 1 Health Services
• Direct Healthcare services:– Diagnostic and Testing facilities, advisory,
health information, health data mining, Internet monitoring services etc.
• Indirect Health-related services– Medical transcription, medical insurance and
claim processing, health system MIS and back-office services, training and advocacy etc.
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The Process
• Prepare a Framework for Country Studies• Select Country (India)• Set up Expert Group• Select/Appoint National Consultant (AHSL)• Carry out Research based on Framework• Semi-structured Interviews and questionnaires• Monitor, review and finalise study• Establish Task Group to carry forward
initiative
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Framework for eHealth Readiness Survey
Framework for a situational analysis (2001)
• 4 KEYS DETERMINANTS– Infrastructural Framework– Policy and strategy framework– Legal and regulatory framework– Human resource framework
Together they create the
E-Health Business & Trade environment
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Country Study Mandate for INDIA
With reference to Mode 1 Services in Cross Border Trade in Healthcare:
• Study the existing e-health environment based on Framework
• Analyse the competitiveness of this environment
• Suggest strategies to strengthen competitiveness
• Suggest the stance India should take in the WTO negotiations
• Profile healthcare websites and e-Health services
• Develop a list of key people in Indian e-healthcare for networking in future
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AGENDA
• E-HEALTH
• PROJECT METHODOLOGY
• FINDINGS OF THE STUDY
• ANALYSIS OF INDIA’S E-HEALTH ENVIRONMENT
• LESSONS
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PROJECT METHODOLOGY (I)
INTERVIEWS• Over 20 personal interviews
were conducted
RESEARCHINTERNET• Close to 70 websites were
profiled
QUESTIONNAIRES• 90 Questionnaires were
sent to multiple stakeholders, categorized into 5 sections
PUBLICATIONS•multiple national and international reports and studies referred to
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PROJECT METHODOLOGY (II)
Cities covered Industries covered• Hospitals• Business Process Outsourcing
• Billing• Coding• Medical Transcription• Claims Processing
• Clinical Research• Infrastructure• Consultants and Industry Experts• Healthcare Portals • Academics• Government (relevant ministries &
bodies)• Government Affiliates and
Organisations
• Delhi• Hyderabad• Bangalore• Trivandrum• Pune
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PROJECT METHODOLOGY (III)
• Infrastructure Framework• Policy and Strategy• Legal and Regulatory Framework• Human Resource Framework• Cross Border Trade
Participants were questioned & interviewed along the following lines
Objective of the Project
Tim
e
Data Collection
FeedbackResponse
Analysis& SWOT
RecommendStance
E-Health Business, another section of the framework, was covered across these 5 sections
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AGENDA
• E-HEALTH
• PROJECT METHODOLOGY
• FINDINGS OF THE STUDY– INFRASTRUCTURE FRAMEWORK– LEGAL AND REGULATORY FRAMEWORK– HUMAN RESOURCE FRAMEWORK– POLICY AND STRATEGY– CROSS BORDER TRADE
• ANALYSIS OF INDIA’S EHEALTH ENVIRONMENT
• LESSONS
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FINDINGS OF THE STUDY: INFRASTRUCTURE
•High quality infrastructure is one of the most important pre-requisites for fostering the growth of the e-health industry as this has significant impact on success
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FINDINGS OF THE STUDY: INFRASTRUCTURE
Government should emphasise on Infrastructure Development
83%
17%
0%YesNoNo Comment
Government should emphasise on Infrastructure Development
83%
17%
0%YesNoNo Comment
Insufficient infrastructure
No Quality Incubators to promote Entrepreneurship.
We need more biotech facilities like IISC
Government should facilitate Conducive
Infrastructure
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FINDINGS OF THE STUDY: INFRASTRUCTURE - TECHNOLOGY
Technology Barriers Hinder Cross Border Trade Progress
0%
13%
87%
YesNoNo Comment
Need broadband and sufficient Internet bandwidth
Cost of Internet Access should come downOutdated Applications and
lack of interoperabilityacross different platforms
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AGENDA
• EHEALTH
• PROJECT METHODOLOGY
• FINDINGS OF THE STUDY– INFRASTRUCTURE FRAMEWORK– LEGAL AND REGULATORY FRAMEWORK– HUMAN RESOURCE FRAMEWORK– POLICY AND STRATEGY– CROSS BORDER TRADE
• ANALYSIS OF INDIA’S EHEALTH ENVIRONMENT
• LESSONS
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FINDINGS OF THE STUDY: LEGAL ENVIRONMENT
• Information Technology Act, 2000 and certification agencies in
place
•However Indian Legal framework still not mature and robust
enough to support cross border trade in e-health services.
•No specific laws to protect the privacy and confidentiality of health
information. Serious threat to healthcare companies outsourcing
their work to India
•Awareness of country specific healthcare regulations such as
HIPAA is very low
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FINDINGS OF THE STUDYLEGAL & REGULATORY FRAMEWORK - BARRIERS
No effective legal framework exists for cross border trade
Existing Frame work is ineffective
26%
0%
74%
YesNoNo Comment ITES companies are
registered under the Shops and Establishments act,
which does not provide for any regulations of privacy
and confidentiality of health information. Legal framework for Mode 1 health
services is not clear. In some cases, rules have not yet been framed. E.g. E-Learning, MT, Billing, Coding, Telemedicine etc
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FINDINGS OF THE STUDY: LEGAL - HIPAA
HIPAA Awareness in India will help
13%0%
87%
Yes
No
No Comment
HIPAA awareness is low. More education
and awareness is Required
More and more healthcare companies in the US will comply with HIPAA in the future. This will require more documentation and administrative work for all the incumbents, leading to more outsourcing. At the same time it will become imperative for Indian vendors to comply with HIPAA, if not they could lose business soon. If they do, it will reduce their profitability by having to follow stringent standards
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AGENDA
• E-HEALTH
• PROJECT METHODOLOGY
• FINDINGS OF THE STUDY– INFRASTRUCTURE FRAMEWORK– LEGAL AND REGULATORY FRAMEWORK– HUMAN RESOURCE FRAMEWORK– POLICY AND STRATEGY– CROSS BORDER TRADE
• ANALYSIS OF INDIA’S EHEALTH ENVIRONMENT
• LESONS
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FINDINGS OF THE STUDY: HUMAN RESOURCES ENVIRONMENT
•Domain knowledge of healthcare administration and financing lacking in workforce (significant amount of healthcare BPO work is healthcare administration)
•Supply of healthcare professionals is not in sync with the demand
•Acceptance of Indian healthcare qualifications in developed countries is limited
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FINDINGS OF THE STUDY: HUMAN RESOURCES
Change in Educational Pattern in India Required
39%
0%
61%
Yes
NoNo Comment
Emphasis on ITES Educational Programs
26%
0%
74%
Yes
No
No Comment
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FINDINGS OF STUDY: HUMAN RESOURCES – BPO EMPLOYMENT
Service Segments EmploymentCustomer Interaction Services 33800Data entry & conversion, Finance & Accounting & HR services 35,000Transcription / Translation services 5200Content development, Animation, Engineering and Design/ GIS 30,000Other Services: Remote education, Data Search, Market Research, Network Consultancy & Management
3,000
Total 107,000
Employment of the BPO Industry,
ESC1999 & NASSCOM, 2002
Employment of the BPO Industry,
ESC1999 & NASSCOM, 2002
NASSCOM: National Association of Software and Services Companies
2000 2005Customer interaction centers 3,000 102,000Medical transcription 6,000 45,000Financial & Accounting services 2,000 15,000Medical billing & collection 350 2,500Insurance claims processing 2,500 5,000Pre-press and digital pre-media 11,000 45,000Geographic Information Systems 5,500 13,000Distance learning 1 7,000HR services 6,000Litigation support services 200 2,000Total 30,551 242,500
EmploymentService Segments
Employment of the BPO Industry
Estimates for eHealth:
Over 25,000 by 2002
Employment of the BPO Industry
Estimates for eHealth:
Over 25,000 by 2002
ESC - Electronics & Computer Software Exports Promotions Council
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AGENDA
• EHEALTH
• PROJECT METHODOLOGY
• FINDINGS OF THE STUDY– INFRASTRUCTURE FRAMEWORK– LEGAL AND REGULATORY FRAMEWORK– HUMAN RESOURCE FRAMEWORK– POLICY AND STRATEGY– CROSS BORDER TRADE
• ANALYSIS OF INDIA’S EHEALTH ENVIRONMENT
• LESSONS
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FINDINGS OF STUDY: POLICY & STRATEGY
•The government has taken some initiatives to promote cross border trade, but appears to be lack of full commitment
•There are no specific strategies for cross border trade in e-health services, however many initiatives have been taken in supporting industry segments such as Telecom & Information Technology
•There is a strong opinion that the industry should be involved more in policy making
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FINDINGS OF THE STUDY: POLICY & STRATEGY
Industry Associations should be Actively Involved
83%
0%17%
YesNoNo Comment
E-Health Policies should be Promoted
0%13%
87%
YesNoNo Comment
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AGENDA
• E-HEALTH
• PROJECT METHODOLOGY
• FINDINGS OF THE STUDY– INFRASTRUCTURE FRAMEWORK– LEGAL AND REGULATORY FRAMEWORK– HUMAN RESOURCE FRAMEWORK– POLICY AND STRATEGY– CROSS BORDER TRADE
• ANALYSIS OF INDIA’S EHEALTH ENVIRONMENT
• LESSONS
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FINDINGS OF THE STUDY: CROSS BORDER TRADE
•There has been a tremendous growth in cross border trade of e-health services, mostly from exports to USA
•Estimated that this industry has crossed $ 200 Million mark, and generated employment for close to 25,000 people so far
•There is no agency monitoring the performance of this industry therefore hard data is lacking.
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FINDINGS OF THE STUDY: CROSS BORDER TRADE
2000 2005Customer interaction centers 60 2250Medical transcription 28-30 800Financial & Accounting services 50 375Medical billing & collection 3 75Insurance claims processing 13 30Pre-press and digital pre-media 45 200Geographic Information Systems - 50Distance learning 60 150HR services - 115Litigation support services 3 27Total 264 4,072
Service Segments Revenue ($ US Million)
Revenue of the BPO Industry Estimates by ESC , 2000Revenue of the BPO Industry Estimates by ESC , 2000
ESC - Electronics & Computer Software Exports Promotions Council
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AGENDA
• E-HEALTH
• PROJECT METHODOLOGY
• FINDINGS OF THE STUDY
• ANALYSIS OF INDIA’S EHEALTH ENVIRONMENT– IMPORT & EXPORT OF TRADE IN E-HEALTH SERVICES
– COMPETITIVENESS OF INDIA’S E-HEALTH ENVIRONMENT
• LESSONS
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IMPORT & EXPORT OF TRADE IN E-HEALTH SERVICES – EXPORTS The picture below shows the services that are already being exported and the potential services that could be offered by Indian e-health services companies
Medical Coding
Medical Billing & Collection
Insurance claims processing
E-Learning
Healthcare customer services
Medical Transcription
Established
Contract Research
Telemedicine
Clinical TrialsOpportunities emergingDisease Management
Healthcare Knowledge Management
Electronic Medical Records Management
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AGENDA
• OUR MANDATE
• PROJECT METHODOLOGY
• FINDINGS OF THE STUDY
• ANALYSIS OF INDIA’S EHEALTH ENVIRONMENT– IMPORT & EXPORT OF TRADE IN E-HEALTH SERVICES
– COMPETITIVE ANALYSIS OF INDIA’S E-HEALTH ENVIRONMENT
• LESSONS
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COMPETITIVENESS OF INDIA’S E-HEALTH ENVIRONMENT -STRENGTHS
• Manpower – English speaking, highly qualified and techno savvy people
• Safe Electronic Environment – Official recognition for Digital Signatures and E-Transactions
• Lower costs of human capital when compared to developed countries
• Strong and buoyant domestic healthcare industry
• Hotbed for alternative medicine –Ayurveda, Unani, etc.
• Indian medical qualifications not recognised globally
• Poor domain skills• Lack of international marketing
capabilities• Immature legal framework• Inadequate infrastructure
• HIPAA compliance for Indian service providers
• Too much dependence on the USA• Backlash against outsourcing in USA• Competition from other countries who are
also strong in Technology, Modern & Alternative medicines. Ex - China
• Interlinkages between different Modes of GATS
• HIPAA compliance of US service providers
• Growing eHealth business• Remote Monitoring and Disease
Management etc.
WeaknessesStrengths
Threats Opportunities
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AGENDA
• OUR MANDATE
• PROJECT METHODOLOGY
• FINDINGS OF THE STUDY
• ANALYSIS OF INDIA’S EHEALTH ENVIRONMENT
• LESSONS
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LESSONS AND ISSUES IN THE RESEARCH
Challenge and achievement during study
•Low response to mailed questionnaires; most responses collated from interviews
•Low level of GATS awareness amongst respondents. Many did not comment due to lack of information on the topic
•In many cases awareness building and explanatory prelude necessary before eliciting response
•Many respondents gave the Private player perspective while a balanced viewpoint needed for both private and public players
Bottom-line: ANALYTICAL FRAMEWORK WAS A SUCCESS
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LESSONS Contd.
Key considerations and potential
• With Mode 1 of health service delivery, there exists an overlap with most other modes.
• Example of overlap between Mode 1 & Mode 3: A foreign healthcare entity setting up back office in India. Service delivery is categorised under mode 1 and commercial presence is categorised under mode 3.
• Mode 2 availing service abroad could be eHealth
• Medical qualification issue of Mode I applies to Mode 4 also..etc.
Overlapping of Modes Exports dominant perspective• Most of the responses focused on the export of e-health services, there were very few mentions of importing e-health services
• Recommendations need however to consider both the aspects of cross border e-health services
• Potential of Mode 1 for trade interest and health provisioning very strong
