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Project on Medical Tourism Industry

Introduction

Medical tourism in India
After the silicon rush India is now considered as the golden spot for treating patients mostly from the developed countries and far east for ailments and procedures of relatively high cost and complexity. India is also aggressively promoting medical tourism in the current years -and slowly now it is moving into a new area of "medical outsourcing," where subcontractors provide services to the overburdened medical care systems in western countries.

India's National Health Policy declares that treatment of foreign patients is legally an "export" and deemed "eligible for all fiscal incentives extended to export earnings." Government and private sector studies in India estimate that medical tourism could bring between $1 billion and $2 billion US into the country by 2012.

Going by the Statistics and various studies it can be easily said that indiawould be the leader in medical tourism within the next decade if only it could improve the infrastructure and tour attractions. The question or rather the doubt that is often asked by critics is how can India provide top line medical care to outsiders while more than 40% of its people languished below poverty line and less than 20% of its people can actually afford medical services. Ethically and morally this problem has to be solved if India has to move into the category of developed country and also as a place which provides medical care to both its own people and patients from other country

The aim of this project is to put a finger on the highly profitable service of medical care combined with tourism in which india is currently considered as a market leader. It has been a known fact for past many decades that Indian doctors are highly skillful in their given field since all around the globe mot hospitals have doctors of Indian origin. Therefore it became almost natural that this trend extended to India.

This project also aims to show why India is attracting medical tourists, is it really a secure destination and how Indiacan promote and develop this particular activity in the coming years so as face competition given by other Asian and African options.

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Medical tourism: A Global perspective

Medical tourism happens when patients go to a different country for either urgent or elective medical procedures. This phenomenon is fast becoming a worldwide, multibillion-dollar industry.

The reasons patients travel for treatment vary. Many medical tourists from the United States are seeking treatment at a quarter or sometimes even a 10th of the cost at home. From Canada, it is often people who are frustrated by long waiting times. From Great Britain, the patient can't wait for treatment by the National Health Service but also can't afford to see a physician in private practice. For others, becoming a medical tourist is a chance to combine a tropical vacation with elective or plastic surgery.

And moreover patients are coming from poorer countries such as Bangladesh where treatment may not be available and going for surgery in European or western developed countries is expensive.

The interesting thing of Medical tourism is that it is a concept which is actually thousands of years old. In ancient Greece, pilgrims and patients came from all over the Mediterranean to the sanctuary of the healing god, Asculapius, at Epidaurus. In Roman Britain, patients took a dip in the waters at a shrine at Bath, a practice that continued for 2,000 years as it was believed that the waters had a healing property . From the 18th century wealthy Europeans travelled to spas from Germany to the Nile. In the 21st century, relatively low-cost jet travel has taken the industry beyond the wealthy and desperate.

Countries that actively promote medical tourism include Cuba, Costa Rica, Hungary, India, Israel, Jordan, Lithuania, Malaysia and Thailand. Belgium, Poland and Singapore are now entering the field. South Africa specializes in medical safaris-visit the country for a safari, with a stopover for plastic surgery, a nose job and a chance to see lions and elephants.

Thailand

While, so far, India has attracted patients from Europe, the Middle East and Canada, Thailand has been the goal for Americans.

India initially attracted people who had left that country for the West; Thailand treated western expatriates across Southeast Asia. Many of them worked for western companies and had the advantage of flexible, worldwide medical insurance plans geared specifically at the expatriate and overseas corporate markets.

With the growth of medical-related travel and aggressive marketing, Bangkok became a centre for medical tourism. Bangkok's International Medical Centre offers services in 26 languages, recognizes cultural and religious dietary restrictions and has a special wing for Japanese patients

The medical tour companies that serve Thailand often put emphasis on the vacation aspects, offering post-recovery resort stays.

South Africa

South Africa also draws many cosmetic surgery patients, especially from Europe, and many South African clinics offer packages that include personal assistants, visits with trained therapists, trips to top beauty salons, post-operative care in luxury hotels and safaris or other vacation incentives. Because the South African rand has such a longstanding low rate on the foreign-exchange market, medical tourism packages there tend to be perpetual bargains as well.

Argentina

Argentina ranks high for plastic surgery, and Hungary draws large numbers of patients from Western Europe and the U.S. for high-quality cosmetic and dental procedures that cost half of what they would in Germany and America.

Dubai

Lastly, Dubai--a destination already known as a luxury vacation paradise--is scheduled to open the Dubai Healthcare City by 2010. Situated on the Red Sea, this clinic will be the largest international medical center between Europe and Southeast Asia. Slated to include a new branch of the Harvard Medical School, it also may be the most prestigious foreign clinic on the horizon.

Other countries

Other countries interested in medical tourism tended to start offering care to specific markets but have expanded their services as the demand grows around the world. Cuba, for example, first aimed its services at well-off patients from Central and South America and now attracts patients from Canada, Germany and Italy. Malaysia attracts patients from surrounding Southeast Asian countries; Jordan serves patients from the Middle East. Israel caters to both Jewish patients and people from some nearby countries. One Israeli hospital advertises worldwide services, specializing in both male and female infertility, in-vitro fertilization and high-risk pregnancies. South Africa offers package medical holiday deals with stays at either luxury hotels or safaris.

Indian tourism: An overview
Tourism will expand greatly in future mainly due to the revolution that is taking place on both the demand and supply side. The changing population structure, improvement in living standard, more disposable income, fewer working hours and long leisure time, better educated people, ageing population and more curious youth in the developed as well as developing countries, all will fuel the tourism industry growth.

The arrival of a large number of customers, better educated and more sophisticated, will compel the tourist industry to launch new products and brands and re-invents traditional markets. The established traditional destinations founded on sun-sea-sand products will have to re-engineer their products. They must diversify and improve the criteria for destinations and qualities of their traditional offers. Alongside beach tourism, the tourism sector will register a steady development of new products based on natural rural business, leisure and art and culture. Thus the study of new markets and emerging markets and necessity of diversified products are the basis of our strategy, which can enhance and sustain, existing and capture new markets.

It is India’s vastness that challenges the imagination: the sub-continent, 3200km (2000 miles) from the mountainous vastness of the Himalayas in the north to the tropical lushness of Kerala in the south, is home to one sixth of the world’s population, a diverse culture and an intoxicatingly rich history. Desert inRajasthan, tropical forests in the north eastern states, arid mountains in the delta region of Maharashtraand Karnataka and vast fertile planes in northern states of Uttar Pradesh, Haryana etc are just some of the geographical diversity that can be observed. We have a wealth of archeological sites and historical monuments. Manpower costs in the Indian hotel industry are one of

the lowest in the world. This provides better margins for any industry which relies on man power.

One of the fascinations of India is the juxtaposition of old and new; centuries of history – from the pre-historic Indus civilization to the British Raj – rub shoulders with the computer age; and Bangalore's ‘Silicon Valley’ is as much a part of the world's largest democracy as the remotest village is.

Weaknesses

Lack of adequate infrastructure is the biggest problem that India faces. The aviation industry in India, for example, is inefficient and does not provide even the basic facilities at airports. The visitors are appalled by the poor sanitation in the public restrooms at the international airports. The road condition in India is very worse. The population has grown exponentially since 1947 but we still use the same rail system constructed by the British.

Even now the government spends next to nothing on proper marketing of India’s tourism abroad. As a result foreigners still think of India as a country ridden by poverty, superstition, and diseases with snake charmers and sadhus at every nook and cranny. Case in point Thailand; where in spite of the huge problem of bird flu disease the tourists arrival only dropped by less then 15% where as in India when cases of plague started occurring in Surat in 1994 the arrival of foreign tourists in India decreased by almost 36%.

Opportunities

More proactive role from the government of India in terms of framing policies. Allowing entry of more multinational companies into the country giving us a global perspective.

Growth of domestic tourism. The advantage here is that domestic tourism and international tourism can be segregated easily owing to the different in the period of holidays.

Threats

Political turbulence within India in Kashmir and Gujarat has also reduced tourist traffic. Not only that fear of epidemics such as for malaria, cholera, dengue, plague etc are foremost in the mind of European and America patients .Aggressive strategies adopted by other countries like Australia, Singapore in promoting tourism are also not helping.

What is India Offering:
AYURVEDA

India has a rich heritage in the areas of traditional and natural medicines. The earliest mention of Indian medical practices can be found in the Vedas and Samhitas of Charaka, Bhela and Shusruta. A systematic and scientific approach was adopted by the sages of the time leading to the development of a system that is relevant even today. India is the land of Ayurveda. It believes in removing the cause of illness and not just curing the disease itself. It is based on herbals and herbal components without having side effects.

Ayurveda considers that the base of life lies in the five primary elements; ether (space), air, fire, water and earth. And the individual is made up of a unique proportion of the five elements in unique combinations to form three doshas (vata, pita and kapha). When any of these doshas become accute, a person falls ill. Ayurveda recommends a special life style and nutritional guidelines supplemented with herbal medicines. If toxins are abundant, then a cleaning process known as Panchkarma is recommended to eliminate those unwanted toxins and revitalize both mind and body. Ayurveda offers

treatments for ailments such as arthritis, paralysis, obesity, sinusitis, migraine, premature aging and general health care. Kerala is a world tourist destination and part of the reasons lies with the well- known stress-releasing therapies of famed Ayurvedic research centers. The climate along with the blessing of nature has turned Kerala into the ideal place for ayurvedic, curative and rejuvenating treatments.

YOGA If Ayurveda is the science of body, yoga is the science of the mind. Practiced together they can go a long way in making an individual fit. The word yoga means to join together. The ultimate aim of yoga is to unite the human soul with the universal spirit. Yoga was developed 5000 years ago and the base of yoga is described in the Yoga Sutra of Patanjali. This describes eight stages of yoga. These are Yam (universal moral commands), Niyam (self purification), Asana (posture), Pranayama (breathing control), Prathyahara (withdrawal of mind from external objects), Dharana (concentration), Dhyana (meditation), and Samadhi (state of superconsciousness). To get the benefits of yoga, one has to practice Asana, Pranayama and Yoganidra. With the regular practice of asanas one can 327 control cholesterol level, reduce weight, normalize blood pressure and improve cardiac performance. Pranayama helps to release tensions, develop relaxed state of mind and Yoganidra is a form of meditation that relaxes both physiological and psychological systems. Today, yoga has become popular in India and abroad and in a number of places including urban and rural areas yoga is taught and practiced.

SPA TREATMENT

Most of the other parts of the world have their own therapies and treatment that are no doubt effective in restoring wellness and beauty. New kinds of health tours that are gaining popularity in India are spa tours. Spas offer the unique advantages of taking the best from the west and the east combining them with the indigenous system and offering best of the two worlds. In hydropathy, Swedish massages work with the

Javanese Mandy, lulur, aromatherapy, reflexology and traditional ayurveda procedures to help keep the tourist healthy and enhance beauty. Combining these therapies with meditation, yoga and pranayama make the spa experience in India a new destination for medical tourism. The spas are very useful for controlling blood pressure, insomnia, cure tension, depression, paralysis and number of other deadly diseases. Ananda

Resort in Rishikesh, Angsana Resort, Golden Palm Spa and Ayurgram in Bangalore offer ayurveda, naturopathy, yoga and meditation packages. (Gaur Kanchilal) Allopathy

India has made rapid strides in advanced health care systems, which provides worldclass allopathic treatment. This has become possible because of the emergence of the private sector in a big way in this field. More and more foreign tourists are realizing that India is an ideal place for stopover treatment. Indian Multi-specialty hospitals are providing worldclass treatment at an amazingly economical cost as compared to the west. Quality services and low price factor primarily go in favour of India. The cardio care, bone marrow transplantation, dialysis, kidney transplant, neuron–surgery, joint replacement surgery, urology, osteoporosis and numerous diseases are treated at Indian hospitals with full professional expertise. Apollo hospital group, Escorts in Delhi, Jason Hospital, Global Hospital, and Max Health Care are catering to medical care for international patients in the areas of diagnostic, disease management, preventive health care and incisive surgeries.

The tourism department has devised websites in order to provide information. Many Ayurveda health resorts that are owned and rum by traditional Ayurveda Institutes have come up. Ayurgram is a novel concept that not only offers heritage accommodation but also offers a whole range of Ayurvedic treatments and rejuvenating packages. Similarly hotels have also included these types of packages in their holidays. Some of the tour operators have worked out all-inclusive medical treatment package that include treatment, accommodation, food, airport transfers, post operation recuperative holidays, along with a host of other facilities. 328 This in fact shows our product offers true value

for money for service. Many world-class state-of-the-art furnishing and equipment are being added to our Ayurveda Resorts to welcome international guests. Along with these hospitals there are many centers which offer not just physical but emotional and spiritual healing to patients. With all these India is going to be one of the leading medical health care destinations in the near future.

SPIRITUAL TOURISM

Globally people are increasingly mentally disturbed and looking for solace in spiritual reading, meditation and moments of divine ecstasy. Our country has been known as the seat of spiritualism and India’s cosmopolitan nature is best reflected in its pilgrim centres. Religion is the life-blood for followers of major religion and sects. Hinduism, Islam, Buddhism, Jainism, Zoroastrianism and Christianity have lived here for centuries. The visible outpouring of religious fervor is witnessed in the architecturally lavish temples, mosques, monasteries and Churches spreads across the length and breadth of the country. India is not only known as a place rich in its culture with varied attractions but also for many places of worship, present itself as embodiments of compassion where one get peace of mind. Thus India has been respected as a destination for spiritual tourism for domestic and international tourists. Spiritual tourism is also termed as religious heritage tourism. It includes all the religions mentioned above; religious places associated with, emotional attachment to these centers and infrastructure facilities for the tourists. This can also be referred to as pilgrimage tourism, as clients are not looking for luxury but arduous journeys to meet the divine goal or simple life. The essence of spiritual tourism is inner feeling through love. Love should not be rationed on the basis of caste, creed and economic status or intellectual attainment of the recipient. Religions come into existence for the purpose of regulating human life; what are common to all of them are the principles of love. Thus through religious

tourism there is a sincere effort to bring better understanding among various communities, nations and thus foster global unity.

Hinduism is one of the oldest religions of India. Over 5000 years of religious history created wonderful temples and survived through ages all over India. The most popular spiritual tours are those that are centered on holy Ganges River. Badrinath, Kedarnath, Haridwar, Gangotri, Yamunotri, Allahabad, Varanasi. Jaganath temple at Puri, Bhubaneshwar, Konark in Orissa, Mata Vaishnodevi of Jammu and Kashmir, are some of the important pilgrim centers in north India. There are many spiritual sites in South India as well which dates back beyond the 10th centaury. Rameshwaram, Mahabalipuram, Madurai Meenakshi temple in Tamilnadu and Tirupati in Andhra Pradesh are some pilgrim centers. Every year millions of tourists, both domestic and international, visit these places. India is special to Buddhists all over the world and India is the destination for pilgrimage because Buddhism emerged in India. The country is dotted with places that are associated with the life and times of Gutham Buddha; Lumbini-the birthplace of Buddha, Saranath where Buddha delivered his first sermon, Buddha Gaya where lord Buddha attained enlightenment and Vaishali where he delivered his last sermon and announced his nirvana. Sikhism also emerged in India. The Golden Temple in Amritsar, the Hemkund Sahib, and Gurunanak Devji Gurudwara at Manikaran, which is also known for its hot water springs with healing properties, the holy city of Patna Sahib and Anandpur Sahib are important for Sikhs.

The Jain temples of Dilwara and Mount Abu in Rajasthan, the Gomateswara temple at Karnataka, draw thousands of Jain followers. Even small communities like the Bahais have their own Lotus Temple at Delhi. The Sultanate and Moghul empires built many historical monuments and mosques during their reign, all over the country. Red Fort, Fatehapur Sikri, Jama Masjid, TajMahal, Charminar etc., bear testimony to the blend of the Indian and Islam traditions of architecture. The followers of Islam have many mosques and shrines of Sufi Saints, like Moin-Uddin Chisti and Nizamuddin Aulia. For Christians, spiritual tours to Goa among other place like Mumbai and Kolkata are must. Among the most popular sites in Goa is the church of Our Lady of Rosary, the Rachel

Seminary, and Church of Bom Jesus. In addition to pilgrim centers there are personalities like the Satya Sai Baba, Osho, Shirdhi and others. This shows that spirituality and religion in India is a serious pursuit. The State Governments concerned, charitable trusts, temple trusts have made elaborate arrangements for accommodation, transport and ritual ceremonies. These organizations are also running hospitals, educational institutes, ashrams, meditation centers which benefit local community. More than 500 religious places have been identified and efforts are being made to develop these centers by Central and State Governments with private participation. ADVENTURE TOURISM

Youth tourism has been identified as one of the largest segments of global and domestic tourism. The young travellers are primarily experience seekers, collecting, enquiring unique experiences. Adventure and risk have a special role to play in the behaviour and attitudes of young travellers. The growing number of young travellers is being fuelled by a number of factors such as increased participation in higher education, falling level of youth unemployment, increased travel budget through parental contribution, search for an even more exciting and unique experience and cheaper long distance travel.

Youth and adventure tourism appears to have considerable growth potential. The rising income in some major potential source markets such as the Central and Eastern Europe, Asia and Latin America, combined with the lower travel cost, growing student populations around the world particularly in developing countries, has fuelled the demand. India: a heaven for adventure tourism India has been an attraction for travellers from all over the world. Though in the field of international tourism, the segment of adventure tourism in India is getting only a fraction of such traffic. The trend has been showing an increased movement year after year with the development of facilities and greater awareness about adventure tourism options.

Indian tourism offers both international and domestic adventurers a wide choice of adventures. Water sports, elephant safari, skiing, yachting, hail-skiing, gliding, sailing, tribal tours, orchid tours, scaling the high peaks of Himalayas, trekking to the valley of

flowers, riding the waves in rapids, and camel safari in the deserts are breath taking opportunities for nature enthusias. Ladakh, the Garwal hills, the Himachal hills, Darjeeling, Goa, Lakshadweep, Andaman and Nicobar, Jaisalmer and wildlife sanctuaries and reserves are some of the places that offer adventure tourism.

RURAL TOURISM

Rural tourism has been identified as one of the priority areas for development of Indian tourism. Rural tourism experience should be attractive to the tourists and sustainable for the host community. The Ninth Plan identified basic objectives of rural tourism as: -

• Improve the quality of life of rural people • Provide good experience to the tourist • Maintain the quality of environment. Indian villages have the potential for tourism development. With attractive and unique traditional way of life, rich culture, nature, crafts, folk-lore and livelihood of Indian villages are a promising destination for the tourist. It also provides tourism facilities in terms of accessibility, accommodation, sanitation and security. Rural tourism can be used as a means to:-

• Improve the well being of the rural poor • Empower the rural people • Empower the women • Enhance the rural infrastructure • Participate in decision-making and implementing tourism policies • Interaction with the outside world • Improve the social condition of lower sections of the society.

• Protection of culture, heritage, and nature.

To tap the immense opportunities, coordinated actives of all agencies involved in the development are required. A carefully planned and properly implemented development will definitely benefit the community economically and improve the quality of life in the villages. The success of such development depends upon the people’s participation at grass root level for the development of tourist facilities and for creating a tourist friendly atmosphere. Development of rural tourism is fast and trade in hotels and restaurants is growing rapidly. Increase in the share of earnings through rural tourism will no doubt; provide an attractive means of livelihood to the poor rural community. It increases the purchasing power at all levels of community and strengthens the rural economy. Development of infrastructure facilities such as rail, electricity, water, health and sanitation will definitely improve the quality of life.

India as a global destination for Medical Tourism
Tourism and healthcare, being an integral part of many economies services industry are both important sources of foreign exchange. Globalisation has promoted a consumerist culture leading to the mushrooming of corporate healthcare settings seized with the necessity to maximise profits and expand their coverage. However, the constraint lies in the fact that these services can be afforded by a relatively small size of population in developing countries.

Low insurance penetration, lack of standardisation of services, poor information base, ineffective monitoring leading to low quality, high levels of fraud and corruption, misallocation of investments and low efficiency of existing hospitals have impeded effective performance leading to a stagnation of the healthcare sector. In this scenario, corporate interests in the medical care sector are looking for opportunities beyond the national boundaries.

This is the genesis of “Medical Tourism” industry. The term medical tourism refers to the increasing tendency among people from the UK, the US and many other third world countries, where medical services are either very expensive or not available, to leave their countries in search for more affordable health options, often packaged with tourist attractions.

Long waiting lists, decline in public spending and rise in life expectancy and noncommunicable diseases that require specialist services are some of the factors directing a wave of medical tourists to more affordable healthcare destinations. Most countries are tapping the health tourism market due to aggressive international marketing in conjunction with their tourism industry. In this rat race, Thailand, Malaysia, Jordan, Singapore, Hong Kong, Lithuania and South Africa have emerged as big healthcare destinations.

India is unique as it offers holistic healthcare addressing the mind, body and spirit. With yoga, meditation, ayurveda, allopathy and other Indian systems of medicine, India offers a vast array of services combined with the cultural warmth that is difficult to match by other countries. Also, clinical outcomes in India are on par with the world’s best centres, besides having internationally qualified and experienced specialists. CII believes that India should capitalise on its inherent strengths to become a world player in medical tourism. According to a CII-Mc Kinsey study, medical tourism in India could become a USD 1 billion business by 2012. Instead of adopting a segmental approach of targeting a few states such as Maharashtra, Kerala, Andhra Pradesh, Chennai, efforts are now being made to project “Destination India” as a complete brand ideal for medical tourists. Countries from where people head for India are the UK, Bangladesh, Oman, Sri Lanka, Indonesia, Mauritius, Nigeria, Kenya, Pakistan, etc.

Visitors, especially from the West and Middle East find Indian hospitals a very affordable and viable option to grappling with insurance and national medical systems in their native lands. There are thousands of expatriates without any social security and health insurance cover who usually compare the costs before going for treatment and India has a cost advantage for this segment. Although, the existing market for medical tourism in India is small, it can grow rapidly if the industry reorients itself to lure foreign patients from all potential regions such as SAARC, Central Asia, Middle East, Africa, Europe, OECD besides the UK and the US. The annual health bill of people from Afro-Asian countries seeking treatment outside their countries is USD 10 billion. If India can even tap a fraction of that market, the potential is enormous. The price advantage is however offset today for patients from the developed countries by concerns regarding standards, insurance coverage and other infrastructure.

The question being asked by many is that how can India become an international destination in healthcare, when the clientele at home is bristling with dissatisfaction. Hence, arises the need to define minimum standards at national level, compulsory registration and adoption of these standards by all providers and regular monitoring and enforcing of such standards at the local level. Quality assessment should combine evaluation of infrastructure as well as outcomes.

An obvious answer to all this is accreditation. This will ensure transparency in the way a hospital performs, and everything from the operating to the cleaning procedures will be monitored, audited and recorded. With an aim to boost the much talked about medical tourism, many corporate hospitals in India are looking to international agencies such as JCAHO/JCI for accreditation. Accreditation will even make tie ups with overseas health insurance agencies such as BUPA and CHUBS easier to route patients to India.

As the medical tourism industry is growing exponentially, government and the private players need to join hands in order to act as a catalyst to build infrastructure for hospitals, create specialty tourist packages to include medical treatment, promote accreditation and standardisation, enable access and tie-ups with insurance companies, provide state of art facilities and improve quality of in-patient care and service to meet the requirements of foreign patients and to attain sustainable competitive advantage.

Many fear about the serious consequences of equity and cost of services and raise a fundamental question on the very existence of medical tourism- why should developing countries be subsidising the healthcare of developed nations? For them, medical tourism is likely to further devalue and divert personnel from the already impoverished public health system. However, with good planning and implementation, medical tourism besides being an economy booster can surely help India maintain good cross border and trade relations, exchange of manpower and technology among countries.

Strategies are thus needed not just to project India as a major healthcare destination, but also to create a system to conduct proper market research and feasibility studies in order to quantify the “How many”, “From where”, “To where”, and most importantly the “How” of medical tourism. Only then can we leverage and channelise all efforts in the right direction. In the absence of proper planning, formulation, implementation and evaluation of coherent strategies, the much created hype and all the talk may just go in vain.

Why the world is moving towards medical tourism
Medical tourists have good cause to seek out care beyond the United States for many reasons. In some regions of the world, state-of-the-art medical facilities are hard to come by, if they exist at all; in other countries, the public health-care system is so overburdened that it can take years to get needed care. In Britain and Canada, for instance, the waiting period for a hip replacement can be a year or more, while in Bangkok or Bangalore, a patient can be in the operating room the morning after getting off a plane.

For many medical tourists, though, the real attraction is price. The cost of surgery in India, Thailand or South Africa can be one-tenth of what it is in the United States or Western Europe, and sometimes even less. A heart-valve replacement that would cost $200,000 or more in the U.S., for example, goes for $10,000 in India--and that includes round-trip airfare and a brief vacation package. Similarly, a metal-free dental bridge worth $5,500 in the U.S. costs $500 in India, a knee replacement in Thailand with six days of physical therapy costs about one-fifth of what it would in the States, and Lasik eye surgery worth $3,700 in the U.S. is available in many other countries for only $730. Cosmetic surgery savings are even greater: A full facelift that would cost $20,000 in the U.S. runs about $1,250 in South Africa.

The savings sound very attractive, but a good new hip and a nice new face don’t seem like the sort of things anyone would want to bargain with. How does the balance of savings versus risk pay off in terms of success rates

Inferior medical care would not be worth having at any price, and some skeptics warn that Third World surgery cannot possibly be as good as that available in the United States. In fact, there have been cases of botched plastic surgery, particularly from Mexican clinics in the days before anyone figured out what a gold mine cheap, highquality care could be for the developing countries.

Yet, the hospitals and clinics that cater to the tourist market often are among the best in the world, and many are staffed by physicians trained at major medical centers in the United States and Europe.

Bangkok’s Bumrundgrad hospital has more than 200 surgeons who are board-certified in the United States, and one of Singapore’s major hospitals is a branch of the prestigious Johns Hopkins University in Baltimore. In a field where experience is as important as technology, Escorts Heart Institute and Research Center in Delhi and Faridabad, India, performs nearly 15,000 heart operations every year, and the death

rate among patients during surgery is only 0.8 percent--less than half that of most major hospitals in the United States.

In some countries, clinics are backed by sophisticated research infrastructures as well. India is among the world’s leading countries for biotechnology research, while both India and South Korea are pushing ahead with stem cell research at a level approached only in Britain. In many foreign clinics, too, the doctors are supported by more registered nurses per patient than in any Western facility, and some clinics provide single-patient rooms that resemble guestrooms in four-star hotels, with a nurse dedicated to each patient 24 hours a day.

Add to this the fact that some clinics assign patients a personal assistant for the posthospital recovery period and throw in a vacation incentive as well, and the deal gets even more attractive. Additionally, many Asian airlines offer frequent-flyer miles to ease the cost of returning for follow-up visits.

Medical tourism trend andwhat statistics shows: Ten years ago, medical tourism was hardly large enough to be noticed. Today, more than 250,000 patients per year visit Singapore alone--nearly half of them from the Middle East. This year, approximately half a million foreign patients will travel to India for medical care, whereas in 2002, the number was only 150,000.

In monetary terms, experts estimate that medical tourism could bring India as much as $2.2 billion per year by 2012. Argentina, Costa Rica, Cuba, Jamaica, South Africa, Jordan, Malaysia, Hungary, Latvia and Estonia all have broken into this lucrative market as well, or are trying to do so, and more countries join the list every year.

Trends in medical tourism in the near future

Some important trends guarantee that the market for medical tourism will continue to expand in the years ahead. By 2015, the health of the vast Baby Boom generation will have begun its slow, final decline, and, with more than 220 million Boomers in the United States, Canada, Europe, Australia and New Zealand, this represents a significant market for inexpensive, high-quality medical care.

Medical tourism will be particularly attractive in the United States, where an estimated 43 million people are without health insurance and 120 million without dental coverage-numbers that are both likely to grow. Patients in Britain, Canada and other countries with long waiting lists for major surgery will be just as eager to take advantage of foreign health-care options.

Advantage India
Indian corporate hospitals excel in cardiology and cardiothoracic surgery, joint replacement, orthopedic surgery, gastroenterology, ophthalmology, transplants and

urology to name a few. The various specialties covered are Neurology, Neurosurgery, Oncology, Ophthalmology, Rheumatology, Endocrinology, ENT, Pediatrics, Pediatric Surgery, Pediatric Neurology, Urology, Nephrology, Dermatology, Dentistry, Plastic Surgery, Gynecology, Pulmonology, Psychiatry, General Medicine & General Surgery

The various facilities in India include full body pathology, comprehensive physical and gynecological examinations, dental checkup, eye checkup, diet consultation, audiometry, spirometry, stress & lifestyle management, pap smear, digital Chest X-ray, 12 lead ECG, 2D echo colour doppler, gold standard DXA bone densitometry, body fat analysis, coronary risk markers, cancer risk markers, carotid colour doppler, spiral CT scan and high strength MRI. Each test is carried out by professional M.D. physicians, and is comprehensive yet pain-free.

There is also a gamut of services ranging from General Radiography, Ultra Sonography, Mammography to high end services like Magnetic Resonance Imaging, Digital Subtraction Angiography along with intervention procedures, Nuclear Imaging. The diagnostic facilities offered in India are comprehensive to include Laboratory services, Imaging, Cardiology, Neurology and Pulmonology. The Laboratory services include biochemistry, hematology, microbiology, serology, histopathology, transfusion medicine and RIA.

All medical investigations are conducted on the latest, technologically advanced diagnostic equipment. Stringent quality assurance exercises ensure reliable and high quality test results.

As Indian corporate hospitals are on par, if not better than the best hospitals in Thailand, Singapore, etc there is scope for improvement, and the country may become a

preferred medical destination. In addition to the increasingly top class medical care, a big draw for foreign patients is also the very minimal or hardly any waitlist as is common in European or American hospitals. In fact, priority treatment is provided today in Indian hospitals.

The Apollo Group, Escorts Hospitals in New Delhi and Jaslok Hospitals in Mumbai are to name a few which are established names even abroad. A list of corporate hospitals such as Global Hospitals, CARE and Dr L.V. Prasad Eye Hospitals in Hyderabad, The Hindujas and NM Excellence in Mumbai, also have built capabilities and are handling a steadily increasing flow of foreign patients. India has much more expertise than say Thailand or Malaysia. The infrastructure in some of India's hospitals is also very good. What is more significant is that the costs are much less, almost one-third of those in other Asian countries.

India will soon become THE global health destination. It is replicating the Thai model, which has been the first Asian destination for International Patients. India benefits from a large staff of world class experts and the ultra-competitive cost advantage it offers.

With prices at a fraction (less than 10% for example in the treatment of gall stone $600 US ) of those in the US or EU, the concept has broad consumer appeal. Indian private facilities offer advanced technology and high-quality treatment at par with hospitals in western countries.

India is promoting "medical outsourcing" where subcontractors aim to provide services to the overburdened medical care systems in western countries. Medical tourism to India is growing by 20% a year. Most non-urgent Western patients usually get a package deal that includes flights, transfers, hotels, treatment and often a postoperative vacation. There are many brokers specialized on the Indian market.

India has top-notch centers for open-heart surgery, pediatric heart surgery, hip and knee replacement, cosmetic surgery, dentistry, bone marrow transplants and cancer therapy, and virtually all of India’s clinics are equipped with the latest electronic and medical diagnostic equipment.

Unlike many of its competitors in medical tourism, India also has the technological sophistication and infrastructure to maintain its market niche, and Indian pharmaceuticals meet the stringent requirements of the U.S. Food and Drug Administration. Additionally, India’s quality of care is up to American standards, and some Indian medical centers even provide services that are uncommon elsewhere. For example, hip surgery patients in India can opt for a hip-resurfacing procedure, in which damaged bone is scraped away and replaced with chrome alloy--an operation that costs less and causes less post-operative trauma than the traditional replacement procedure performed in the U.S.

Healthcare procedures across the world show a wide cost difference. It leads to a question of affordability even to the developed country like the US where significantly huge number of population is not covered under any insurance scheme. In some developed country, long waiting period for elective inpatient and outpatient care has created a situation where people do not hesitate to buy healthcare from other developing countries like India without compromising on quality.

Complimentary tourism packages make the entire offer more attractive to the people who are interested to travel for their healthcare. Globalisation of healthcare industry has started in many level. For instance, Indian software companies like TCS and Mastek has signed IT contract recently worth more than US $ 200 million.

Scope & Opportunities

Though the service sector has considerable contribution in India’s GDP, it is negligible on the export front with only around 25 per cent of total export. Value added services generally exceed 60 per cent of total output in the high income industrialised economy. In the global scenario, India’s share of services export is only 1.3 per cent (2003) i.e USD 20.7 billion which has gone up from 0.57 per cent (1990). Overall service export growth rate in India is 8 per cent (2002) against a global growth rate of 5 per cent.

It had a tremendous impact on India’s Forex reserve. Forex reserve rise to USD 118.628 on May, 2004 in comparison to USD 79.22 for the same period in 2003. Being a service sector member, medical and tourism services export can further rise India’s Forex Reserve along with a major contribution from software exports.

In India, international tourist rose 15.3 per cent between January and December, 2003. Though tourism and travel industry contribution is 2.5 per cent to our countries GDP (international ranking 124) but recent initiative from the government like liberalised open sky policy to increase flight capacity, lower and attractive fares, increase in hotel room capacity by nearly 80 per cent (from 2000) and better connectivity between major tourist destination (Express Highway project) has helped India to rank among the top five international holiday destination when independent traveler conducted a poll in 134 countries.

Healthcare industry has shown considerable growth in last few years. Emergence of top notch corporate hospitals and continuous effort for improvement of quality of care has placed Indian private healthcare in a respectable position on the global map.

High ratio of foreign qualified medical practitioners and well-trained nursing and paramedical staff have developed confidence amongst the people who are seeking

medical care from Indian Hospitals. If everything moves in the right direction, MT alone can contribute an additional revenue of Rs 5000 - Rs 10,000 crore for up market tertiary centre by 2012 (3-5 per cent of total delivery market).

Need For Medical Tourism
Medical tourism can be broadly defined as provision of 'cost effective' private medical care in collaboration with the tourism industry for patients needing surgical and other forms of specialized treatment. This process is being facilitated by the corporate sector involved in medical care as well as the tourism industry - both private and public.

Medical or Health tourism has become a common form of vacationing, and covers a broad spectrum of medical services. It mixes leisure, fun and relaxation together with wellness and healthcare.

The idea of the health holiday is to offer you an opportunity to get away from your daily routine and come into a different relaxing surrounding. Here you can enjoy being close to the beach and the mountains. At the same time you are able to receive an orientation that will help you improve your life in terms of your health and general well being. It is like rejuvenation and clean up process on all levels - physical, mental and emotional.

Many people from the developed world come to India for the rejuvenation promised by yoga and Ayurvedic massage, but few consider it a destination for hip replacement or brain surgery. However, a nice blend of top-class medical expertise at attractive prices is helping a growing number of Indian corporate hospitals lure foreign patients, including from developed nations such as the UK and the US.

As more and more patients from Europe, the US and other affluent nations with high medicare costs look for effective options, India is pitted against Thailand, Singapore and some other Asian countries, which have good hospitals, salubrious climate and tourist destinations. While Thailand and Singapore with their advanced medical facilities and built-in medical tourism options have been drawing foreign patients of the order of a couple of lakhs per annum, the rapidly expanding Indian corporate hospital sector has been able to get a few thousands for treatment.

In India, the Apollo group alone has so far treated 95,000 international patients, many of whom are of Indian origin. Apollo has been a forerunner in medical tourism in India and attracts patients from Southeast Asia, Africa, and the Middle East. The group has tied up with hospitals in Mauritius, Tanzania, Bangladesh and Yemen besides running a hospital in Sri Lanka, and managing a hospital in Dubai.

Another corporate group running a chain of hospitals, Escorts, claims it has doubled its number of overseas patients - from 675 in 2000 to nearly 1,200 this year. Recently, the Ruby Hospital in Kolkata signed a contract with the British insurance company, BUPA. The management hopes to get British patients from the queue in the National Health Services soon. Some estimates say that foreigners account for 10 to 12 per cent of all patients in top Mumbai hospitals despite roadblocks like poor aviation connectivity, poor road infrastructure and absence of uniform quality standards.

Analysts say that as many as 150,000 medical tourists came to India last year. However, the current market for medical tourism in India is mainly limited to patients from the Middle East and South Asian economies. Some claim that the industry would flourish even without Western medical tourists. Afro-Asian people spend as much as $20 billion a year on health care outside their countries - Nigerians alone spend an estimated $1 billion a year. Most of this money would be spent in Europe and America,

but it is hoped that this would now be increasingly directed to developing countries with advanced facilities.

India’s Future Prospect
The global healthcare market is USD 3 trillion and size of the Indian healthcare industry is around 1,10,000 crores accounting for nearly 5.2 per cent of GDP. It is likely to reach 6.2- 8.5 per cent of the GDP by 2012. It is expected that medical tourism will account about 3-5 per cent of the total delivery market.

More than 1,50,000 medical tourists came to India in 2003. Around 70,000 people came from the Middle East for the medical treatment. Traditional system of medicine is able to attract a sizeable number of people from western countries (Kerala, for instance). Most of the medical tourists are Indian in origin. We need to attract more number of people of foreign origin.

International experience shows some of the countries like Thailand, Singapore, Jordan and Malaysia have done extremely well. There is technical committee formed by Jordan Government operating for the non-Jordanian Arab patients who visit Jordan for healthcare. This office regulates the healthcare institutions treating those patients and monitor the entire activity.

Making of a Medical Tourism destination

Our healthcare industry has some inherent drawbacks. Lack of standardisation in medical care and cost, lack of regulatory mechanism, infrastructural bottlenecks and poor medical insurance coverage are a few to mention here. On the other hand, tourism and hospitality industries are facing some major challenges to develop the infrastructure and services. Industry and government collaboration in terms of some incentives and creation of soothing environment can further make this endeavor easy for both the service sector. The immediate need is the establishment of health and tourism players

consortium to discuss about all these issues and maintain closer interaction and coordination to develop medical tourism - a growth engine for Forex earnings.

Price Comparison Overview
COST COMPARISON – INDIA VS UNITED STATES OF AMERICA (USA)

Significant cost differences exist between U.K. and India when it comes to medical treatment.

India is not only cheaper but the waiting time is almost nil. This is due to the outburst of the private sector which comprises of hospitals and clinics with the latest technology and best practitioners.

Procedure Charges in India & USA

Procedure

United States (USD) Approx

India (USD) Approx

Bone Marrow transplant Liver Transplant Heart Surgery Orthopedic Surgery Cataract Surgery Smile Designing

USD 2,50,000 USD 3,00,000 USD 30,000 USD 20,000 USD 2,000 USD 8,000

USD 69,200 USD 69,350 USD 8,700 USD 6,300 USD 1,350 USD 1,100

Metal Free Bridge Dental Implants Porcelain Metal Bridge Porcelain Metal Crown Tooth Impactions Root Canal Treatment Tooth Whitening Tooth Colored Composite Fillings / Tooth Cleaning

USD 5,500 USD 3,500 USD 3,000 USD 1,000 USD 2,000 USD 1,000 USD 800 USD 500 USD 300

USD 600 USD 900 USD 600 USD 100 USD 125 USD 110 USD 125 USD 30 USD 90

Procedure Liver Transplant Heart Surgery Orthopedic Surgery Cataract Surgery

India 3,00,000 30,000 20,000 2,000

USA 69,000 69,000 8,000 6,000 1,250

Bone Marrow Transplant 2,50,000

Procedure

United states (USD) India (USD) Approx Approx

Breast : Mastopexy – Reduction Mammoplasty – Mammoplasty Augmentation -Replacement Of Implants Face : USD 7,500 USD 8,000 USD 8,000 USD 6,500 USD 6,000 USD 2,800 USD 3,300 USD 2,750 USD 3,000 USD 2,000 USD 2,800 USD 2,150 USD 2,200 USD 3 Per graft USD 2,300 USD 2,400 USD 1,500 USD 2,900 USD 1,300 USD 3,200 USD 3,150 USD 6,000 USD 1,750

Blepheroplasty (Upper & Lower) -Facelift USD 6,500 -Dermabrasion (Total face) -Canthopexy USD 5,500 w/Orbicularis suspension – USD 6,000 Hair Transplant – USD 50 Per graft Endoscopic Brow lift – USD 5,800 Neck lift – Otoplasty(For prominent Ears) Nose : -Primary Rhinoplasty -Tip Rhynoplasty Body Contouring : -Abdominoplasty -Thigh Lift (Bilateral) -Total Lower Body Lift(Belt Lipectomy) -Liposuction (One Region) Non – Surgical Procedures : Laser Hair Removal – Laser Resurfacing/ Wrinkle Reduction – Laser Acne Treatment – Laser Scar Treatment – Botox USD 550 USD 575 USD 500 USD 70 Per Unit USD 550 USD 6,100 USD 4,700 USD 7,300 USD 6,300 USD 7,700 USD 7,200 USD 9,500 USD 6,100

USD 225

USD 225 USD 230 USD 210 USD 8 Per Unit

COST COMPARISON – INDIA VS UNITED KINGDOM (UK)

Significant cost differences exist between U.K. and India when it comes to medical treatment. Accompanied with the cost are waiting times which exist in U.K. for patients which range from 3 months to over months.

India is not only cheaper but the waiting time is almost nil. This is due to the outburst of the private sector which comprises of hospitals and clinics with the latest technology and best practitioners. Procedure

Procedure

United Kingdom (USD) Approx

India (USD) Approx USD 4,800 USD 4,500

Open Heart Surgery

USD 18,000

Cranio-Facial surgery and skull USD 13,000 base Neuro- surgery with Hypothermia Complex spine surgery with implants Simple Spine Surgery Simple Brain Tumor -Biopsy -Surgery Parkinsons Lesion DBS USD 6,500 USD 4,300 USD 10,000 USD 6,500 USD 26,000 USD 13,000 USD 21,000 USD 13,000

USD 6,800 USD 4,600

USD 2,300 USD1,200 USD 4,600 USD 2,300 USD 17,800 USD 4,500

Hip Replacement

Procedure Heart Bypass Heart Valve Replacement Angioplasty Hip

US Cost $130,000 $160,000 $57,000 $43,000

India $10,000 $9,000 $11,000 $9,000 $3,000 $8,500 $5,500

Thailand $11,000 $10,000 $13,000 $12,000 $4,500 $10,000 $7,000

Singapore $18,500 $12,500 $13,000 $12,000 $6,000 $13,000 $9,000

Replacement Hysterectomy $20,000 Knee $40,000

Replacement Spinal Fusion $62,000

Cost comparison between India, USA, Thailand, Singapore:

*approximate retail costs, US figures based on HCUP data, intl. figures based on hospital quotes in named countries

Here's a brief comparison of the cost of few of the Dental treatment procedures between USA and India

Dental Procedure

Cost in USA ($)

Cost in India ($)

General Smile designing Metal Free Bridge Dental Implants Porcelain Metal Bridge Porcelain Metal Crown Tooth impactions Root canal Treatment Tooth whitening Tooth colored composite fillings Tooth cleaning Dentist 1,800 600 500 600 350 200 100

Top End Dentist 8,000 5,500 3,500 3,000 1,000 2,000 1,000 800 500 300

Top End Dentist 1,000 500 800 300 80 100 100 110 25 75

General cost sheet for a stay in Delhi :

Taxi fare from airport to hospital Registration and consultation with senior consultant at hospital X ray of chest Whole abdomen ultrasound Laparoscopic Cholecystectomy for Gall Bladder Stones Endoscopic Thoracic Hyperhidrosis Stay at nearby hotel Big Mac Meal combo at Mc Donald Tour of Delhi Tour to Agra ( 125 miles from Delhi)

Non A/C $10 $25

A/C $30

$4 $15 Economy Ward $600 (Total Cost) Economy Ward $1200 Single Room $900 (Total Cost) Single Room $2000 (Total Cost) 4 star $150,

Sympathectomy for (Total Cost) Economy

class $50/ day 5 star $250 $2

$ 50 by coach $ 150 same day return

$ 150 by personal car $ 250 with overnight stay at 5 star hotel

Major players offering Medical Tourism packages

Indian corporate hospitals excel in cardiology and cardiothoracic surgery, joint replacement, orthopedic surgery, gastroenterology, ophthalmology, transplants and urology to name a few. The various specialties covered are Neurology, Neurosurgery, Oncology, Ophthalmology, Rheumatology, Endocrinology, ENT, Pediatrics, Pediatric Surgery, Pediatric Neurology, Urology, Nephrology, Dermatology, Dentistry, Plastic Surgery, Gynecology, Pulmonology, Psychiatry, General Medicine & General Surgery

The various facilities in India include full body pathology, comprehensive physical and gynecological examinations, dental checkup, eye checkup, diet consultation, audiometry, spirometry, stress & lifestyle management, pap smear, digital Chest X-ray, 12 lead ECG, 2D echo colour doppler, gold standard DXA bone densitometry, body fat analysis, coronary risk markers, cancer risk markers, carotid colour doppler, spiral CT scan and high strength MRI. Each test is carried out by professional M.D. physicians, and is comprehensive yet pain-free.

There is also a gamut of services ranging from General Radiography, Ultra Sonography, Mammography to high end services like Magnetic Resonance Imaging, Digital Subtraction Angiography along with intervention procedures, Nuclear Imaging. The diagnostic facilities offered in India are comprehensive to include Laboratory services, Imaging, Cardiology, Neurology and Pulmonology. The Laboratory services include biochemistry, hematology, microbiology, serology, histopathology, transfusion Medicine and RIA

All medical investigations are conducted on the latest, technologically advanced diagnostic equipment. Stringent quality assurance exercises ensure reliable and high quality test results

The chief cities attracting foreign patients to India are Mumbai, Bangalore, Hyderabad, Kolkata and Chennai. Similarly, the speciality hospitals excelling in the medical tourism industry in the country are:

* Escorts Heart Institute and Research Centre Limited, New Delhi * All India Institute of Medical Sciences, Delhi * Manipal Heart Foundation, Bangalore * B. M. Birla Heart Research Centre, Kolkata * Breach Candy Hospital, Mumbai * Wockhardt Hospitals * Christian Medical College, Vellore * Asian Heart Institute, Mumbai * PD Hinduja National Hospital and Medical Research Centre, Mumbai * Jaslok Hospital, Mumbai * Apollo Hospital, Delhi * Apollo Cancer Hospital, Chennai

Medical Packages
The health care sector in India has witnessed an enormous growth in infrastructure in the private and voluntary sector. The private sector which was very modest in the early stages, has now become a flourishing industry equipped with the most modern state-ofthe-art technology at its disposal. It is estimated that 75-80% of health care services and investments in India are now provided by the private sector. An added plus had been that India has one of the largest pharmaceutical industries in the world. It is self sufficient in drug production and exports drugs to more than 180 countries.

* Bone Marrow Transplant * Brain Surgery * Cancer Procedures (Oncology) * Cardiac Care * Cosmetic Surgery * Dialysis and Kidney Transplant * Drug Rehabilitation * Gynaecology & Obstetrics * Health Checkups * Internal/Digestive Procedures * Joint Replacement Surgery * Nuclear Medicine

* Neurosurgery & Trauma Surgery * Preventive Health Care * Refractive Surgery * Osteoporosis * Spine Related * Urology * Vascular Surgery

* Gall Bladder stones surgery ( Laparoscopic Cholecystectomy ) * Hernia surgery ( Laparoscopic mesh repair ) * Piles ( Stapled Hemorrhoidectomy ) * Varicose Veins surgery * Endoscopic Thoracic Sympathectomy for Hyperhidrosis * Laparoscopic Appendicectomy * Laparoscopic Adrenalectomy * Laparoscopic Fundoplication for Hiatus Hernia * Laparoscopic Banding of stomach for Morbid Obesity * Laparoscopic splenectomy

Other packages include:

•

Hip-Knee replacement surgeries and other orthopedic surgeries.

•

Bone marrow transplantation surgery.

•

Heart surgery packages like Cardiac Surgery And Cardiology, Open Heart Surgery, Angiographies and Angioplasties.

•

Treatments of different skin problems including skin grafting.

The services provided by the host country’s hospital/ organisation are:

•

Put in touch with aworld class Private hospital or Nursing home and the doctor & fix up an appointment with the doctor at the hospital.

•

Receive you at the airport and provide transportation to the hotel and for the rest of the days during your stay here.

•

Provide accommodation in a hotel as per your choice and budget near the Nursing Home or the Private hospital.

•

We can arrange for another place to stay or a rejuvenating sight-seeing tour while your mother recovers after the treatment.

•

In addition to the increasingly top class medical care, a big draw for foreign patients is also the very minimal or hardly any waitlist as is common in European or American hospitals. In fact, priority treatment is provided today in Indian hospitals.

STEPS OF SEEKING TREATMENT WITH MEDICAL TOURISM

1. Is the medical ailment suitable for treatment in a country different from yours the

patients own country. The answer to this question will be based on combined information from your own doctor and the overseas doctor.

2. Ailments that require a one shot treatment like surgery for gall stones, hernia, piles,

varicose veins, hysterectomy, adrenalectomy, nephrectomy, thyroidectomy, joint replacement etc are more suitable for medical tourism.

3. The ailment should be such that a follow up should not be necessary and you should

not need to visit the country again to ‘ tie up loose ends.

4. The patient/ tourist should be otherwise well enough to be able to utilize the tourism

part of it. Other wise you could just go to the hospital directly for treatment.

5. Mostly planned elective surgery for which there may be a long waiting list in your country is best suited for medical tourism.

6. Decide on the country, hospital and doctor who would be treating . This information

would be available through the net or from recommendation by another patient. Visit the website of the hospital and doctor is the next step. Writing and asking about their training and experience in the procedure along with the cost implications is vital.

FOR COMPLETE REPORT AND DOWNLOADING VISIT HTTP://PAKISTANMBA.JIMDO.COM

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Labels: internship reports, Projects

Final Project of Indian Railways

Introduction of Indian Railways ³A Super Navratna´

Type: Departmental undertaking of The Ministry of Railways, Government of India. Founded: 26th April 1853 Headquarter: New Delhi, India. Area server: India Union Railway Minister: Mamata Banerjee. Ministers of State for Railways: E. Ahamed and K. H. Muniyappa. Chairman, Railway Board: S. S. Khurana. Industry: Railways and Locomotives. Services: Rail transport. Revenue: Rs. 107.66 billion (US$19.13 billion).

Employees: 1,406,430 (2007) Parent: Ministry of Railways, Government of India. Divisions: 16 Railway Zones, further divided into 67 divisions.

*** www.indianrailways.gov.in

India is the land of diverse culture and Indian Railways play a key role in not only meeting the transport needs of the country, but also in binding together dispersed areas and promoting national integration.Railways in India provide the principal mode of transportation for freight and passengers. The Indian Railways have been a great integrating force during the past 150 years and more. It has bound the economic life of the country and helped in accelerating the development of industry and agriculture. From a very modest beginning in 1853 it has played a vital role in the economic, industrial and social development of the country. The Indian Railways operates the world¶s second largest rail network under a single management. The network runs multi-gauge operations extending over 63,327 route kilometres. In terms of infrastructure it operates more than 14,444 trains backed by 7,739 locomotives and 39,263 coaches. Thus it is one of the largest and busiest railway networks in the world carrying sixteen million passengers on a daily basis. It also carries more than one million tonnes of freight on a daily basis and with the employee strength surpassing 1.6 million is also one of the biggest commercial employers and is only next to Chinese Army in terms of people recruited by it. The main characteristic of the Indian Railways is that it is an independent, corporatized, customer focused, and financially viable railway; run along commercial principles and subject to generally accepted corporate accounting principles and reporting. The Indian Railways Corporation (IRC) is responsible for managing railway assets and resources to meet the objectives of Indian Railways. The Indian Railway Executive Board (IREB) manages IRC and is responsible for restructuring process.The functions of the Indian Railways can be divided into core and non-core activities. # The core activities comprise transportation of passengers (Running of trains and owning of assets). freight and

# The non-core activities comprises catering, running schools and colleges for the children of the railway staff, medical healthcare facilities for the railway staff production units and workshops, protection force for the safety of railway assets & maintenance of an exclusive telecommunications network etc.

History
Indian Railways.... the golden Era
16th April, 1853...............The Beginning The novel plan for the introduction of a rail system, transformed the whole history of India. This innovative plan was first proposed in 1832; however no auxiliary actions were taken for over a decade. In the year 1844, private entrepreneurs were allowed to launch a rail system by Lord Hardinge, who was the Governor-General of India. By the year 1845, two companies were formed and the East India Company was requested to support them in the matter. The credit from the UK investors led to the hasty construction of a rail system over the next few years. On 22nd Dec' 1851, the first train came on the track to carry the construction material at Roorkee in India. On September 22, 1842, British civil engineer Charles Blacker Vignoles, submitted a Report on a Proposed Railway in India to the East India Company.[1] By 1845, two companies, the East Indian Railway Company operating from Calcutta, and the Great Indian Peninsula Railway (GIPR) operating from Bombay, were formed. With a passage of one and a half years, the first passenger train service was introduced between Bori Bunder, Bombay and Thana on the providential date 16th Apr' 1853. This rail track covered a distance of 34 kms (21 miles). Ever since its origin, the rail service in India never turned back. The British Government approached private investors and persuaded them to join the race with a system that would promise an annual return of 5% during the early years of operation. Once finished, the company would be transferred under the Government ownership, yet the operational control will be enjoyed by the original company. In 1880, the rail network acquired a route mileage of about 14,500 km (9,000 miles), mostly working through Bombay, Madras and Calcutta. By 1895, India had started manufacturing its own locomotives. In no time, different kingdoms assembled their independent rail systems. In 1900, the GIPR became a government owned company. The network spread to modern day states

of Assam, Rajasthan and Andhra Pradesh and soon independent kingdoms began to have their own rail systems.

various

In 1901, an early Railway Board was constituted, but the powers were formally invested under Lord Curzon. It served under the Department of Commerce and Industry and had a government railway official serving as chairman, and a railway manager from England and an agent of one of the company railways as the other two members. For the first time in its history, the Railways began to make a profit.. In 1901, a Railway Board was formed though the administrative power was reserved for the Viceroy, Lord Curzon. The Railway Board worked under the guidance of the Deptt of Commerce and Industry. It was comprised of three members - a Chairman, a Railway Manager and an Agent respectively. For the very first time in its history, the Railways instigated to draw a neat profit. In 1907, most of the rail companies were came under the government control. Subsequently, the first electric locomotive emerged in the next year. During the First World War, the railways were exclusively used by the British. In view of the War, the condition of railways became miserable. In 1920, with the network having expanded to 61,220 km, a need for central management was mooted by Sir William Acworth. Based on the East India Railway Committee chaired by Acworth, the government takes over the management of the Railways and detaches the finances of the Railways from other governmental revenues. The period between 1920 to 1929 was a period of economic boom. Following With the Second World War, the railways got incapacitated since the trains were diverted to the Middle East ( the Great Depression, the company suffered economically for the next eight years). The Second World War severely crippled the railways. Trains were diverted to the Middle East and the railways workshops were converted to munitions workshops. By 1946 all rail systems were taken over by the government. On the occasion of India's Independence in 1947, the maximum share of the railways went under the terrain of Pakistan. The existing rail networks were forfeited for zones in 1951 and 6 zones were formed in 1952. With 1985, the diesel and electric locomotives took the place of steam locomotives. In 1995, the whole railway reservation system was rationalized with computerization.

Growth
Start of Indian Railways
Following independence in 1947, India inherited a decrepit rail network. On the whole, 42 independent railway systems with thirtytwo lines were merged in a single unit and were acknowledged as Indian Railways & hence it earned the distinction of being one of the largest railway networks in the world.. About 40 per cent of the railways then passed through the newly independent republic of Pakistan. A large number of lines had to be rerouted through Indian territory, and new construction had to be undertaken. Underinvestment and unproductive management and maintenance practices have sharply curtailed growth in route length. A total of forty-two separate railway systems, including thirty-two lines owned by the former Indian princely states existed at the time of independence spanning a total of 55,000 km. These were amalgamated into the Indian Railways.

In 1951, the rail networks were abandoned in favour of zones. A total of six zones came into being in 1952. As India developed its economy, almost all railway production units started to be built indigenously. Broad Gauge became the standard, and the Railways began to electrify most lines to AC. In 1985, steam locomotives were phased out.

Under Rajiv Gandhi, reforms in the railways were carried out. In 1987, computerisation of reservation first was carried out in Bombay and in 1989 the train numbers were standardised to four digits. In 1995 the entire railway reservation was computerised through the railways intranet. In 1998, the Konkan Railway was opened, spanning difficult terrain through the Western Ghats. Few of the recent developments include construction of Calcutta Metro and Delhi Metro.

History of Railway in India- Important Years
y y y y y y y y y y

1832- Plans were proposed to introduce a rail network in India. 1844- Private entrepreneurs set up a private rail system in India. 1851- Trains became operational. 1853- Passenger trains were introduced. 1875- 95 million pounds were invested into Indian railways by British companies. 1895- Indian locomotives began to operate in the country. 1901- A Railway Board was established. 1907- The government obtained total control over most of the rail companies. 1908- First electric locomotive was introduced. 1947- 40% of the railway network came under Pakistan's possession.

History of Indian Railways- Important Years After India obtained independence from the British, the rail network in the country was christened as the Indian Railways.
y y y y

1951- Nationalization of the rail system in India took place. 1952- Six railway zones were introduced. 1995- Steam locomotives became obsolete. Only diesel and electric locomotives were operational. 1987-1995- The Indian Railways reservation system was computerised.

Railways (Post Reforms)
Post reforms in the 1990's the progress of the railways was not satisfactory. The Rakesh Mohan Committee report suggested that the railways needed a complete overhaul if any progress had to be made. Since it was not that easy from a political point of view, it was not given due importance by the inner circle in the railways. But with the appointment of Mr. Lalu Prasad in 2004 as railway minister, things changed dramatically. In the next five years the minister and his team worked out a strategy to bring about a complete turnaround in the working of the railway. Currently Mamata Banerjee has chalked out future plans for railways which seem optimistic and achievable.

The economic turn-around was a result of :y y y

Higher freight volumes. Increased occupancy in passenger trains. Monitor costs and reduce tariffs.

The railways have managed to improve their market share and operating margins. The government has been credited with pursuing inclusive reforms, without comprising on the social obligation. The railways have been applauded for improved customer service and for reducing passenger fares.

Some of the salient features of the reform are:
y A well planned strategy to build around capacity generation through optimization of the existing infrastructure and assets. y Adopting a different approach to the social and commercial segment of the traffic. y Increasing the passenger carrying capacity of important trains. Improved operational efficiency meant the unit cost of operation reduced. y Dynamic and market driven tariff policy linked to seasonality and price elasticity of demand. y The policy of overhaul increase in freight rates has been replaced by a system of differential tariff based on market conditions. y Tremendous growth in traffic volumes, revenues and surpluses has proven the fact that the process of globalization has brought positive results for everyone concerned.

The Future Prospects
y The railways have devised a planned strategy to remove bottlenecks and increase capacity to meet the demand. The key areas of focus would be up gradation of infrastructure, modernization of wagons technology, advanced signaling and telecommunication, induction of high horse power locomotives, grade separation and usage of information technology to decrease transit times and reduce unit operational cost. The railways also propose to construct state of the art passenger and freight terminals bench. y Over the next 5 to 10 year the government plans to give utmost priority to low cost, rapid pay back and high return investments with the view of speeding up works on doubling railway line, port connectivity, gauge conversion, signaling and telecom, renewal of assets and modernization of passenger terminals. y The government has initiated private investments in major stations to create world class passenger amenities and services.

y There is an increase in demand for coaches. The government has proposed to meet the increase in demand partly through increase in the capacity in the existing production units and partly by setting up a new manufacturing unit through a joint venture under Public Private Partnership (PPP).

The railways are also planning to build a super specialty hospital in Patna. If successful, the concept would be extended to other parts of the country.
y

HUMAN RESOURCE
Human Resource
Manpower is the most valuable asset in any organization, more so in IR which is highly labour intensive. The Indian Railways with a work force of nearly 1.5 million is one of the biggest employers in the world. To have the optimum output from the workforce, higher motivation level and stress free environment is to be ensured. Suiting the job requirements, skills of manpower have to be suitably developed requiring adequate attention in their training facilities.

Organisational structure
Indian Railways is a department owned and controlled by the Government of India, via the Ministry of Railways as on May 2009, the Railway Ministry is headed by Mamata Banerjee, the Union Minister for Railways and assisted by two ministers of State for Railways. Indian Railways is administered by the Railway Board, which has a financial commissioner, five members and a chairman.

Indian Railways is divided into zones, which are further sub-divided into divisions. The number of zones in Indian Railways increased from six to eight in 1951, nine in 1952, and finally 16 in 2003. Each zonal railway is made up of a certain number of divisions, each having a divisional headquarters. There are a total of sixty-seven divisions.

Each of the sixteen zones, as well as the Kolkata Metro, is headed by a General Manager (GM) who reports directly to the Railway Board. The zones are further divided into divisions under the control of Divisional Railway Managers (DRM). The divisional officers of engineering, mechanical, electrical, signal & telecommunication, accounts, personnel, operating, commercial and safety branches report to the respective Divisional Manager and are in charge of

operation and maintenance of assets. Further down the hierarchy tree are the Station Masters who control individual stations and the train movement through the track territory under their stations' administration. There are six production units (PUs) each headed by a General Manager (GM), who also report directly to the Railway Board.

The production units are:
1. 2. 3. 4. 5. 6. Chittaranjan Locomotive Works: Chittaranjan Diesel Locomotive Works: Varanasi Integral Coach Factory: Perambur (Near Chennai) Rail Coach Factory: Kapurthala Rail Wheel Factory: Yelahanka (Near Bangalore) Diesel Modernisation Works: Patiala

In

addition

to

this

the

Central

Organisation for Railway Electrification (CORE) is also headed by a GM. This is located at Allahabad. This organisation undertakes electrification projects of Indian Railway and monitors the progress of various electrification projects all over the country.

Apart from these zones and production units, a number of Public Sector Undertakings (PSU) are under the administrative control of the ministry of railways.

These PSUs in Ministry of Railways are:
1. 2. 3. 4. 5. 6. 7. 8. Indian Railways Catering and Tourism Corporation Konkan Railway Corporation Indian Railway Finance Corporation Mumbai Rail Vikas Corporation Railtel Corporation of India ± Telecommunication Networks RITES Ltd. ± Consulting Division of Indian Railways IRCON International Ltd. ± Construction Division Rail Vikas Nigam Limited

***Centre for Railway Information Systems is an autonomous society under Railway Board, which is responsible for developing the major software required by Indian Railways for its operations.

Personnel
The number of regular employees in Indian Railways as on 31.3.2007 stood at 1,406,430. The Indian Railways with such a work a huge workforce is one of the biggest employers in the world. To have the optimum output from the workforce, higher motivation level and stress free environment is to be ensured. Suiting the job requirements, skills of manpower have to be suitably developed requiring adequate attention in their training facilities. Now when we talk about workforce, we are including both executives as well as labourers. The Management personnel (Groups A & B ) constitute up 1.1% of the total strength, while Group C and D account for 64.5% and 34.4% respectively. Of the employees in Group C and D, 4.44 lakhs (31.96%) are workshop employees and artisans and 9.46 lakhs (68.04%) from other categories including running staff. Railway Protection Force/RPSF personnel totalled 60,704. In the non-gazetted cadres, the ratio of Group C to D changed from 25:75 in 1950-51 to 65:35 in 2006-07, indicating a shift towards induction of skilled manpower.

PERSONNEL

Group A+B Group C Group D

Wage bill including pension etc. during 2006-07 was Rs.24,354.6 crores registering an increase of Rs.434.7 crores over the previous year. The average wage per employee was up by 2.6 % from Rs.1,69,770 per annum in 2005-06 to Rs.1,74,112 per annum in 2006-07. The ratio of staff cost on open line (excluding payment towards pension and gratuity) to ordinary working expenses (excluding appropriation to DRF and Pension Fund) was 46.7%. Recruitment and Training Indian Railways is the largest civilian employer in the world at approximately 1.6 million employees. 1200 officers form the line and staff management organisation. The recruitment of the Officers (Group 'A' service) is done through the Indian Engineering Services examination conducted by the Union Public Service Commission (UPSC); and also through the Special Class Railway Apprentices (S.C.R.A.) exam conducted by UPSC. The recruitment to Group 'C' and 'D' employees on the Indian Railways is done through 19 RRBs (Railway Recruitment Boards) which are controlled by the Railway Recruitment Control Board (RRCB). The training of all cadres is entrusted and shared between six centralised training institutes.

Recruitment and Training
There have been dynamic change in the technology and modernisation, electrification, computerisation, mechanisation of track maintenance etc. are taking place at fast rate to meet the challenges of traffic requirements in Indian Railways. To meet the challenges of the changing environment, systematic manpower planning is essential. Therefore a category-wise analysis of staff should be carried out, to identify surplus and to arrange manpower in the areas of need. This adjusts the surplus in one category to other categories, where there is demand. Manpower planning ensures that the existing manpower is utilised to the maximum possible extent. The Research, Design and Standards Organisation (RDSO) at Lucknow is the research and development wing of the Indian Railways.It functions as a consultant to the Indian Railways on technical matters. It also provides consultancy to other organisations connected with railway manufacture and design. RDSO has been reorganized with effect from January 1, 2003 by elevating its status

from µAttached Office¶ to µZonal Railway¶ to give it greater flexibility and a boost to the research and development activities. Modernisation and Up gradation of Training Centres As main Training Centres have already been granted Rs.73.5 crores out of the SRSF for up gradation, remaining training centres, including Basic Training Centres spread all over the Indian Railways are also proposed to be modernized with provision of necessary infrastructure at an overall outlay of Rs. 220 crores (inclusive of allotment under SRSF). Modernisation of training centres would cover institutions imparting training of various disciplines viz. Civil, Mechanical, Signalling and Electrical Engineering etc. Special emphasis shall be laid on training of bridge engineers and supervisors on regular and continuous basis, at least for next 5 to 6 years to adapt technologies appropriately. Following seven Centralized Training Institutes (CTI) cater to the training needs of railway officers:(i) Railway Staff College, Vadodara. (ii) Indian Railways Institute of Civil Engineering, Pune. (iii) Indian Railways Institute of Signal Engineering &Telecommunications, Secunderabad. (iv) Indian Railways Institute of Mechanical & Electrical Engineering, Jamalpur. (v) Indian Railways Institute of Electrical Engineering, Nasik. (vi) Indian Railways Institute of Transport Management, Lucknow. (vii) Jagjivan Ram Railway Protection Force Academy, Lucknow

ISO certification
In the long run it is desirable that all staff training centres and work centres would obtain ISO _ 9002 certification and the concept will be extended to all divisional control offices and stations and other work centres.

Promotion rules and procedure
Over a period of time, a question bank containing objective type questions with multiple-choice answers covering the entire syllabus will be built up. Data bank containing questions covering the entire syllabus will be made available to trainees. At Training Centres,

written examinations/test papers will contain objective type questions covering the entire syllabus in random order with multiple-choice answers. When any staff belonging to a safety category becomes overdue for periodic medical examination, refresher course or safety camp, he would not be permitted to continue on duty until he completes the stipulated training/examination. After recruitment, for initial training at ZTCs/STCs, pass marks may be upgraded. For promotional course training also, pass marks may be revised. Strength of staff and vacancies Staff requirement are proposed to be worked out afresh for zerobased assessment of manpower. Based on the exercise, sanctioned strength of staff may be revised and made uniform. Concept of multiskilling would be adopted. Categories having difficulties in filling up of promotional posts, existing AVCs may be revised. All Safety category vacancies would be filled up on urgency basis . Accountability for filling up of vacancies in safety categories will be clearly assigned at appropriate level.

Inspections
To improve quality of inspections, detailed check list of various types of inspections would be made out and circulated. The quality and compliance of inspections would be made an important plank of the management tools. Special safety audits by multi-disciplinary teams would be intensified. A computer data base would be prepared at the Divisional and Zonal Headquarters to assess the efficacy of field inspections.

Safety critical checks would be conducted by all inspecting officials. Safety test checks will be intensified as vigilance-like powers have been given to the safety organisation. As the element of surprise and the opportunity to observe performance of staff under actual working conditions in the field is of prime importance, surprise inspections give an accurate indication of health of the particular unit. Surprise inspections would be intensified, specially between 0 hrs. and 4 hrs. at night. Test checking of inspections of subordinate officers. Maintenance depots and other activity centres would also be covered by night inspection.

Periodical Safety Drives
Certain activities in the railway working, which are seasonal in nature, are neither required to be performed by staff nor required to be checked by supervisors during the course of normal working for the most part of the year. It is for these kind of activities that safety drives are generally targetted. Safety drives would be launched in order to correct a system failure, whenever detected. In the safety drives, all equipment that are to be attended would undergo a cyclic inspection before a particular season. Number, duration and contents of particular safety drives would be selectively decided to retain their focus and value.

Safety Audit
Inspections generally single out individual failures, safety audits are expected to identify system failures and generic shortcomings. Periodic safety audits would be undertaken at various levels for making an in-depth assessment of safety systems. These safety audits may be of many types viz, multi-disciplinary team from Railway Board, inter-Railway, multi- disciplinary headquarters team, inter-divisional, etc. The main purpose behind conducting safety audit

is to check only safety critical items and identify system failures or generic shortcomings. Railways will identify the worst sections on the divisions with unsatisfactory safety record. Teams would thoroughly audit different units pinpointing deficiencies including ancillary activities viz. staff training, material supply, availability of funds, defective policies/rules etc. Safety audits would be carried out at a number of installations within the target area. To promote devotion, dedication and sincerity towards duties, Human Resource Development (HRD) Cells are proposed to be constituted at Zonal, Divisional Headquarters involving dynamic and knowledgeable supervisors to study : (i) Working habits of ground level staff (ii) Factors leading to short cuts (iii) To reduce fatigue, minimize monotony and improve safety consciousness.

Strengthening of Railway Protection Force
To combat outside interference with railway installations like track and signalling equipments etc., it is proposed to equip Railway Protection Force/Railway Protection Special Force with specialized training, weaponry, vehicles and wireless communications and necessary backup support in terms of manpower and barracks. These personnel will also help in guarding railway bridges, microwave towers, route relay cabins and track in identified vulnerable sections.

Conclusion
In our railway system, though the system of recruiting, training, placing or posting and promotion are inherited from the system of British Railways, yet manpower planning is given importance only in late 70¶s, which envisages making of quality human resource towards attaining the goals of the organization duly giving importance as a service organization for transporting of goods and passenger services to all sorts of the people across the country.

Major Player
Monopoly of Indian Railways :
In economics, a monopoly (from the Latin word monopolium ± Greek language monos, one + polein, to sell) is defined as a persistent market situation where there is only one provider of a product or service. Monopolies are characterized by a lack of economic competition for the good or service that they provide and a lack of viable substitute goods. Monopoly should be distinguished from monopsony, in which there is only one buyer of the product or service; it should also, strictly, be distinguished from the (similar) phenomenon of a cartel. In a monopoly a single firm is the sole provider of a product or service; in a cartel a centralized institution is set up to partially coordinate the actions of several independent providers (which is a form of oligopoly).

Primary characteristics of a monopoly

Single Sellers - A pure monopoly is an industry in which a single firm is the sole
producer of a good or the sole provider of a service. This is usually caused by barriers to entry.

No Close Substitutes - The product or service is unique in ways which go
beyond brand identity, and cannot be easily replaced (a monopolyon water from a certain spring, sold under a certain brand name, is not a true monopoly; neither is Coca-Cola, even though it is differentiated from its competition in flavor).

Price Maker
In a pure monopoly a single firm controls the total supply of the whole industry and is able to exert a significant degree of control over the price, by changing the quantity supplied (an example of this would be the situation of Viagra before competing drugs emerged). In subtotal

monopolies (for example diamonds or petroleum at present) asingle organization controls enough of the supply that even if it limits the quantity, or raises prices, the other suppliers will be unable to make up the difference and take significant amounts of market share.

Blocked Entry
The reason a pure monopolist has no competitors is that certain barriers keep would-be competitors from entering the market. Depending upon the form of the monopoly these barriers can be economic, technological, legal (e.g. copyrights, patents), violent (competing businesses are shut down by force), or of some other type of barrier that completely prevents other firms from entering the market.

Price setting for unregulated monopolies

In economics a company is said to have monopoly power if it faces a downward sloping demand curve (see supply and demand). This is in contrast to a price taker that faces a horizontal demand curve. A price taker cannot choose the price that they sell at, since if they set it above the equilibrium price, they will sell none, and if they set it below the equilibrium price, they will have an infinite number of buyers (and be making less money than they could if they

sold at the equilibrium price). In contrast, a business with monopoly power can choose the price they want to sell at. If they set it higher, they sell less. If they set it lower, they sell more.

In most real markets with claims, falling demand associated with a price increase is due partly to losing customers to other sellers and partly to customers who are no longer willing or able to buy the product. In a pure monopolymarket, only the latter effect is at work, and so, particularly for inflexible commodities such as medical care, the drop in units sold as prices rise may be much less dramatic than one might expect.

If a monopoly can only set one price it will set it where marginal cost (MC) equals marginal revenue (MR) as seen on the diagram on the right. This can be seen on a big supply and demand diagram for many criticism of monopoly. This will be at the quantity Qm; and at the price Pm. This is above the competitive price of Pc and with a smaller quantity than the competitive quantity of Qc. The offensive monopoly gains is the shaded in area labeled profit (note that this diagram looks only at the case where there is no fixed cost. If there were a fixed cost, the average cost curve should be used instead). As long as the price elasticity of demand (in absolute value) for most customers is less than one, it is very advantageous to increase the price: the seller gets more money for less goods. With an increase of the price, the price elasticity tends to rise, and in the optimum mentioned above it will be above one for most customers. A formula gives the relation between price, marginal cost of production and demand elasticity which maximizes a monopoly profit: (known as Lerner index). The monopolist¶s monopoly power is given by the vertical distance between the point where the marginal cost curve (MC) intersects with the marginal revenue curve (MR) and the demand curve. The longer the vertical distance, (the more inelastic the demand curve) the bigger the monopoly power, and thus larger profits.

The economy as a whole loses out when monopoly power is used in this way, since the extra profit earned by the firm will be smaller than the loss in consumer surplus. This difference is known as a deadweight loss.

Suburban rail
Many cities have their own dedicated suburban networks to cater to commuters. Currently, suburban networks operate in Mumbai (Bombay), Chennai (Madras), Kolkata (Calcutta), Delhi, Lucknow, Hy derabad and Pune. Hyderabad, Mumbai and Pune do not have dedicated suburban tracks but share the tracks with long distance trains. New Delhi, Chennai and Kolkata have their own metro networks, namely the New Delhi Metro, the Chennai MRTS and the Kolkata metro, respectively. Suburban trains that handle commuter traffic are mostly electric multiple units. They usually have nine coaches or sometimes twelve to handle rush hour traffic. One unit of an EMU train consists of one power car and two general coaches. Thus a nine coach EMU is made up of three units having one power car at each end and one at the middle. The rakes in Mumbai run on direct current, while those elsewhere use alternating current. A standard coach is designed to accommodate 96 sitting passengers, but the actual number of passengers can easily double or triple with standees during rush hour. The Kolkata metro has the administrative status of a zonal railway, though it does not come under the seventeen railway zones.The Suburban trains in Mumbai handle more rush than any other suburban network in India. The network has three lines viz, western, central and harbour. It¶s considered to be the lifeline on Mumbai. Delhi Metro has been one of the recent additions in the suburban rail services systems available today in India.

KOLKATA METRO Kolkata Metro

Info Locale Kolkata, India Rapid transit 1 17

Transit type

The Kolkata Metro or Calcutta Metro Kolkata Metro) is the underground rail network in Kolkata (Calcutta), India. It is considered to have the status of a zonal railway . It is run by the Indian Railways. It was the first underground railway to be built in India, with operations starting in 1984; the New Delhi Metro, which opened in 2002, is the second. The line runs from Dum Dum in the north and continues south through Park Street,Esplanade in the heart of the city till the southern end to Tollygunge. The burgeoning transport

Number of lines Number of stations Operation Began operation Operator(s)

1984 Metro Railway, Kolkata

Technical System length Track gauge 16.5 km Broad Gauge

problem of Kolkata drew the attention of the city planners, the State Government and also the Government of India. It was soon realised that something had to be done and done quickly to cope with the situation

A survey was done by a team of French experts without any concrete results. Efforts to solve the problem by augmenting the existing fleet of public transport vehicles barely touched the fringe of the problem as the roads account for only 4.2% of the surface area in Calcutta, compared to 25% in Delhi and even 30% in other cities.[

With a view to finding an alternative solution, the Metropolitan Transport Project (Rlys)(i.e., Railways) was set up in 1969. After detailed studies, the MTP (Rlys) came to the conclusion that there was no other alternative but to construct a Mass Rapid Transit System. The MTP (Rlys) had prepared a Master Plan in 1971 envisaging construction of five rapid-transit lines for the city of Kolkata, totalling a route length of 97.5 km.

Of these, the highest priority was given to the busy North-South axis between Dum Dum and Tollygunge over a length of 16.45 km, and the work on this project was sanctioned on June 1, 1972. The foundation stone of the project was laid by Smt. Indira Gandhi, the then Prime Minister of India, on December 29, 1972, and the construction work started in 1973.

Delhi Metro

Much of Delhi Metro runs on elevated tracks along road medians The Delhi Metro is a rapid transit system in the Indian city of Delhi that was built and is operated by the Delhi Metro Rail Corporation Limited (DMRC). The first section of the Delhi Metro was opened on December 24, 2002. It became the second underground rapid transit system in India, after Kolkata. The Delhi Metro has a combination of elevated, at-grade and underground lines. The Delhi Metro has won numerous awards for its environmentally friendly practices from many renowned organisations including the United Nations, RINA, and ISO. Delhi Metro was the first metro in

the world to be ISO 14001 certified for environmentally friendly construction. The concept of a metro for Delhi was first formalized in the Delhi Master Plan of 1960, and the legal framework for the metro was laid out in the Metro Railways (Construction of Works) Act of 1978. Actual work towards building the metro, however, only started in March 5,1995, when the DMRC was established. After the previous problems experienced by the Calcutta Metro, which was badly delayed and 12 times over budget due to "political meddling, technical problems and bureaucratic delays", the DMRC was given full powers to hire people, decide on tenders and control funds. Mumbai Suburban Railway The Mumbai Suburban Railway system, part of the public transportation system of Mumbai, is provided for by the staterun Indian Railways' two zonal Western Railways and Central Railways. The system carries more than 6.6 million commuters on a daily basis and constitutes more than half of the total daily passenger capacity of the Indian Railways itself. It has one of the highest passenger densities of any urban railway system in the world. The trains plying on its routes are commonly referred to as local trains or simply as locals by the general populace. The Mumbai Suburban Railway, as well as Indian Railways, are an offshoot of the first railway to be built by the British in India in April 1853. This was also the oldest railway system in Asia. The first train ran between Mumbai and Thane, a distance of 34 km. The Bombay Railway History Group[1] has been striving to document railway heritage along this line. Given the geographical spread of the population and location of business areas, the rail network is the principal mode of mass transport in Mumbai. A metro system and a monorail system are under construction to ease the travelling conditions in the Suburban network.

Passenger services

Indian Railways operates 8,702 passenger trains and transports around five billion annually across twenty-seven states and three union territories (Delhi, Pondicherry and Chandigarh). Sikkim is the only state not connected.

The passenger division is the most preferred form of long distance transport in most of the country. In South India and North-East India however, buses are the preferred mode of transport for medium to long distance transport.

A standard passenger train consists of eighteen coaches, but some popular trains can have up to 24 coaches. Coaches are designed to accommodate anywhere from 18 to 72 passengers, but may actually accommodate many more during the holiday seasons and on busy routes. The coaches in use are vestibules, but some of these may be dummied on some trains for operational reasons. Freight trains use a large variety of wagons.

Each coach has different accommodation class; the most popular being the sleeper class. Up to nine of these type coaches are usually coupled. Air conditioned coaches are also attached, and a standard train may have between three and five air-conditioned coaches.

Overcrowding is the most widely faced problem with Indian Railways. In the holiday seasons or on long weekends, trains are usually packed more than their prescribed limit. Ticket-less travel, which results in large losses for the IR, is also an additional problem faced.

Production Services

. The interior of an Express Train in India. Food is being served by an Indian Railways employee The Indian Railways manufactures a lot of its rolling stock and heavy engineering components. This is largely due to historical reasons. As with most developing economies, the main reason is import substitution of expensive technology related products. This was relevant when the general state of the national engineering industry was immature.

Production Units, the manufacturing plants of the Indian Railways, are managed directly by the ministry. The General Managers of the PUs report to the Railway Board. The Production Units are,Diesel Locomotive Works, Varanasi responsible for manufacturing all the mainline dieselelectrics used for passenger and freight traffic. The plant also produces diesel-electric shunters. Currently the factory is also producing locomotives in collaboration with General Motors, USA.

Chittaranjan Locomotive Works, Chittaranjan manufactures Electric Locomotives. Traditionally, the locomotives made by CLW use DC traction. In recent times, CLW has manufactures locomotives with AC-AC transmission.

Diesel-Loco Modernisation Works, Patiala-Earlier called Diesel Component Works, DMW makes key sub-assemblies for Diesel Locomotives. It also does heavy repair and overhaul of engines and locomotives.

Integral Coach Factory, Chennai-The first factory to make coaches for the Indian Railways. The coaches were monocoque structures.

Rail Coach Factory, Kapurthala-The second coach factory is a more modern plant and has a much more flexible automation.

Wheel & Axle Plant, Bangalore-Makes the cast wheels for wagons and other rolling stock. Axles are forged and machined in the same plant. Most output is sent out as finished and pressed wheel & axle sets.

Performance
The performance of Production Units during 2004-05, was as under,

y

Chittaranjan Locomotive Works, Chittaranjan manufactured 90 BG electric locomotives

including 22 state-of-the-art 3-phase 6000 HP electric locos. y Diesel Locomotive Works, Varanasi produced 121 BG diesel locomotives including 15

indigenous high power 4000 HP GM locomotives. In addition, 4 diesel locomotives were supplied to Non Railway Customers. y Integral Coach Factory, Chennai manufactured 1,119 coaches including 112 Electric

Multiple Units (EMUs). y Rail Coach Factory, Kapurthala manufactured 1,201 coaches including 77 light weight

LHB coaches with higher passenger comfort and amenities. y Rail Wheel Factory, Bangalore produced 32,732 wheel-sets. It also manufactured 95,125

wheels and 49,502 axles. It sold products to the tune of Rs.18.39 crore to NCRs thus earning a profit of approx. Rs.173.69 lakh.

Budget and Finances
The Railway Budget deals with planned infrastructure expenditure on the railways as well as with the operating revenue and expenditure for the upcoming fiscal years, the public elements of which are usually the induction and improvement of existing trains and routes, planned investment in new and existing infrastructure elements, and the tariff for freight and passenger travel. The Parliament discusses the policies and allocations proposed in the budget. The budget needs to be passed by a simple majority in the Lok Sabha (Lower House). The comments of the Rajya Sabha (Upper House) are non-binding. Indian Railways is subject to the same audit control as other government revenue and expenditures. Based on anticipated traffic and the projected tariff, requirement of resources for capital and revenue expenditure of railways is worked out. While the revenue expenditure is met entirely by railways itself, the shortfall in the capital (plan) expenditure is met partly from borrowings (raised by Indian Railway Finance Corporation) and the rest from Budgetary support from the Central Government. Indian Railways pays dividend to the Central Government for the capital invested by the Central Government. As per the Separation Convention (on the recommendations of the Acworth Committee), 1924, the Railway Budget is presented to the Parliament by the Union Railway Minister, two days prior to the General Budget, usually around 26th February. Though the Railway Budget is separately presented to the Parliament, the figures relating to the receipt and expenditure of the Railways are also shown in the General Budget, since they are a part and parcel of the total receipts and expenditure of the Government of India. This document serves as a balance sheet of operations of the Railways during the previous year and lists out plans for expansion for the current year.

The formation of policy and overall control of the railways is vested in Railway Board, comprising the Chairman, the Financial Commissioner and other functional members of Traffic, Engineering, Mechanical, Electrical and Staff departments. Indian Railways, which a few years ago was operating at a loss, has, in recent years, been generating positive cash flows and been meeting its dividend obligations to the government. The railway reported a cash surplus of INR 9000 cr in 2005, INR 14000 cr in 2006, INR 20,000 cr in 2007 and INR 25,000 cr for the 2007-2008 fiscal year. Its operating ratio improved to 76% while, in the last four years, its plan size increased from INR 13,000 cr to INR 30,000 cr. The proposed investment for the 2008-2009 fiscal year is INR 37,500 cr, 21% more than for the previous fiscal year.[2] Budget Estimates2008 for Freight, Passenger, Sundry other Earnings and other Coaching Earnings have been kept at INR 52,700 cr, INR 21,681 cr, INR 5,000 cr and INR 2,420 cr respectively.

Maintaining an overall double digit growth, Gross Traffic Earnings have been projected as INR 93,159 crore in 2009-10 (19.1 billion USD at current rate), exceeding the revised estimates for the current fiscal by INR 10,766 crore. Around 20% of the passenger revenue is earned from the upper class segments of the passenger segment (the air-conditioned classes). On 3rd July 2009 Railway Minister Mamata Banerjee presented the Railway Budget 2009-2010, which included many improvements.

The Ministry of Railways in India is in charge of the Indian Railways, the state-owned company that enjoys a monopoly in Rail transport in India. The Railway Board which is the apex body of the Indian Railways reports to this ministry. Shri. S.S.Khurana took over as the Chairman of the Railway Board recently.

Thanks to historical reasons, the Ministry of Railways presents a budget separate from the general budget of India. The practice started in 1924. At that time, the Railway Budget formed about 70% of the country's budget. So separating it out allowed better focus on each budget's priorities. The Railway Budget now is less than 15% of the national budget. Though the Railway budget can no longer be justified as a separate budget presentation, it is still watched eagerly as the annual fare and tariff setting event. It was in the historic year of 1921, when the recommendation of the Acworth Committee ratified through the Resolution for separation in 1924 when for the first time the Indian Railway finances were separated from the General Finances. This segregation of Railway Finances together with acceptance in principle at least of the responsibility for the direct operation of its Railways was a watershed moment in the history of Railways as a whole. With the recommendations not only was the segregation of Railway Finance clearly established, but the office of the Financial Commissioner was envisaged in an embryonic manner, and accordingly, the first Financial Commissioner was appointed on 1st April 1923. The necessity of such an appointment was thus emphasized by the Acworth Committee, The large financial responsibility of the department being perhaps sufficient justification in itself for the addition to the organization of a member competent to advise on the questions of great financial magnitude. Accordingly, from 1st April 1929, the responsibility for the compilation of accounts for the Railways was taken over by the Financial Commissioner, Railways from the Auditor General. The Accounts organisation was thus brought under the control of the Financial Commissioner, Railways, and the Indian Railway Accounts Service was constituted simultaneously.

Budgetary Details
A. Budget Terms

1. Budget Estimates.²Every Railway Administration has to prepare estimates of expenditure expected to be incurred by it in a year and submit them on prescribed dates well in advance of the beginning of that year to the Railway Board for obtaining the sanction of the Parliament or the President. Such estimates are called '" Budget Estimates ". 2. Demands for Grants.²On the basis of the Budget Estimates received from the various Railway Administrations and other spending units, the Railway Board prepare their " Demand for Grants " and present them to the Parliament or the President, as the case may be, for sanction. 3. Grants and Appropriations.²The ' Demands for Grants ' as finally approved by the Parliament are called the Budget ' Grants ' and those sanctioned by the President without reference to the Parliament are called ' Appropriations '. 4. (i) Budget Orders and Allotments.²The Railway Grants and Appropriations for a year are distributed by the Railway Board to the various Railway Administrations and other spending units directly under the Railway Board through what are known as ' Budget Orders'. The Budget Orders are accompanied by the Budget Documents. (ii) The Grants and Appropriations distributed to the various Divisions and spending units are called Budget ' Allotments '.

5. Re-appropriation.²The transfer of funds originally assigned for expenditure on a specific object to supplement the funds sanctioned for another object is called " Re-appropriation ". The powers of the Railway Board and Railway Administration in respect of reappropriation are detailed in Chapter III of the Indian Railway Financial Code Volume I (extracts at Annexure ' 11 '). 6. Review of Expenditure.²The sufficiency or otherwise of the

sanctioned budget allotments shall be reviewed periodically by each Railway Administration on the basis of expenditure actually incurred upto the time of review and the anticipated expenditure during the remaining portion of the financial year. The detailed procedure in regard to review of Expenditure is contained in Chapter III of the Indian Railway Financial Code, Volume I (extracts at Annexure ' 12 '). B. Demands for Grants.²All revenue working expenses of the Railway are classified under 13 sub major heads with separate abstract for each sub major head. The sub major heads are divided into minor, sub and detailed heads as detailed in Volume II of the Indian Railway Financial Code Estimates for Working Expenses or Revenue Budget C. Works, Machinery and Rolling Stock Budget Detailed instructions for preparation and submission of Works, Machinery and Rolling Stock Budget are contained in Chapter III of Indian Railway Financial Code, Volume I). The classification of expenditure by primary units of expenditure are contained in Volume II of the Financial Code.

Frequently Asked Railway Budget Questions:
Is it necessary to have a separate budget for the Railways ? The Indian Railways is one of several arms of the government. It is like any other government department engaged in commercial activity (such as telecommunications, posts and telegraph). There is a ministry of railways, headed by a minister answerable to Parliament. The fund requirements of the Indian Railways are mentioned in the annual financial statement tabled in Parliament in pursuance of Article 112. Also, Article 114 dealing with the Appropriations Bill applies to the Indian Railways. Strictly speaking, there is no constitutional requirement for a separate Rail Budget. All the mandatory things which the Rail Budget seeks to do can be done by the Union Budget. Why then do we need a separate Rail Budget? First, owing to tradition. railway finances were separated from general finances in the government budget of 1924. The Railway Board was expanded to have a financial commissioner in pursuance of a resolution, popularly known as the µSeparation Convention¶, adopted by the then Central Legislative Assembly. The first Railway Budget was presented in 1925. The second reason for a separate Rail Budget is the scale of operations and quantum of funds involved. The network of Indian Railways covers 63,000 km of rail route. It runs around 15,000 trains everyday and is of great strategic importance for the nation. What does the Rail Budget seek to do? Like any other budget, it too seeks to align receipts and expenditure, and also find resources for the modernisation of the organisation, keeping in view future requirements. In addition to meeting the operating expenses, the Rail Budget will be required to find resources for the Integrated Railway Modernisation Plan (2005-2010), estimated to cost Rs 24,000 crore, spread over five years. As a major portion of the funds will flow to the Railways in the form of borrowings and support from the Union Budget, the Railways will need to generate adequate resources for servicing the inflows.

What are the main sources of earnings for the Railways? The two basic sources are freight charges and passenger fares. The Railways also generates some income from other operations, but it is neither significant nor related to the core operations of the organisation. The Railways generates a bulk of its revenue by transporting goods. During 2005-06, it was expected to earn Rs 33,480 crores as freight charges. The target is likely to be exceeded. From passenger traffic, the Railways is estimated to earn Rs 15,080 crore, which is almost half the amount it earns from freight. Although the Railways earns more from freight, it accords greater focus to passenger services. What is cross-subsidy? The practice of undercharging from passengers, especially at the lower end of the spectrum, and overcharging on freight transport is broadly called cross subsidisation. Basically, it means that freight is overcharged to make up for losses on account of low realisation from passenger fares. While the Railways does so to make a journey affordable to a larger number of people, the industry feels the heat, as higher freight charges make manufactured goods dearer. Railway minister will have to balance the expectations of the two sections of rail users. What is operating ratio? It is a standard measure for judging the financial health of the Railways. What it means is how many units the Railways spends to earn 100 units. In the Indian context, it would mean the rupees needed by the Indian Railways to earn Rs 100. The lower the ratio, the better the health of the Railways. The Indian Railways¶ operating ratio has been decreasing after touching an alarming high of 98.3% in 2000-01. It is expected to improve from 91.2% (March 2005) to 90.8% at the end of the current fiscal. It would be the lowest operating ratio in the last eight years. In the recent past, the best operating ratio, of 82.5%, was witnessed in 1995-96.

Product Profile

Notable trains and achievements
The Darjeeling Himalayan Railway is a World Heritage Site, and one of the few steam engines in operation in India.

The Darjeeling Himalayan Railway, a narrow gauge train with a steam locomotive is classified as a World Heritage Site by UNESCO. The route starts at Siliguri in the plains in West Bengal and traverses tea gardens en route toDarjeeling, a hill station at an elevation of 2,134 metres (7,000 ft). The highest station in this route is Ghum. The Nilgiri Mountain Railway, in theNilgiri Hills in southern India, is also classified as a World Heritage Site by UNESCO. It is also the only rack railway in India. The Chatrapati Shivaji

Terminus (formerly Victoria Terminus) railway station in Mumbai is another World Heritage Site Operated by IR.

The Rajdhani Express is a series of trains that journey to and from the Capital New Delhi. Shown here are two Rajdhani Trains approaching each other

The Palace on Wheels is

a specially designed

train, lugged by a steam engine, for promoting tourism in Rajasthan. The Maharashtra government did try and introduce the Deccan

Odyssey along the Konkan route, but it did not enjoy the same success as the Palace on Wheels. The Samjhauta Expresswas a train that ran between India and Pakistan. However, hostilities between the two nations in 2001 saw the line being closed. It was reopened when the hostilities subsided in 2004.

Another

train

connecting Khokhrapar(Pakistan)

and Munabao (India)

is

the Thar Express that restarted operations on February 18, 2006 since being closed down after the 1965 Indo-Pak war. The Kalka Shimla Railway till recently featured in the Guinness Book of World Records for offering the steepest rise in altitude in the space of 96 kilometers.

The Lifeline Express is a special train popularly known as the ³Hospital-on-Wheels´ which provides healthcare to the rural areas. This train has a compartment that serves as an operating room, a second one which serves as a storeroom and an additional two that serve as a patient ward. The train travels around the country, staying at a location for about two months before moving elsewhere. Among the famous locomotives, the Fairy Queen is the oldest running locomotive in the world today, though the distinction of the oldest surviving locomotive belongs to John Bull. Kharagpur railway station also has the distinction of being the world¶s longest railway platform at 1072 m (3,517 ft). The Ghum station along the Toy Train route is the second highest railway station in the world to be reached by a steam locomotive.[5] Indian Railways operates 7,566 locomotives; 37,840 Coaching vehicles and 222,147 freight wagons. There are a total of 6,853 stations; 300 yards; 2,300 goods-sheds; 700 repair shops and a total workforce of 1.54 million.

The Deccan odyssey is a new line of tourist trains that travel across the Indian State of Maharashtra. The shortest named station is Ib and the longest is Sri Venkatanarasimharajuvariapeta. The Himsagar Express, between Kanyakumari and Jammu Tawi, has the longest run in terms of distance and time on Indian Railways network. It covers 3,745 km (2,327 miles) in about 74 hours and 55 minutes.

The Trivandrum Rajdhani, between Delhi¶s Nizamuddin Station and Trivandrum, travels nonstop between Vadodara and Kota, covering a distance of

528 km (328 miles) in about 6.5 hours, and has the longest continuous run on Indian Railways today. The Bhopal Shatabdi Express is the fastest train in India today having a maximum speed of 140 km/h (87 mph) on the Faridabad-Agra section. The fastest speed attained by any train is 184 km/h (114 mph) in 2000 during test runs. This speed is much lower than fast trains in other parts of the world. One reason attributed for this difference is that the tracks are not suited for higher speeds.

Challenges Facing Indian Railways
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To increase operational efficiency Improve productivity from existing systems Streamline and optimize business procedures To be responsive to business constituents Create end-to-end visibility into the business Make the information accessible and actionable To provide adaptability to change

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Re-act quickly to threats and opportunities Turn I.T. into a competitive business asset To support higher demand for Freight and Passenger transport, with planned economic growth Need for capacity enhancement in the Railway network over the next 10-15 years Technological up gradation for better maintenance of railway assets To fight back the greater competition from Roadways, with major investments in Highway network up gradation Increase freight market share through higher availability of services at competitive prices Greater attention to passenger services and safety To manage heavily subsidised passenger fares & distorted passenger fares pricing Up gradation of the Railway Production units for improved efficiency and productivity

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Labels: Projects