On April 17, a Nigerian man named Tobi Ajisegbede wrote a long Twitter thread about the death of his mother, alleging it was caused by medical negligence and malpractice at Manipal Hospital in Bengaluru. The hospital, however, has insisted that “despite best possible care, patient had a prolonged hospitalisation and succumbed to the illness”.

This may indeed have been one of those unfortunate cases of a surgical procedure resulting in death despite all medical protocols being adhered to. But the case highlighted the lack of support for foreign patients in India. Despite being a top destination for medical tourism, India has a poorly regulated private medical sector.

Ajisegbede’s mother, 58, had been diagnosed with degenerative lumbar canal stenosis, a condition in which the spinal canal narrows and compresses spinal nerves, causing pain in the back and legs and leading to difficulty in walking. The condition is commonly treated by decompression surgery on the spine.

The woman’s conditioned was diagnosed at Vedic Lifecare Clinic, a hospital in Lagos city set up with clinical and management support from the Manipal Health Enterprises. She was subsequently referred to Manipal Hospital in Bengaluru for surgery. At the time, Ajisegbede said, he was told the treatment would cost an estimated $10,000, nearly Rs 7 lakh. He was shocked, he added, when just before the operation the hospital said the cost would be double the estimate – $20,000 or around Rs 14 lakh.

They went ahead with the surgery. But after being discharged, Ajisegbede said, his mother developed infections and complications from the procedure. She had to be hospitalised repeatedly until April 14, when the infections led to multiple organ failure and she died.

Ajisegbede wrote about how he repeatedly tried to contact representatives at Vedic Lifecare in Lagos for support but got no response from them.

Manipal Hospital replied to a query from Scroll.in about the case saying the risks of the surgery, including paralysis and infection, were explained to and consent taken from the patient.

Here is the statement from the hospital’s spokesperson in full:

“58-year-old lady from Nigeria underwent a high risk complex spine surgery at Manipal Hospital on 04/12/2018. Possible risks/complications including paralysis/infection were well explained and a high risk consent taken from the patient. Post operatively patient was walking and was discharged in a stable condition. Unfortunately the patient developed an infection about 10 days after surgery.

Infection is a known complication which  was recognised immediately and she was started on appropriate treatment keeping the best interests of the patient in mind without financial considerations.

Despite best possible care, patient had a prolonged hospitalisation and succumbed to the illness. Patient’s family were informed about the clinical condition on a regular basis of the clinical condition throughout the treatment period. There has been no deficiency of services and in this case death is due to a known complication. An independent second opinion was taken which also concurred with the line of treatment. We sympathise with the patient’s family for the loss and have extended all possible assistance to them.   

Unfavourable outcomes and complications may happen on a few occasions despite all possible efforts. It is unfortunate that the treating doctor and the hospital that provided best possible care are being portrayed negatively based on an incomplete comprehension of facts.”

Medical tourism

India is considered a top medical tourism destination, along with Thailand and Singapore, largely because it boasts advanced medical facilities, skilled medical practitioners fluent in English and cheaper treatment costs than in hospitals in the West. Government agencies such as Niti Aayog as well as industry bodies such as the Federation of Indian Chambers of Commerce and Industry refer to Medical Value Travel as a source of substantial revenue and foreign exchange.

According to government data from December 2018, around five lakh foreigners visit India for medical and wellness purposes a year. The number almost doubled between 2015 and 2016. They bring over $25 billion in foreign exchange earnings.

The government is promoting medical tourism in many ways – offering hospitals marketing development assistance, allowing medical visas, setting up facilitation counters at major airports, launching a website to provide information on medical tourism in the country and constituting a National Medical and Wellness Tourism Board.

But India’s vast private medical sector, which is were most international patients seek treatment, is largely unregulated.

Cost escalation

Ajisegbede’s story is not uncommon. Even where there is no malpractice or negligence, complications from surgery frequently escalate treatment costs.

“It happens a lot with local patients also where you come in with an illness, there is an estimate given, and things go wrong and costs escalate,” said Mumbai surgeon Dr Sanjay Nagral. “In the case of medical tourism, it is probably a shade exaggerated because people think these patients are very rich. Most hospitals charge them higher than local patients.”

Nagral claimed this kind of cost escalation, which might even lead to catastrophic expenditure, cannot be completely stopped. A few cases are inevitable, he argued. Currently, any financial relief to a patient at a private hospital depends entirely on whether the doctor or the hospital is willing to help.

“The problem with a foreign patient is that you cannot just send them back,” said Nagral. “With a local patient, if things are going haywire, we transfer them to a smaller facility or get a [charitable] trust to help [with medical bills]. All sorts of firefighting measures can be done which cannot be done with foreign patients.”

Poor regulation

Dr George Thomas, chief orthopaedic surgeon at St Isabel’s Hospital in Chennai, said that the poor implementation of existing regulations is a major problem.

“When there is no government regulation of costs, then it is a negotiation between the hospital and the patient,” he explained. “The hospital states the cost for surgery and the patient can accept or not accept and not go for surgery.”

If the government wants to promote medical tourism and give all patients the same protections irrespective of where they come from, it must ensure regulations like the codes of the National Accreditation Board of Hospitals and Healthcare Providers are implemented properly.

“The idea of NABH is to introduce protocols but there is no way to force individual doctors to follow the protocols,” Thomas said. “Unless the hospital administration is very strong, protocols can be violated.”

Another critical aspect of medical tourism is the availability of data on medical procedures, but it is severely lacking in India. “In India, nobody publishes infection rates in hospitals,” said Thomas. “In well-regulated systems like Sweden and other places in western Europe, this kind of data is collected. There are a lot of things in India that we do not know because we do not have data and it is not a regulatory requirement to collect such data. Patients have no good source of information.”

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