A recent article in the British Medical Journal entitled “Corruption ruins the doctor-patient relationship in India” made me feel quite ashamed for my country and my chosen profession. The author, David Berger, a district medical officer in Australia, recounted his experiences as a volunteer physician in a small charitable hospital in the Himalayas and concluded that “kickbacks and bribes oil every part of the healthcare machinery”, and suggested that the will to reform it promptly from within the country seems to be lacking.
After working here for 38 years, both in the public as well as in the private sector, I could not, unfortunately, agree with him more. The process of individual corruption starts early, with the capitation fees for entry for the MBBS course in many of the now ubiquitous private substandard medical colleges, which are mainly owned by politicians. There, the student encounters poorly qualified and disinterested teachers and, worse still, few patients from whom to learn. He or she then appears in the final examinations, where there may have been pressure put on examiners to pass him and his colleagues, who hardly then deserve to be called doctors. It is not surprising that the end result is a practitioner who not only lacks adequate knowledge but is also deeply in debt and has at his mercy a poor, ill-informed and trusting patient. Can we expect him to be ethical when, to survive, he has to compete against colleagues who are giving kickbacks or “cuts” for referrals and receiving them in cash-filled envelopes from imaging centres and laboratories? The temptation to do unnecessary investigations, like CT scans (Rs1,500 cut) and MRIs and perform unnecessary procedures in the form of Caesarean sections, hysterectomies, appendicectomies and other operations for cash payments, must be difficult to resist. And this does not only affect the doctor in a single-handed practice. In many of our five-star corporate hospitals, where the main motive seems to be profit for the shareholders, there is an institutionalised system of so-called “facilitation charges” or fees for “diagnostic help” given to the physicians who refer patients regularly and for expensive procedures like organ transplants, which may reach Rs1-2 lakh. The senior doctors, we are told, whose pay is in astronomical figures, are visited by neophyte financial experts at the end of every month with sheaves of financial data and asked to justify whether they deserve the salaries [they] are being paid, especially when the revenue they have generated for the hospital from investigations and operations falls short of certain set goals.
And this corruption is by no means confined to private hospitals. Talking with colleagues in the public sector, it seems that to get selected and promoted or avoid being transferred from a comfortable job to a less “lucrative” post is almost impossible if one doesn’t use the influence of politicians and bureaucrats before the actual day of decision.
These instances of corruption in medicine are perhaps only a small part of the larger picture. Suffice it to say that most doctors with whom I have spoken agree that this state of affairs exists and Transparency International (TI) has concluded that the Indian healthcare sector is the second most corrupt organisation that an ordinary citizen has to encounter (next to the police force).
But instead of giving up, we, the silent minority, must try and do something about it because being a doctor involves duties and responsibilities over life and death entrusted to us by patients and society. To place the problem in some kind of perspective and to start finding solutions, we must answer three questions.
The first is that is corruption in medicine a universal phenomenon or does it exist only in India? The second is that why does it occur? Finally, how do we go about trying to get rid of it?
The truth is that medical corruption exists all over the world and this has been thoroughly researched by organisations like TI. It can be classified into petty corruption, for example, jumping queues, bribing for early admission, fitness certificates, etc and grand corruption, like the procurement of drugs and equipment for hospitals, recognition of medical colleges and other facilities as well as for plum postings and admissions for undergraduate and postgraduate training. It occurs in India, China, Pakistan, Bangladesh, Africa, South America and most eastern European countries and Russia, as well as in the United States and Western Europe. However, it seems that in the third world and eastern Europe, both petty and grand corruption exist together. The petty variety mainly affects the poor.
Berger’s proposed solutions for reforming private medical colleges (near impossible now as they are firmly entrenched in the system), or de-recognising their degrees by Western medical licensing authorities (affects few of these doctors, as it is mostly those who have graduated from the elite institutions who go abroad), will not change anything. I believe the main reasons that corruption in medicine occurs are lack of information to users, excessive red tape, shortages of doctors and healthcare supplies, poor salaries in the public sector and finally, poor management and supervision. Its vast scale means that the corrupt can be fairly certain they will not be found out, let alone punished for their misdeeds.
What is to be done? The first step is to provide information to users about services available as well as their cost. The gulf between healthcare providers and users in India and the trust that is reposed in the generally revered doctor means that a patient will nearly always do what is advised. The second is to strictly monitor all engagements between parties in the healthcare sector, such as between an individual patient and doctor as well as a pharmaceutical supplier and a hospital. All this can be done by the use of electronic medical record systems, using even smartphones. The advantage of electronic records is that they are cheap, portable, accessible and accurate. There is evidence too that not only does the use of electronic records make healthcare more effective, it also reduces the scope for corruption. In the US, with Obamacare, it is becoming widespread and in India we, and here I must declare a conflicting interest, are already working on a prototype called RaxaDoctor, which is appropriate to our needs.
We can create national watchdogs like Britain’s National Fraud Authority, which has brought down corrupt practices in the National Health Service. Finally, once he or she is caught, the corrupt doctor or health worker should be subjected to exemplary punishment.
The new government in India has been elected mainly because people are disgusted with the all-pervasive corruption in this country. There is now hope that we can get out of this current morass, but we must act soon.
(The writer, a gastroenterologist and surgeon at Sir Ganga Ram Hospital, is the editor-in-chief of the journal ‘Current Medicine Research and Practice’. This article has been excerpted from the same journal )