The taint of corruption in healthcare has forced us to ask whether doctors are god incarnate, fallen angels or merely flawed mortals like the rest of us? By Raelene Kambli
As an act, corruption is an insidious plague which not only corrodes moral values but also impairs the functioning of an economy. It defeats the purpose of democracy and causes the entire society to suffer. Corruption has an adverse impact on the long-term economic growth of a nation. As per a study conducted by Transparency International, a global movement working against corrupt practices, corruption affect economic development in terms of economic efficiency and growth. It also affects equitable distribution of resources across the population, increasing income inequalities and undermining the effectiveness of social welfare programmes, ultimately resulting in lower levels of human development.
According to a World Bank study, the infant mortality rate in countries with higher corruption is about three times higher and the literacy rate is 25 per cent lower. In fact, World Bank statistics also reveal that the level of corruption in countries with emerging market economies is much higher than it is in developed countries.
Despite the knowledge that corruption hampers the overall welfare of an economy, no country has been able to completely eliminate it and India is no different.
Concept of corruption in healthcare
Although India claims to be the tenth largest democratic economy in the world, corruption has consumed every sphere of its public life. There is no single institution or sector in India that remains corruption free. However, in recent times corruption within the healthcare sector in the country has caught the international eye. Scores of articles published in various national and international publications bear witness to the growing nepotism in Indian healthcare. Even as Prime Minister, Narendra Modi and the Union Health Minister, JP Nadda claimed that there would be a crackdown on corruption, scams continue to surface across every aspect of the healthcare system in India, spanning from medical education to patients being looted through unnecessary procedures and diagnostics tests in large and reputed corporate hospitals.
Monsters behind the mask
What are the reasons for the entrenched corruption within India’s healthcare system? Dwindling morals, high medical education fees or vulnerability and peer pressure?
Replies Dr Arun Gadre, Coordinator, Support for Advocacy and Training to Health Initiatives (SATHI), “The reason is the unequal power equation between the patient and the doctor. However smart, empowered and educated the patient may be, she or he would never feel equal in power with the doctor when suffering from an illness. The patient would never be able to dictate terms as any other consumer can.”
Dr Gadre, who has interviewed 78 doctors and has published their shocking testimonies of corruption in a book titled, ‘Voices of Conscience from the Medical Profession’ furthers avers, “Healthcare is now a predominant marketplace. With dwindling moral standards, most doctors have ceased to take the interest of the patient into account as they should. The rot has been compounded by growing influence of medical technology industry, pharmaceuticals, vaccine industry and private medical colleges. Here, we depart from the moral standards and now the main culprit is systemic rot.”
“It is a known fact that doctors accept kickbacks from pharma companies and hospitals but the bigger criminals are corporate (hospitals who) under the guise of providing care, pressurise doctors to convert general check ups into surgeries to add to their revenues. Government-run hospitals are no less. A premier government-run healthcare institution in Delhi has cases where poor patients need political help to get a bed for treatment,” he shares.
In defense of doctors
Referring to an article written by Dr Samiran Nundy in the British Medical Journal (BMJ) Dr Ramakant Panda, Vice Chairman and MD, Asian Heart Institute, Mumbai says that this article has raised several questions about ethical values among Indian doctors and has sparked a fresh debate within the healthcare community and policy makers. “Dr Nundy in his article mentions about corruption being all pervasive in healthcare delivery in India, starting with capitation fees for the entry into medical colleges,” he states. “First, let’s understand that errant doctors and hospitals are reflection of the moral norms of the society, and not a problem that pervades the entire profession. There are black sheep in every profession, representatives of post-independence generations that have grown up in an environment of scarcity, tax-evasion and corruption and hence have not known better ways to survive. In future, this will change,” says Dr Panda.
He elaborates, “Here’s what’s happening on the ground. After 10-12 years of study and work, most doctors are well into their 30s before they begin earning. They start with Rs three to five crores capitation fee debt on their balance sheet, at 32 years of age. Add to this, the cost of a house, which could range upwards of Rs one crore. Their peers in other professions have started earning a full decade earlier. Time and money is invested amidst stiff competition. After becoming qualified doctors they must bear the high costs of setting up a practice, space, equipment and running an establishment. This means borrowing, which in turn, means repayment with interest. Moreover, the environment of medical practice has changed significantly in recent decades. Physicians providing patient care have experienced reduced autonomy and increased administrative burdens. Absence of regulation in private healthcare has its effect on the cost, quality and transparency in the healthcare industry. Cuts, therefore seem essential to build a quick profitable practice. And every holiday offered by a pharma company seems like a reward for the long years of hardwork. All this ‘hand-in-glove’ practice makes the patient suffer.”
Dr Panda certainly has a point when he says that high capitation fees in private medical colleges is one of the root causes of corruption in India’s healthcare system. As part of this Express Healthcare story, the correspondent spoke to parents whose children had recently given the medical entrance exam. They showed snapshots of SMS messages sent by agents claiming to represent various medical colleges in and around Mumbai. As per these messages, colleges have quoted capitation fees that range anywhere between Rs 30-50 lakhs. (See image on pg 27)
Moreover, these parents also informed that they receive calls from various agentswho claim to hold seats in government as well as private medical colleges. It was also revealed that agents quote around Rs five crores for a post graduate seat in Navi Mumbai’s premium medical college. “One of the agents told us that our ward need not appear for the entire question paper during the entrance exam. If he could answer just 20 marks of the paper, the rest would be done by their sources within. All we would have to do is pay him money. Now I have lost faith in this profession and have asked our child to choose another career,” reveals a disillusioned parent.
The dividend on medical devices
Apart from this, Dr Anant Pandhare – Medical Director – Dr Hedgewar Hospital, Aurangabad reports on the nexus within the heart stent industry. Dr Pandhare informs that hospitals charge around Rs 1-1.5 lakhs for a high standard stent that costs anywhere between Rs 25,000-40000 “This is my own experience . I, once, personally negotiated with vendors of medical products and equipment for my hospital. Once while purchasing stents, one of the vendors quoted Rs one lakh per stent. Knowing that that stents do not cost so much, I questioned his quotation. On this the vendor replied saying that this would include my cut. Thereafter, I decided that I will personally keep a track of all purchases of such products for my hospital so that no one in my hospital would ever be tempted by such offers.”
If this is the state of healthcare in most parts of our country, are our laws adequate to hold these wrong doers accountable for their misdeeds?
Lack of regulation
India does have an anti-corruption act – the Prevention of Corruption Act 1988 – enacted to combat corruption in government agencies and public sector businesses in India. However, there are many loopholes to maneuver around it. Where the private sector is concerned, there are no regulations and accountability mechanisms.
Referring to the most talked about and sordid tale of disgrace, about how ex-MCI president, Dr Ketan Desai caught red-handed by the CBI while taking a bribe from a private medical college in 2010, is still running Indian medical education and regulatory system sitting behind the curtain, Dr FD Dastur, PD Hinduja Hospital & Medical Research Centre, points out that money, power and political patronage has allowed MCI to be run by the wrong type of individuals who corrupt the profession for personal gain.
Commenting on the lack of proper regulations and laws for corruption within the healthcare sector, Dr Gadre shares, “In 2010, the government had introduced the Clinical Establishment Act. It is a welcome step, as due to it, at least now we are having a discourse on regulation of the private healthcare sector. But if you search the entire document; an important word is missing i.e. the patient. It does not talk about patients’ rights. It is bureaucratic. We doctors have (our) worst nightmares when we imagine any regulation. It only means that there is one more tool in the hands of a few corrupt (government) babus to exploit. Jan Arogya Abhiyan has come out with a draft of the model act. However, the government must adapt it. In its present form, there is a great danger that it would not be implemented on the field as it should be and in that scenario, both patients and ethical doctors would suffer.”
Dr Dastur opines, “The government’s Central Drugs Standard Control Organization (CDSCO) does not have the stringent rules of the US FDA. It is woefully understaffed with a mere 1500 inspectors compared to 14,500 of US FDA. Furthermore, the relationship between certain plant officials and inspectors has at times been reported as ‘too cordial’ and quality control issues have arisen. Thus, three leading Indian companies in 2013-14 have had their manufacturing plants banned from exporting drugs to US on account of poor quality control. In August 2014, the Bombay Municipal Corporation reported a sudden outbreak of 38 adverse drug reactions (ADRs) in two of its city hospitals. The drugs responsible appeared to be two antibiotics, namely Ceftriaxone and Cefotaxime. Those affected developed convulsions, breathlessness and vomiting. One patient died. An investigation is ongoing.” Dr Dastur also recounts last year’s botched sterlisation camp and says, “In November 2014, in a sterilisation camp in Chhattisgarh, 28 women became acutely ill within hours of surgery and died, provoking worldwide condemnation. Adulterated antibiotics from a Mumbai company are suspected to have contributed to these fatalities. Such incidents demoralise public confidence in government healthcare schemes and in Indian drugs in the market.”
These testimonies indeed paint a very dark picture of the healthcare system within India. So, has any one raised the alarm? What have been the consequences so far?
Fight for justice
Dr Kunal Saha, a US-based professor and private consultant in HIV/AIDS, is known for his struggle against a case of medical negligence in which his wife, Anuradha Saha lost her life. She died at the age of 36 at Kolkata-based Advanced Medicare Research Institute (AMRI) on May 28, 1998. Since then, Dr Saha has been waging a tireless war against corrupt practices.
“Corruption in the medical regulatory system is the root cause of the present abysmal condition of healthcare in India. I established “People for Better Treatment” (PBT) in 2001 primarily to spread awareness about medical negligence and to stop the rapidly spreading evils of medical corruption. Over the past 14 years, PBT has brought major changes in the flawed Indian medical system through numerous public interest litigations (PILs) in the High Courts and Supreme Court of India. For example, our PIL in the Supreme Court (W.P. No. 317/2000) made the shocking discovery that not only different state medical councils were deliberately keeping silent for decades on complaints against negligent doctors, no medical councils were even established in a large number of states across India, more than 50 years after independence. As a result of this historic PIL, sections 8.7 and 8.8 were enacted into the MCI “Code of Ethics & Regulations, 2002”, mandating a six month timelimit to dispose of complaints against doctors (section 8.7) and also giving right to appeal against the decision of the state medical council (section 8.8). PBT is also fighting numerous legal battles against the disgraced ex-MCI chief, Dr Ketan Desai and deep-rooted corruption in the medical councils,” he states.
Describing his personal legal battle he goes on to say, “Although a more personal legal battle against ‘eminent’ Kolkata doctors and AMRI hospital in Kolkata, the recent verdict and highest-ever compensation in Indian medical history (Rs 11.5 crore including interest) by the Apex Court in the case for the wrongful death of my wife, have rekindled hope for countless victims of malpractice in India. This historic judgment by the Supreme Court has sent a strong deterrent signal to the errant and unethical doctors and hospitals across India. The Apex Court has declared in an unequivocal manner that an innocent patient’s life must (be) worth a lot more than what was given until now. It has also awarded ‘exemplary or ‘punitive’ damages for the first time in a case of medical negligence underscoring the point that reckless treatment is an act against the society at large. Until the Anuradha Saha case judgment by the Apex Court, consumer courts across India were awarding measly amounts as compensation to the tune of Rs one or two lakhs for loss of a human life even on the rare occasion when a doctor was found guilty for medical negligence. The Indian medical community and Indian Medical Association (IMA) have received a strong message for the first time against medical negligence through the historic judgment in my wife’s case. This was reflected with the filing of a desperate and unprecedented ‘review’ petition by the IMA seeking to reduce the quantum of compensation in the Anuradha case even though IMA was not even remotely connected with this personal litigation against Kolkata doctors/ AMRI hospital. However, the review petition by IMA was promptly dismissed by the Supreme Court.”
The Apex Court judgment in Dr Anuradha’s case and Dr Saha’s movement has served as a corner stone in starting a social campaign against corruption. How effective can such social crusaders be in making a difference or holding people accountable?
Dr Annirudha Malpani, Aniruddha Malpani, Medical Director, HELP – Health Education Library for People, challenges the success of social campaign. “The problem with the campaigns against medical corruption is that while they do a good job of documenting the problems, they fail to provide effective solutions. Most of the solutions are impractical – after all, preaching to unethical doctors that they need to start practising medicine ethically by refusing to take cuts and kickbacks is hardly going to help! What’s worse is that these crusades just drive the wedge further between doctors and patients. Patients start treating all doctors with suspicion – and this lack of trust will prevent doctors from being able to provide high quality medical care to their patients,” he believes.
Agreed Dr Malpani, a social crusader perhaps does not have the capacities and capabilities to bring about a renaissance. However, we cannot turn a blind eye to the malfeasance flourishing within the healthcare system. We need to take a stand. At least for patients who become victims of such malicious crimes and for those medical professionals who still practise with all ethical values. Certainly there is always light at the end of the tunnel. We only need to find proactive measures and execute them; the rest will fall in line.
Transparency is the key
Dr Panda suggests some reform areas. “We need to increase the number of post graduation seats for medical sciences in India. Look at the recent AIPMT cheating case-6.3 lakh children are competing for 3700 medical seats: the inequality is the problem. AIPMT is the gateway for admission to 15 per cent of seats in all central government medical colleges and participating state government medical colleges. Inequity sends law breakers ahead of law makers. The government has to allow private players to start off PG courses within their hospital setting. Also, we need to reduce the nuisance of cut practice by way of making medical education less expensive. Public investment in new medical colleges, liberalising infrastructure norms for setting new medical colleges and encouraging participation from private hospitals will help. Furthermore, a better pay package for teachers will enhance the quality of faculty, thereby incentivising them and ensuring limited private practice for teachers. It is also crucial to make it mandatory for hospitals to go for accreditation,” he recommends.
Dr Sen adds, “We can take some lessons from the US, where they have a medical audit committee. Likewise, we need to commission a hospital review committee wherein hospitals will be audited at regular intervals. We also need to alter the current patent laws and make them more patient-friendly. Lastly, we need to define the meaning of brain death in our medical books, to curtail the growing organ market.”
Another suggestion comes from Dr Pandhare who urges hospitals to opt for full time doctors, paying them good salaries. On the other hand, Dr Malpani speaks of empowering the patient. “Information therapy has an important role to play. If every doctor had their own website, patients would be able to reach out to them directly, so there would be no need for specialists to pay referral fees. Also, hospitals would be able to maximise their bed occupancy, so they would not need to incentivise specialists to refer patients to them,” he sums up.
Wanted: A Gabbar for healthcare?
Corruption in healthcare that begins with high capitation fees for medical seats and many more such practices only raise questions about the next generation of doctors. In a recent incident, the IMA demanded a ban on Akshay Kumar-starrer film ‘Gabbar is Back’, only because the movie’s hero highlighted some corrupt practices in healthcare. However, it is undeniable that several unethical practices are prevalent in the healthcare industry. So, why are industry bodies turning a blind eye to such happenings? Do we need a Gabbar in healthcare too?
It is time that PM Modi’s government comes through on their electoral campaign promise to cut down corruption. Similarly, it is time for the many healthcare professionals in India to recall their Hippocrates oath and live by it.