Kickbacks and bribes

  1. David Berger, district medical officer, emergency medicine

Author Affiliations

  1. daveberger@gmail.com

Kickbacks and bribes oil every part of the country’s healthcare machinery, writesDavid Berger. If India’s authorities cannot make improvements, international agencies should act

“The corruption strangles everything, Sir. It’s like a cancer.” Accompanied by apologetic shrugs and half smiles, statements like this are commonly heard in India. I knew this was the case before I went to work as a volunteer physician in a small charitable hospital in the Himalayas, but what I didn’t realise was how far the corruption permeates the world of medicine and the corrosive effect it has on the doctor-patient relationship.

Although the causes and effects of corruption are complex, a few strands can be teased out. The healthcare system itself is a model of inequity; it is one of the most privatised in the world, with out of pocket expenditure on healthcare at more than 70%, far higher even than in the United States.1 This phenomenon is at least partly the result of the neoliberal World Bank policies of the 1990s, which mandated a reduction in public financing of healthcare, fuelling growth of the private sector.2 The latest in technological medicine is available to people who can pay, albeit at a high price, but the vast underclass, 800 million people or more, has little or no access to healthcare, and what access it does have is mostly to limited substandard government care or to quacks, who seem to operate with near impunity. There is one leveller, however: corruption is rife at all levels, from the richest to the poorest.

One day in the outpatient department I was writing a request for an exercise electrocardiogram at a private heart clinic when the devout young resident consulting beside me said, “Give me that. I have to sign it.” Perplexed, I handed it over, and the story unfolded: all investigations attract a 10-15% kickback to the referring doctor. One day, the marketing executive for this clinic had turned up at the hospital with an envelope full of cash—the commission for investigations ordered in the past few months. The senior doctor refused it and stipulated that in future the commission was to be paid back to patients, which is why the resident had to sign the form. The country’s doctors and medical institutions live in an “unvirtuous circle” of referral and kickback that poisons their integrity and destroys any chance of a trusting relationship with their patients.

Given these practices, it is no surprise that investigations and procedures are abused as a means of milking patients. I saw one patient with no apparent structural heart disease and uncomplicated essential hypertension who had been followed up by a city cardiologist with an echocardiogram every three months, a totally unnecessary investigation. A senior doctor in another hospital a couple of hours away was renowned for using ultrasonography as a profligate, revenue earning procedure, charging desperately poor people Rs1000 (£10; €12; $17) each time. Everyone who works in healthcare in India knows this kind of thing is widespread.

There is also widespread corruption in the pharmaceutical industry, with doctors bribed to prescribe particular drugs. Tales are common of hospital directors being given top of the range cars and other inducements when their hospitals sign contracts to prescribe particular antibiotics preferentially.

I met a former pharmaceutical sales executive who left the industry, sickened by the corrupt practices he was supposed to employ. Working for one of the largest drug companies in the country, he was expected to bribe doctors with money and luxury goods. The crunch came when a doctor demanded that the company fly him to Thailand for a holiday and then provide him with prostitutes at his home. When the company representative queried this, his manager told him to comply, and he felt he had no choice but to resign, protesting that he was “not a pimp.”

It is no wonder, therefore, that a common complaint I heard from poor and middle class people is that they don’t trust their doctors. They don’t trust them to be competent or to be honest, and they live in fear of having to consult them, which results in high levels of doctor shopping.

Lack of trust in doctors, and the costs associated with going to see them, mean many patients rely on pharmacists, who seem to have a similar lack of ethics, selling inappropriate drugs over the counter at exorbitant prices to people who often have to borrow the money to pay for them.

Endemic corruption extends to medical studies themselves. In another “unvirtuous circle,” students can have to pay very large “donations” (perhaps $200 000 or more, some 20 times the average doctor’s annual salary) to get into the rapidly increasing number of private medical colleges and to get on to sought after postgraduate training schemes. This means that doctors can have high levels of debt or family obligation when qualifying, which is a strong incentive against working as generalists in rural areas and favours them practising technological medicine for maximum profit in urban areas to try to recoup their investment.

Many Indian doctors have huge expertise, and many are honourable and treat their patients well, but as a group, doctors have a poor reputation. Until the profession is prepared to tackle this head-on and acknowledge the corrosive effects of its corruption then the doctor-patient relationship will continue to lie in tatters.

The arrest on bribery allegations in 2010 of the Medical Council of India’s (MCI) president Ketan Desai,3 and the subsequent dissolution of the council by the president of India,4 were indicative of the crisis in probity among the Indian medical profession. Subsequently, there has been controversy over the surprise removal, on the day India was declared polio-free, of the health secretary Keshav Desirajus, possibly in response to his resistance to moves to reappoint Desai to the reconstituted MCI.5 6

Medicine has globally accepted standards of conduct. The Indian profession should want to adhere and be held accountable to these. Currently, however, it seems to be failing in this regard. This is not only bad for India but bad for other countries that take doctors trained in India. In wanting to draw attention to these problems, I am holding my Indian colleagues to the same standards of ethical behaviour as I would my colleagues at home.

So what can be done? One place to start would be to reform the private medical colleges, the number of which is burgeoning as the Indian government tries to expand the number of medical graduates.7 As long as places are available for sale at astronomical prices at these institutions,8 and as long as they resort to fraudulent practices and bribery to pass their inspections,9 then the integrity and competence of their graduates will remain questionable and the cycle of corruption will remain unbreakable.

If prompt reform is not forthcoming from within the country (and the will seems to be lacking10), then the spotlight needs to turn global. The medical licensing authorities of the United Kingdom, the US, Canada, Australia, and New Zealand could withdraw recognition from all suspect private Indian medical colleges, sending a signal that there is no longer such a thing as “local corruption.” These countries are popular foreign destinations for Indian medical graduates, but they do not want to accommodate potentially corrupt doctors of uncertain competence, and neither do the people of India

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