Corruption ruins the doctor-patient relationship in India
BMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g3169 (Published 08 May 2014) Cite this as: BMJ 2014;348:g3169All rapid responses
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Nobody disputes that corruption exists in every Country, but in India it is more widespread.
Cheating, extortion, bribery, plagiarism, guest-student impersonations, corrupt teachers, under-the-table deals with politicians, assassinations, etc, before-during-after medical school examinations, did not happen in any other Country. [1][2]
Not long ago, India's Supreme Court ordered more than 600,000 students to retake the main medical school exams after they found that the question paper had been leaked. [1]
Later on, resulting staffed mainstream healthcare systems in India are riddled with corruption and inefficiency. [4][5][7]
The Bar Council of India claimed that only 55% of practicing lawyers in India are genuine, following a two-year long verification, the rest have fake degrees. [10]
Across India, there are more fake doctors practicing than real ones! [15]
Dubious Indian Colleges grant airplane pilot qualifications/licences in just 35 minutes. [11][12][13][14]
Furthermore, various quacks of dubious traditional practices are already legalized as doctors in India. [3][6][15]
References
[1] http://www.bbc.com/news/world-asia-india-33421572
[2] http://www.bmj.com/content/350/bmj.h3324
[3] http://www.bmj.com/content/346/bmj.f4145
[4] http://www.bmj.com/content/326/7379/10.4
[5] http://www.bmj.com/content/347/bmj.f6881
[6] http://www.bmj.com/content/348/bmj.g422
[7] http://www.bmj.com/content/346/bmj.f2834
[8] http://www.bmj.com/content/350/bmj.h565
[10] http://www.dailymail.co.uk/indiahome/indianews/article-4302396/Indian-La...
[11] https://www.bloomberg.com/news/articles/2015-06-01/pilots-qualified-to-f...
[12] http://www.dailymail.co.uk/travel/travel_news/article-3118475/Pilots-Ind...
[13] https://www.usatoday.com/story/travel/roadwarriorvoices/2015/06/06/catch...
[14] http://time.com/3906733/india-pilots-license-air-safety-aviation/
[15] http://www.bbc.com/news/world-asia-india-37571259
Competing interests: No competing interests
Sir,
Transparency International lists India 79th amongst 176 countries1, much worse than USA and UK but better than our neighbors Bangladesh and Nepal. Although the ranking has improved over the last few years, we cannot disagree that corruption is rampant everywhere. You must agree that doctors, like all other professionals, are a living-breathing part of this same society, which is corrupt. So to expect that they would be an exception to what is happening all around them, would be like living in a fairy tale (although desirable but impractical). In 2013 S. Chattopadhyay had reported exhaustively on the dynamics of corruption in the healthcare (mainly in India)2. Contrary to popular belief the areas of corruption in healthcare are not just centered on kickback, “cut-money” or commission for medicines or investigations. It is actually a much larger scenario involving false attendances, false certification to individuals and organizations (so that they can get their requisite licenses), incorporating illiterate people for research (including drug testing) without proper explanation or consent, etc. Paramedical staffs in government organizations have been known to damage equipments so that samples could officially be sent to private agencies. The doctors and technical staffs are just the tips of the icebergs. In the multi-billion dollar pharmacy industry the same drug is sold at absurdly different prices, e.g. Meropenem (1gram) is available from Rs. 700 (USD 10.30) to Rs. 2600 (USD 38.30) and medicine shops are giving discounts from 10% to 70% on their MRP (maximum retail price). This raises the question whether the cheaper alternatives are of inferior quality or the expensive ones are fleecing the customer. What about spurious medicines? In India, medicines are manufactured and marketed by multinational companies, reputed indigenous companies as well as spurious companies3. Although there is a Drug controlling authority, do they have enough resources (financial, technical, manpower and motivational) to bring parity and weed out the corrupt players? Why not fix prices of all medicines and medical equipments? Why not make the retail medicine shops sell medicines procured only from reputed companies and at government controlled rational prices? At least a start has been done by the Central government of India with fixing the price of the cardiac stents. What about corruption at the institutional level? It starts from inflation of bills by falsely entering medicines and services that have not been given to the patient, creating ghost patients to extract money from the insurance agencies, and denying payment to staff and doctors after utilizing their services4-6. Everyone seems to be reaping the fruits of corruption but only doctors get crucified.
Is corruption in the medical industry unique to India? In 2004 there was report of corruption in healthcare in Europe, even in “non-corrupt” countries like Poland7. Thereafter the Annual corruption report 2006 by Transparency International showed how corruption has percolated into almost all the strata of healthcare in almost all the countries worldwide8. Later that year the Lancet reported in its Editorial that “The spectrum of corruption ranges from physicians with conflicts of interest advocating a particular treatment for the wrong reasons to aggressive marketing strategies by pharmaceutical companies; from underpaid health workers accepting small bribes from patients to the provision of ineffective counterfeit drugs; from large-scale embezzlement of public-health funds to massive distortions of health policy and funding by corrupt government officials”9. Even UK is not immune to corrupt practices10. Recently there was report of a NHS (National Health Service) doctor siphoning off huge sums of money11 that too in the presence of a robust anti-fraud system in NHS. What about the USA12? This year itself there were multiple reports of corruption in their healthcare13-15. Doctors had received bribes in the range of USD 130,000 to 200,000 (which is much more than what an average Indian doctor would earn in his entire life).
Corruption is a world-wide phenomenon. The United Nations (UN) acknowledged this problem in their report and said “Corruption in the health sector is a reflec¬tion of the structural challenges in the health care system as well as where it takes place within the health care sector”16. Since India is the largest democracy and we Indians are an emotional lot, we are much more vocal about it. Besides, being a developing nation these instances of corruption are expectedly more common than in the developed nations. Another possibility could be the fact that there is lack of proper policing and law enforcement in India, unlike that in the West, where the whole nation is much less corrupt and there is much more prompt action by the law enforcement authorities and judiciary.
The most hilarious aspect of corruption in healthcare possibly occurs only in India. Here you will find instances where a patient would come for treatment in a private/corporate setup fully knowing the charges and expenses, and when they get cured they would either create a ruckus for a discount or just lodge a complaint with the government agencies claiming that they were overcharged or deceived into improper treatment, and walk off without paying the bills. Situation is worse if the patient dies. There is a new blooming profession, the “discount getters”. These are groups of individuals who masquerade as patients’ relatives and create chaos in the hospitals on death of patients so that the hospitals release the dead body without taking payment against their hospital bills or gives huge discounts just to pacify these miscreants. Sadly, no one talks about these corruptions.
In conclusion, corruption in healthcare system is an undeniable reality. Everyone starting from the local quacks, the rickshaw-pullers, the ambulance drivers, the doctors, the para-clinical staffs, the corporate hospitals, the pharmacy industry, everyone is involved. It is sad and it has to be abolished. Just by saying that the medical profession is a noble profession and it should be free from corruption does not solve the problem. The entire nation and the whole global community have to assume responsibility in tackling it, and it starts from our own families and our own spheres of work.
References:
1. Corruption perception index 2016. Transparency International. 25 Jan 2017. https://www.transparency.org/news/feature/corruption_perceptions_index_2016
2. S Chattopadhyay. Corruption in healthcare and medicine: Why should physicians and bioethicists care and what should they do? Indian J Med Ethics. 2013 Jul-Sep;10(3):153-9.
3. A. N. Khan, R. K. Khar. Current scenario of spurious and substandard medicines in India: a systematic review. Indian J Pharm Sci. 2015 Jan-Feb; 77(1): 2–7.
4. Imran Gowhar. Hospital staff fake bills, pocket money from selling pills. The Hindu. Updated 2nd June 2016. http://www.thehindu.com/news/cities/bangalore/hospital-staff-fake-bills-...
5. Kate Ashford. 8 things you should know about challenging a medical bill. Forbes. Personal Finance. 15th August 2014. https://www.forbes.com/sites/kateashford/2014/08/15/challenging-a-medica...
6. Tommy Sawnson. The 5 most types of medical billing fraud. B2C. Health & wellness. 28th July 2012. http://www.business2community.com/health-wellness/the-5-most-common-type...
7. Nick Watson. Central Europe dabbles in private health. The Lancet. Volume 364, No. 9447, p1745–1746, 13 November 2004
8. Transparency International. Global Corruption Report 2006. London: Pluto Press; 2006.
9. Editorial. Corruption in health care costs lives. Lancet. 2006 Feb 11;367(9509):447.
10. Fiona Godlee. Medical corruption in the UK. BMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h506 (Published 29 January 2015)
11. Julia Crouch. Dailymail UK. Radiologist, 53, fraudulently claimed £24,000 in overtime pay from the NHS by logging thousands of X-ray reports just ONE MINUTE after his shift ended. 17 February 2017 http://www.dailymail.co.uk/news/article-4235712/Radiologist-scammed-24-0...
12. Owen Dyer. Six doctors are charged with taking kickbacks for sending patients to Chicago hospital for no reason. BMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h22 (Published 08 January 2015)
13. Todd South. Totowa doctor charged in lab bribery case. Northjersey.com. Jan. 10, 2017. http://www.northjersey.com/story/news/crime/2017/01/10/totowa-doctor-cha...
14. Keldy Oritz. Saddle Brook doctor convicted on bribery charges. Northjersy.com. March 6, 2017 http://www.northjersey.com/story/news/bergen/2017/03/06/saddle-brook-doc...
15. Mathew Harper. Billionaire's Former Protege Arrested For Bribing Doctors To Prescribe Fentanyl. Forbes. Pharma & Healthcare. 8th December 2016. https://www.forbes.com/sites/matthewherper/2016/12/08/billionaires-forme...
16. Fighting corruption in the health sector: Methods, tools and good practices. United Nations Development Programme. October 2011.
Competing interests: No competing interests
The remuneration structure must be based on metrics and matrix. All professionals should be given equal weight and the opportunity to grow.
Competing interests: No competing interests
This has reference to an article published in the BMJ 2014 dated 8th May with the title “corruption ruins the doctor patient relationship in India by David Berger”.
It is unfortunate that in most of the articles written against Indian Medical Profession the author directly or indirectly somehow is related to the BMJ. In the present article, also the author is an Executive Director of BMJ.
The article is defamatory in nature and it generalizes medical practice in India without any specific allegation against a particular professional. The examples given should have been specific who can be traced and accountable.
Giving one vague example of a senior resident of referring a case for exercise ECG to a private clinic cannot extrapolate to whole medical profession.
Another example of a patient with no apparent structural heart disease with high Blood Pressure getting an echocardiogram done every three months does not reflect it as approved Indian Guideline or practice.
Another example given of a doctor doing ultrasound and charging Rs.1000/- each time, one should remember, that in India radiologists and ultrasonologists who do ultrasound do not do practice and see patients.
The allegation that it is common for hospital directors to be given cars for prescribing specific antibiotic should have been written with specific examples and not a generalized allegation.
The pharmaceutical Sales Executive example is also without any specific reference. Most of the material has been copied from other articles without any substantial proofs.
The allegation that poor middle class people do not trust their doctors is without any authentic survey.
Authors is not aware that the system of medical education has changed in India with a centralized transparent exam and there is no question of accepting any donation against the medical seats.
Paragraph about the then President of Medical Council of India Dr Ketan Desai is also without facts. The disproportionate assets case against him has been cleared by the CBI which forms the backbone of any corruption.
The removal of Health Secretary Dr. Keshav Desi Raju written in the article is only a speculation.
Author further recommended that UK, US, Canada, Australia and New Zealand should withdraw recognition from all questionable private Indian medical colleges has no merit.
Competing interests: No competing interests
I thank Dr. Berger for bringing out such an article although upon Indian medical practice system.
Your article provides answer to the enigmatic question put forward by many doctors from India, in many online as well as print platforms, " why the doctor is being roughed up/ beaten up, these days".
It's simple, because the patient doesn't trust the doctor now. That's why the beatings, when something goes bad.
It's all because of the mistrust created by unscrupulous business tactics creeping in to the medical practice( kick backs, commissions, and so on).
I appreciate( and also sad looking upon our current state) Dr. Berger, for a detailed picture of the current medical practice and education and also the changes which need to be done.
I think MCI and IMA would also look in to such articles, and make some changes in their functioning, which is need of the hour.
Otherwise, there would not be any difference between a Kirana shop( departmental store ) and a clinic.
Thanks.
Competing interests: No competing interests
The article highlights a growing problem in many developing countries including India. The nexus between big pharma and diagnostics companies is growing by the day. . The government investments in health are either stagnant or don't keep pace with the reality on the ground, and the corporatization of public services like health care, are making these services like any other business, just oriented to generating profits.
It may be important the Indian authorities bring in changes that force these multinational companies to come clean on their funding to doctors. For e.g. a database set up by the British Pharma industry disclosed that UK doctors were paid £340 million in 2015 for research (£229 million) and £111 million for consultancy, workshops etc. https://www.ft.com/content/b3e42806-3ec7-11e6-8716-a4a71e8140b0
If this can be done in the UK then what prevents such companies bribing the underpaid doctors in developing countries?
The Indian government through the national pharmaceutical pricing authority has tried to cap the prices of various drugs but has come under tremendous pressure from private companies.
Competing interests: No competing interests
As a practising primary care physician in the government set up I am saddened by the state of affairs of our current health system. The corruption in health care is a complex issue and has multiple dimensions to it.
You highlight issues with regard to kickbacks in referring patients and prescribing medicines. That is only a part of the problem. Recently there was a decision by MCI to suspend six doctors for a duration of six months who had accepted hospitality by a pharma company in the form of a paid foreign trip. I was surprised as well pained to see the justification given by some in our profession for such behaviours. All the guidelines seem to be only on paper.
Health equity is not an electoral issue. There seems to be a dichotomous approach. The political elite and policymakers get reimbursed for their treatment in five star hospitals at the cost of taxpayers money. The rest of the public are left to go to understaffed and underfunded public hospitals. Private health care has grown at the cost of neglect of public health care. The present system is a fee for service and encourages Corporate hospitals to do more consultations, investigations and procedures. Added to this there is no national/regional like NICE to assess the cost effectiveness of the care provided.
The professional bodies of different specialties have failed to look beyond their own for enhancing the overall health of the nation. They need to take more responsibility in regulating their members and enhancing the trust of the public in our health system.
Competing interests: No competing interests
India has the best of the best apex Hospitals, but primary care and seconday care take a backseat. Everyone wants to specialise here. As a result primary care in rural areas is really pathetic and terrible. Sadly in India more Institues are being built and no importance is given to primary and secondary care. A sad trend
Competing interests: No competing interests
Sir,
Your views come as no surprise for those familiar with the Indian Health Care System.
But what was not adequately emphasized is the miserable scenario in which the Indian doctors are practising. They are paid peanuts both in Govt. and in the Private set up. In my childhood, I remember paying the barber Rs 0.50 and my doctor Rs 5.00 (1967 or 1968). Now the barber gets Rs 60-80 for a haircut and the doctor gets Rs 100 for a consultation. This is not to justify corruption, but a fact nobody can deny.
And corruption is rampant in that part of the hemisphere as well. But the corresponding words for ' corruption ' in the affluent countries are: 'profit sharing', ' kickback ', 'lobbying', 'grant' from this or that company, 'conflict of interest', etc (beautiful words indeed !! )
Competing interests: No competing interests
Re: Corruption ruins the doctor-patient relationship in India
At the outset, let me congratulate Dr. Berger for an excellent article written based on what I assume are his personal experiences in India.
I have read through the other responses to the article and the one thing that stands out, unfortunately, is that we as the Indian Medical Fraternity are either in Denial of the Problem or are so engulfed by it that we chose to turn a blind eye.
Sadly, turning a blind eye to this would only serve to it getting worse. Denial is an even bigger problem because, in no uncertain terms, it means that the people in power (be it in the associations or in the councils) are in the know and still choose to do nothing about it by denying the problem even exists.
Everyone here is quick to defend the medical profession as soon as something is pointed out.
The education process is in dire need of a major overhaul as most fresh pass outs cannot be trusted to deal with a patient on their own without supervision. Standardization is required but in a very controlled manner. Closing our eyes to the problem or looking away will not help this situation. Denial is the biggest danger right now and it needs to be addressed before the government intervenes too much because we can't solve our own problems.
The opinion of the public towards the doctors at this point of time isn't something they have just thought up over the past month or two. It has been building up slowly and gradually over the years with the slow change in the way we treat our patients, the way we have lost the famous doctor patient trust relationship, google based diagnosis, trigger finger law suits and medico-legal instigators.
Everyone seems to agree that cut practice is a disease but almost everyone is doing nothing about it. So is pharmaceutical promotions, gifts, sponsorships which have been defended by words like 'items of clinical utility' etc which is just sugar coating gifts that are given on promoting their products. They are very intelligent businesses so they stave off responsibility by saying it is the 'learned customers' choice to accept or reject that gift. What starts with a clinical utility pen and prescription pad soon escalates into items for personal use, printed material for personal consumption, household items, cars, foreign vacations etc etc. It is conveniently forgotten that it all started with that one pen that the Doctor could afford on his own if it was that important from a clinical utility point of view!
Unity is the key going forward if we intend to put an end to this menace of corruption in any and all forms penetrating into the system (even more than it already has)
Competing interests: No competing interests