Corruption ruins the doctor-patient relationship in IndiaBMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g3169 (Published 08 May 2014) Cite this as: BMJ 2014;348:g3169
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Re: Corruption ruins the doctor-patient relationship in India. There are other types of corruption, elsewhere and these too need attention.
Dr Berger has done a good job, shining a light on financial corruption in medical practice in a far-off country of which we in Britain know a little and for which we care a little.
Now let us turn our attention to our own country. For, here we must care a lot.
Reports from China implicate a major UK drug firm in corrupt practices in China. Do all health related industries operating abroad have clean hands? No financial inducements offered? It will be recalled that some years ago, a major defence supplier based in Britain acknowledged paying (pounds sterling, I suppose) sweetners to foreigners to speed up negotiations. The excuse trotted out : this has to be done with these foreigners if we want to do business with them.
Here in England, we have seen plenty of changes in the health service, structural and in personnel. Changes which were to the detriment of patients. Did people (medical and non-medical) who stayed silent do so for the sake of preserving the good reputation of the Secretary of State. Or, to safeguard their own personal interests - interests which which have been jeopardised if they had spoken out? There have been curious cases, such as that of a Coventry cardiologist who finally won his case in the courts. His clinical colleagues appear to have stayed silent.
Some of the guilty ones might confess in the confessional box. Others might claim justification of self-preservation?
Competing interests: No competing interests
Re: Corruption ruins the doctor-patient relationship in India - Moving beyond sensational claims and wholesale accusations
The views expressed in the publication titled ‘Corruption ruins the doctor-patient relationship in India’ make interesting reading.1 The article has generated responses from India as well as other countries.2, 3 The author has expressed concern about the ‘highly’ prevalent corrupt practices in Indian health care system. The article also makes a note of the ‘widespread corruption in the pharmaceutical industry’. The author also seems perturbed when he states that ‘common complaint I heard from poor and middle class people is that they don’t trust their doctors’. Concerns have also been expressed about the reputation of Indian doctors with the author noting that ‘…but as a group, doctors have a poor reputation’.
Interestingly the views expressed in the article are based primarily on the personal experiences of the author in a single heath care facility. There are anecdotal accounts of certain instances that helped the author arrive at the aforementioned conclusions. The article also cited references from popular media (press) to substantiate some of the expressed views.
Corruption in health care system is an important issue that has gained widespread attention of general public, academics, researchers and public health institutions.4 Interestingly, reports on corruption in medical practice from India have been published earlier as well.5, 6 Published literature has cited ‘circumstantial evidence’ to support the possibility of corruption in the health care system.7 Concerns have also been expressed about the role of political corruption in hampering health care service delivery. Indictors of political governance in a country have been used as a proxy measure for corruption in health care service delivery in some of these studies.8 However, it has been argued that the issue of corruption in healthcare service delivery ‘remains poorly addressed in scholarly journals and by professional associations of physicians and bioethicists’.9
It is important to explore, identify and understand corruption in health care service delivery. But in this era of evidence based medicine it is important to move beyond proxy indicator based studies and opinion based commentaries on this theme. Making sensational claims and wholesale accusations is not going to serve the purpose and satisfy the sceptics. It is time to study scientifically whether it’s the fish (or a few fish) or the pool that’s dirty.
1. Berger D. (2014) Corruption ruins the doctor-patient relationship in India. BMJ 348: g3169
2. Jain A, Nundy S, Abbasi K. (2014) Corruption: medicine's dirty open secret. BMJ 348: g4184
3. Madhok R. (2014) Corruption in healthcare in India: why the NHS should take an interest. BMJ 348: g3951
4. WHO. How does corruption affect health care systems, and how can regulation tackle it? 2014; Available from: http://www.euro.who.int/en/data-and-evidence/evidence-informed-policy-ma....
5. Mahajan V. (2010) White coated corruption. Indian J Med Ethics 7(1): 18-20
6. Sachan D. (2013) Tackling corruption in Indian medicine. Lancet 382(9905): e23-24
7. Ibrahim J, Majoor J. (2002) Corruption in the health care system: the circumstantial evidence. Aust Health Rev 25(2): 20-26
8. Young Nicola Man W, Worth H, Kelly A, Wilson DP, Siba P. (2014) Is endemic political corruption hampering provision of ART and PMTCT in developing countries? J Int AIDS Soc 17: 18568
9. Chattopadhyay S. (2013) Corruption in healthcare and medicine: why should physicians and bioethicists care and what should they do? Indian J Med Ethics 10(3): 153-159
Competing interests: No competing interests
David Berger has raised the ugly issue of medical corruption in India. Such corruption has come a long way from ball point pens and small bribes in cash or kind to hospitality to doctors on junkets, cuts by consultants to referring doctors, demands by government medical officers that patients pay for services and many more such ‘innovative’ modes of unethical and exploitative wealth creation.
At least 20-30% of the expense may be saved if corruption is eliminated from Indian medicine and further reduction would follow if needless medical interventions are minimized.
The causes and solutions of medical corruption can be broadly seen as structural, procedural and ethical.
Structural issues include private medical care inflating demand through unethical practices, competition for clients, and under supply of functioning public hospitals. There is also the growth of high tech hospital businesses and burgeoning of ‘super’ specialists (especially cardiac, uro, neuro, joints, diagnostics, etc.), the mushrooming pathology labs and lack of formal hierarchy from primary to tertiary care. The presence of non-allopathic doctors doing cross-practice without adequate training and low regulation from their Councils adds to our woes.
Procedural gaps show up in the lack of standard guidelines and monitoring systems, the large share of cash payments in bills; and pliant and/or complicit reimbursement by insurance companies. The wide information gap between providers and people is complicated by language barriers. Surgical procedures and ICU care take most of the medical expenses and so they are linked most with kickbacks.
Ethics are already under pressure from competition for ‘business’, high stakes, and uncertain future of new entrants in the fray. Academic and professional integrity is waning. The MCI Code of Conduct precludes both advertising and kickbacks; but this is openly flouted by big hospital owners, doctor owners and GP cartels which control consultant practice through fixed commission rates.
We suggest some major systemic reforms: (a) Improve the public hospitals to match peoples’ needs, especially the medical colleges for tertiary care. (b) Create regulatory systems consisting of protocols, audits and reviews of private and public hospital effectiveness from the patient’s perspective. (c) Only non-profit hospitals (rather than private hospitals) committed to affordability, service and transparency must be enlisted for services under national assurance schemes. (d) Streamline procedures of payment in private care. (e) Implement strict guidelines on use of generic drugs and lab-tests, X-rays, CT scans and MRIs.
Other supportive strategies would include broadly defining the primary, secondary and tertiary care hierarchy and expanding /deepening the primary care through sub-centers, primary health centres, etc.
The fight must continue through medical councils (after cleansing them), press, various fora and law courts. It is possible to explore nexuses of doubtful integrity through financial data searches as also by use of civil and criminal laws to stem the rot. There are no quick fix solutions as the private health care sector cannot be wished away. Countries with full public health system also have not been able to weed out medical corruption. With state run health insurance schemes often designed to facilitate loot, and the entry of FDI in private insurance, we should increase our vigil and educate the stakeholders.
We need vision and statesmanship to steer from this chaotic and unjust situation to a more transparent, rational, value-based and affordable health care system with a human face.
[Authored on behalf of Medico Friend Circle by Shyam Ashtekar. Email: email@example.com]
Competing interests: No competing interests
This is a well written article which strives to shed light on an extremely complex topic of medical corruption in a country as diverse and populous as India! Corruption is indeed accepted and pervasive in all the areas in India. Common people cannot often get simple things done like getting an electricity line or getting their rightful pension without paying bribes. Indians truly know the value of connections (colloquilly called “setting”) and money as these are the things you need to get even simple routine jobs done. Doctors are part of this very society and unfortunately what the society sows so shall the society reap!
The lack of political will is unfortunately not highlighted in this article. Health has been a low priority for successive governments. India spends a mere 3-4% of its GDP on public health. Many smaller and poorer countries do better. Indian public hospitals are often mis-managed. Poor patients have to wait long hours, and end up paying for medicines and lab tests thus taking away an important advantage of treatment in public setting. Politicians do not care as they can easily go to big Private Hospitals or fly out ofthe country to get treatment in Western Countries! Private players have realised the massive opportunity and have entered medical education and medical care big time. Often Private hospitals get good subsidy for buying land from government on the condition that they will treat a certain percentage of poor patients free but these promises are hardly kept and poor patients are shoo’ed away by these hospitals. Many young doctors still wish to work in public hospitals despite sub-standard pay because of the academic environment, not having to worry about private practice and not having to indulge in mal-practice. Getting a position in good academic hospitals is difficult though with preference often given to well-connected candidates rather than merit alone. Working in private setting is also hard for anybody with integrity as there are numerous pressures to bring patients (making doctor’s feel like a pimp), pressure to do un-necessary tests and the cut practice. This of course leads to erosion of public trust and doctor shopping. Our regulatory medical body is again mired in corruption so who will regulate these doctors?
I welcome the article as it puts the problem in a global forum and shines a torchlight on it. I am however, not sure of blanket western style sanctions as suggested by the author being a solution though! I thing the solutions have to come from within the country with doctors demanding for a stronger medical council. Doctors and public should also exert pressure on Government demanding better medical care which we deserve and minimisation of private players.
Competing interests: No competing interests
Very well written and pointed out indeed. I think the beginning should be from the school level. Poor primary education, rampant dishonest behaviour to meet day today needs by the middle class of India makes its children and future adults complacent to corruption. How many times do we see people looking at a corrupt practice in any sphere of life with surprise . Poor governance, acceptability of ' this always happens' by the people of this country are responsible. Doctors have grown up and are a part of the same society which has given them poor moral values and dishonest behaviour as a normal norm from childhood . Yes, it is very important to do away with the donation system of private medical colleges ,most of which are owned by the extremely corrupt politicians of India, but it is also important to have subjects like moral science for children from nursery to class XII. Any corrupt practice anywhere should be seriously viewed and with surprise rather than with laid back acceptable attitude . With some political parties targeting corruption in India I hope corruption at all levels, let alone medical practice , would significantly come down.
Competing interests: No competing interests
We read Dr Berger’s article with interest. As doctors who have returned to India after an eight year stint in the NHS we would like to share our experience from the two systems.
In a lot of the private sector hospitals in Karnataka where we work and many other states in India, government sponsored schemes are helping the poor patients below the poverty line (BPL) have the same surgical and medical care as other patients who are self funded. For example a CABG is being performed at about 1,500 pounds whereas it can range from 12,000 to 20,000 pounds in the UK.
“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.”
These practices might be prevalent in some of the cities but there are a lot of doctors who are able to practise medicine in its purest form without any of the kickbacks. We had similar apprehensions on our return to India but have never faced this situation. Moreover our experience in India is that the busiest doctors are those whose reputation has spread by word of mouth from a grateful clientele and not because of kickbacks as mentioned in the above article.
With regards to unnecessary investigations our experience is in fact to the contrary. Rather than order a battery of tests the investigations requested are quite specific based on clinical judgement which is more sound in view of the phenomenal number of patients treated by each doctor. In fact a lot of foreign medical graduates are travelling to India to do their electives and tap into this resource.
A bus travels from a remote village over 5-6 hours packed with patients arriving in the outpatients in the morning. Most of them are examined, investigated and given a definitive form of treatment without prior appointment before they take their bus back home the same evening. This contrasts with our own experience in the UK where it may take days to see your own GP or an agonizing wait in A&E. Private medical care was financially unthinkable.
“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.”
In the last 1 year of our practice in India, we have seen over 8000 patients, a vast majority of whom came from the poor and lower middle class families. The faith shown and the gratitude expressed by these patients during their treatment has reaffirmed our faith in this noble profession.
We understand that no system is without its flaws and no country is without its problems. However we take strong exception to the author’s comments “potentially corrupt doctors of uncertain competence” generalizing the medical profession in India. Most of the doctors here still want to heal their patients and do not look at them as a means to just making money. The competence, the habit of hard work and the adaptability of Indian doctors is an asset not only to India but also to all the “popular foreign destinations” which employ them.
Competing interests: No competing interests
I went through the article by D Berger1. It is really an excellent depiction of the scenario of corruption in medical field. There are examples in this medical journal of repute of how corruption is having a corrosive effect on doctor patient relationship in India. The author has implicated inequality, privatization, huge out of pocket expanses as important reasons for corruption1. Also there are very important articles in other esteemed journals recently in favor and against doctors and pharmaceutical companies2,3. Here I would like to share my views and opinion in this regard-
1. Health practice in ancient India used to be a holy thing where a health healer used to charge nothing. Starting From CHARAK, SUSHURUTA, AYURVEDA till the modern medicine about a few decades back where it used to be a free service or rather no profit no loss service, it has indulged into a commercial entity and corruption.
2. Starting from elementary education there is an unhealthy competition in school teaching, where the parents have to spend a lot, prompting to arrange money for this by any available means as per the social, human and ethical habit/feeling of an individual.
3. While getting into medical colleges the students have to go through various coaching institutes, which I think are of no use, if we are giving adequate teaching into schools. I do not know the status of foreign nations but in India there are more or rather innumerable coaching institutes starting from police, teacher, military and paramilitary entrance to the premier services like Indian civil services, again creating economic burden on students and parents.
4. As the eminent author raised the issue of private medical colleges, once a student is not getting entry into government college he or she will try admission in private college, leading to huge economic burden and getting inferior training, creating a complex among private and government college passed out medical graduates and postgraduates, which a health worker would like to compensate by means of earning more money by one or the other trick, making way for corruption. There is almost always a saying in India about a serviceman, private or government, that how much one is earning other than salary.
5. The placement of medical graduates, post graduates and post-post graduates is not even giving rise to frustration depending upon the interplay of overall factors. Because there have been a burden of huge past expenses and a commercial feeling the health worker is inclined towards corruption, of course not all as the author has pointed out1.
6. There are innumerable pharmaceutical companies, which one cannot count or remember by name, having drugs of different standards. This leads to an unhealthy competition giving rise to corruption. Of course drug invention is a costly affair and same way the approval is also long and not easy, which can be compensated by certain regulations that how much it should be and how fast. By putting high price on a drug, we are putting a price on life. And what we see in the price of many drugs is that life and, by extension, health is therefore unaffordable to most people in the world4.
7. Similarly there are various laboratories of different standards, operated upon by health workers of different standards, again leading to unhealthy competition and corruption. Furthermore there is no strict government regulation or monitoring of these laboratories.
8. Recently there was a very famous saying by a leading supreme court lawyer of India that "the law is to give justice rather than to earning". Same way I think medicine is to cure the disease and not to earn money, medical science is to serve mankind rather than a business. George Merck, the then president of chemical manufacturing company Merck & Co in1929 had to say on the subject "We try never to forget that medicine is for the people. It is not for the profits. The profits follow, and if we have remembered that, they have never failed to appear. The better we have remembered it the larger they have been." It is reminder to pharmaceutical industries of their responsibility towards non-wealthy patients4.
9. Improving elementary education, to coaching and higher education, eliminating or improving substandard private as well as government medical colleges, strict enforcement of law on pharmaceutical companies, laboratories, private hospitals, improving government hospital facilities round the clock, providing free service to the needy ones, improving working conditions of health care workers and strict enforcement of anti corruption law could be the key to success of the problem under discussion.
10. As the author has pointed out there are many competent and honest doctors/health care workers which can be served as models for the task. Such honesty people should be honored from time to time to give message to the dishonest ones.
11. Last but not least the best important thing is to learn humanity. If each and every person behaves humanly there are no chances of malpractices. Private sector health services should be monitored by government agencies and there is supposed to be a uniform code of conduct, which is still lacking in the largest democracy of the planet i.e. India.
1. Berger D. Corruption ruins the doctor-patient relationship in India. BMJ 2014; 348: g3169.
2. John R. The relationship between physicians and pharma- playing the devil's advocate. Neurol Clin Pract April 2014 vol. 4 no. 2 161-163.
3. Carl Elliott. Relationship between physicians and pharma. Why physicians should not accept money from the pharmaceutical industry. Neurol Clin Pract April 2014 vol. 4 no. 2 164-167.
4. Majumdar K-Shaw. Fight Medical Apartheid- while Indian Pharma keeps drugs affordable, western MNCs can be blatantly discreminatry. Time of India May 30,2014
4. Berger D. Corruption ruins the doctor-patient relationship in India. BMJ 2014; 348: g3169.
Competing interests: NONE
In answer to Hemadri, in my case I was seeing any patients in the outpatient clinic under the close supervision of an Indian colleague sitting at the same desk, reviewing the management of any patients I saw, and I will not comment further on my own situation here. However, Hemadri’s general concerns about MCI registration, in a country where the regulation of healthcare activity is at best inconsistent and where pharmacists freely sell prescription medications to the public without a prescription, illustrate beautifully the kinds of structural impediments which exist in India for doctors attempting to ‘do the right thing’. The MCI has been shown to be a corrupt organisation, which had to be dissolved by the President of India in 2010, and it can take years to process a registration. Some of the charitable hospitals in India, hospitals which serve the poorest of the poor, people who would otherwise have little or no access to healthcare, depend at least partly on Western doctors paying their own expenses and then volunteering their labour in order to provide a service. Without them, many charitable hospitals may have to reduce their operations drastically .
It is these kinds of paradoxes, and the invidious choices they demand, which underpin the delivery of medical care in India, where in order to function at all physicians and organisations need to find real world workarounds or else the system grinds to a halt and their personal practice is imperilled. Until such structural barriers can be removed, then the practice of medicine in India will remain fraught with such anomalies.
Hemadri will find very positive commentary on my article and its accompanying BMJ editorial in the mainstream Indian press in the last week. And not only is the interviewee and editorial comment positive, but the 440 comments (at the time of writing) on the Times of India’s article reporting the BMJ’s position are overwhelmingly supportive and reflect accurately the large email postbag I have received personally since the original publication of my article: http://timesofindia.indiatimes.com/opinions/37350397.cms. Dr Samiran Nundy, a distinguished Indian doctor and co-author of the BMJ’s editorial, has written another article, reprinted in the Indian Express, which is also supportive and puts forward some very creative solutions: http://indianexpress.com/article/opinion/columns/first-give-the-patient-... Two former Indian health secretaries have also commented positively on my article and highlighted the structural elements which contribute to healthcare corruption in India: http://indianexpress.com/article/india/india-others/bmj-article-on-graft...
Of course, Hemadri is correct that externally imposed solutions can never be the sole answer, but shining a bright, global light on local dark corners can be a helpful part of the answer by raising awareness, as we have done here. I certainly do not have any blindingly obvious answers and fully accept that what I have proposed may not be the way forward. Hopefully, however, the BMJ’s campaign, lead from within India by its Indian editorial team and in conjunction with major Indian healthcare institutions and NGOs will help to define a way forward. In the meantime, Hemadri must be aware through his own work which he tells us about that the levels of endemic, structural corruption in the Indian healthcare system are of an order of magnitude not seen in Western countries, where being corrupt generally remains a free choice, rather than a survival imperative. He should acknowledge that this is an important distinction, which will dictate the direction of any possible solutions.
Competing interests: I am a director of the BMJ. These views are my own.
I read with interest the editorial by Jain A., Nundy S., Abbasi K, of 25 June 2014, entitled "Corruption : Medicine's dirty open secret". The authors clearly point out that " private medicine has flourished in India because of a weak regulatory climate with no standards to monitor quality or ethics". While this has adversely impacted many patients across all specialties, it is perhaps more of a problem in the field of transplantation in India as the impact is not just on sick individuals, but on normal individuals - the donors - as well.
Over the last decade, transplantation has grown exponentially in India and the numbers are second only to the USA, and greater than any other Asian, European, or South American country. Twenty years after the Human Organs Transplantation Act in India, the majority of transplants done in India continue to be from live donors. Lack of support from Neurosurgeons and Neurophysicians who refuse to diagnose brain death is cited as the principal reason for this. What may be of importance, but unstated in this discussion, is the fact that most live donors fuelling transplant activity in India continue to be unrelated individuals who are financially compensated for donation. This is permitted via a loophole in the 1994 law which permits organ donation by "emotionally related " individuals, and each state government has a "Authorization Committee" that permits such donations to proceed.
Continuation of the organ trade, albeit with government supervision, may be one reason why Neurosurgeons and Neurophysicians avoid encouraging deceased organ donation by patients under their care. Centers doing transplantation are mostly in the private sector, and competition between centers is driven by numbers of transplants done, not outcomes. Currently the kickback offered to a doctor referring a patient for live donor liver transplantation is rumored to be in the range of Rs 400,000 ($ 6,666). Many of these patients are transplanted at a MELD score less than 14 which is accepted scientifically as the point at which benefits outweigh risks.
Donor deaths continue to occur, and are under-reported or frankly suppressed. On Friday June 27th, 2014, CNN broadcast the story of how foreign nationals are coming to India for transplants, bringing along donors whose antecedents are difficult to confirm. After donation they return to their countries with no hope of follow up as is standard of care for live donors. No center-specific outcomes data are available when it comes to live donor transplant in India. Transplantation is thus a field where the lack of standards and ethics in India adversely affects not just sick individuals desperately seeking treatment, but also normal individuals ensnared by a corrupt system into becoming live organ donors.
It may be noted here, that in the case of deceased donor transplantation, the coordinating body in Kerala, called Kerala Network for Organ Sharing (KNOS), has made a start by starting a registry of outcomes in the different centers to which deceased donor organs have been allocated. This regulatory climate needs to be replicated throughout India, and rigorously applied to live donor transplantation as well.
Competing interests: Am personally interested in the development of deceased donor organ transplant in India, and the adverse impact of corruption on the development of transplantation in India.
David Berger has done well to expose the corrupt medical practices in India, yet he has merely scratched the surface. Corruption has permeated every crevice of the system, and all Indians are suffering as a result. Let me give some more examples how patients are literally milked by pharmacists and hospitals.
The Indian pharmaceutical market is a crazy one, with a large number of brands of most drugs available in the market, priced differently. Lets take the example of Glimepiride, there are over 25 brands. The cheapest brand is of KAPL at Rs. 1.01 per 1 mg tablet while Sanofi's Glimepiride costs Rs. 5.5 for the same strength.
It is no surprise that Sanofi's brand is most widely prescribed. If some consentious doctor were to prescribe KAPL's Glimepiride, most probably the patient would not find it in the pharmacists shop. Pharmacist get 20% on non controlled drugs. Hence for selling 10 tablets of Sanofi, the pharmacist makes Rs. 11 and for KAPL brand the margin earned is Rs. 2. Despite the high price of the brand Sanofi makes money both for themselves and for the chemist. The loser in this transaction, and every other transaction is the patient.
If a patient is admitted to a hospital, he has to purchase all medication prescribed to him from the medical shop run by the hospital. This shop, usually owned by a relative or friend of the hospital management, sells drugs at a higher price than the market. The poor patient is forced to pay more, just because he is under treatment in the hospital. This happens not only in small nursing homes, but also large corporate hospitals.
The foreign visits by doctors, for pleasure or for conferences, the ambience of hospitals and losses of the government health care system, all are supported by a single individual. The entire healthcare system of India, depends upon money that is extracted from the patient.
It is ironic that the doctors, hospitals, pharmaceutical companies and pharmacists exist only because of the patient. Yet the patient is the one who is bullied, ignored and illtreated, so that these others may benefit.
Competing interests: No competing interests