Corruption: medicine’s dirty open secret
BMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g4184 (Published 25 June 2014) Cite this as: BMJ 2014;348:g4184
All rapid responses
Two of the authors of the article are Indians. I welcome the outspoken article.
The US has been mentioned. The authors do say that corruption has many forms. It is a pity that they forgot to mention the corrupt practices of one of our largest drug firms (even our National Treasure), found guilty of corrupt practices in the Peoples' Republic of China.
Our biggest armaments firm had the investigations into its corrupt practices in the Middle East halted by the then Prime Minister. The Opposition parties did NOT protest. It says do something.
The culture of corruption is well-entrenched in the business mores of our country.
At least some of the readers have functionally active memory cells. They might remember about the hospital building irregularities (which reached the courts) of about forty years ago.
Again, money (bar geld) may not have changed hands. But, when staff are sacked without due process - a dismissal in a child neglect case in Inner London, resolved with compensation payment of several hundred thousand to the sacked employee) comes to mind - there is a variety of corruption. To try to deflect the wrath of the public. Something must be done.
I ask: when are we going to develop, in our country, a culture that honours clean hands, clear consciences?
Competing interests: No competing interests
A BRIEF HISTORY OF INDIAN AND GLOBAL INTELLECTUAL AND CULTURAL TRADITIONS
1. All successful European and Chinese intellectual and cultural traditions of the world were founded on strong social moral, ethical and religious values very long time ago (nearly 2000 years ago).
2. All major religions of the world began a new chapter in their history 2000 years ago (Hinduism, Buddhism, Judaism and Christianity). Certainly all cultures and civilizations were in touch with each other during ancient Greek and Roman periods. Therefore, each culture must have learned from other cultures and enriched their native culture.
3. For example, Europeans acquired Judaism and Christianity from Israelites and built their intellectual and cultural tradition. From these glorious traditions, all modern discoveries and inventions originated. Therefore, modern economy of all cultures of the globe is based on European discoveries and inventions.
4. Chinese cultures learned Buddhism from India and built their intellectual and cultural traditions. These traditions were enriched by European traditions during the last 500 years of Renaissance period. Their economies also reformed by modern technologies. Therefore, both European and Chinese cultures are better organized and as a consequence they lead the globe at present.
5. But in India, Indian intellectuals rejected Buddhism and founded Indian culture based on Hinduism and caste divisions. The caste based culture is purely for economic purposes and not based on any social moral, ethical and religious values. Therefore, Hinduism is about economics and politics and not related to value based society. Therefore, Indian cultures and traditions are founded upon very weak social values.
6. India has acquired all modern discoveries and inventions and built the modern economy. The economic hierarchy built by ancient Indians is not based on social moral, ethical and religious values. Therefore, this ancient system and hierarchy gave plenty of room for the growth of anti-social elements in India.
7. In India Modern laws, economy, military, education and Government of India, etc. were founded by Great Britain. All these organizations were founded upon social moral, ethical and religious values. Therefore, Indian caste based economy is in sharp contradiction with the modern organizations. Therefore, these modern organizations have increased volume of anti -social elements and activities instead of reducing it.
8. M. K. Gandhi has rejected the modern Government, Laws and economy for protecting the Indian culture and tradition. He wanted to liberate all Indians by modern social moral and ethical values first and then build the modern economy. This is how all leading economies of the world were built. His proposal was very much possible since he knew the power of modern educational system and wanted to give social moral and ethical value based education through the modern educational system in addition to giving professional based education.
9. If M.K. Gandhi’s suggestions were followed and implemented, India would have become a Great nation like China, Japan, Korea, etc. However, Gandhian ideas were rejected and as speculated by Gandhi, Indian cultural values were destroyed by modern economy and now, India has become a highly corrupted nation in the world.
10. India also has failed to build an intellectual and cultural tradition which is suited with modern laws and organizations. Gandhi was not only an internationally leading politician but also a Great moral and spiritual teacher like Jesus Christ and Buddha to millions and millions of Indians. But Gandhi has failed to create an organization and a tradition to guide the future generations of Indians.
11. Indian National congress party to which Gandhi was affiliated with was founded by an English Man. Initially congress party was organized like Royal Society of England where many Indians Lords used to come together and meet periodically to solve their common problems. Then after Tilak and Gandhi it was converted into a political party.
12. Therefore, what is required in India to solve the present and future problems of India is an organization to build and develop Indian Intellectual and cultural traditions based on social moral, ethical and religious values like that of ROYAL SOCIETY OF ENGLAND. Since this organization is association of LORDS, NOBLES AND INTELLECTUALS, they could very well control all activities related to society, economics and politics. In this corruption in all sectors of India could be reduced and possibly eliminated. Maybe an Indian Chapter of ROYAL SOCIETY OF ENGLAND could be opened and operated for the betterment of India and the people.
References:
0. John Daniel, "Rapid Response to this article-1", 6-10-14, Under review for publication in BMJ.
1. John Daniel (V.Sundaravadivel), “Importance of Philosophy and Theology in Education”, Proceedings of National Teacher’s Science Conference, Barkathullah University, Bhopal, September 9-12, 2003.
2. John Daniel (V.Sundaravadivel), “Right Management”, Proceedings of National Teacher’s Science Conference, Barkathullah University, Bhopal, September 9-12, 2003.
3. John Daniel, “Right View”, Proceedings of National Teacher’s Science Conference, Vikram University, Ujjain, September 9-13, 2004.
4. John Daniel, “To unite the World”, New Leader, Chennai, Feb. 2006.
5. John Daniel, “Knowledge Management towards Excellence”, Proceedings of NCBPEE, Pune, Feb. 2007.
6. John Daniel, “Social Information and Communication Theory (S.I.C.T.) and It’s Applications for the Welfare of Humanity”, CLICK-2014, February 12-13, 2014, Sankara College of Arts and science, Ennathur, Kancheepuram, Tamil Nadu, India.
7. John Daniel, “A Brief History Of Knowledge”, CLICK-2014, February 12-13, 2014,Sankara College of Arts and science, Ennathur, Kancheepuram, Tamil Nadu, India.
8. John Daniel, “Indian Culture - Most Advanced Culture of The World”, CLICK-2014, February 12-13, 2014, Sankara College of Arts and science, Ennathur, Kancheepuram, Tamil Nadu, India.
9. John Daniel,” Importance of Uniting Socio- Cultural Values of India and the World”,CLICK-2014, February 12-13, 2014, Sankara College of Arts and science, Ennathur, Kancheepuram, Tamil Nadu, India.
10. John Daniel, “A Christian Philosophy and Theology based Analysis and Design of Indian and Global Social, Economic and Political System”, Ph.D. thesis, October, 2013, I.I.C.M., Florida, USA.
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Competing interests: No competing interests
Yesterday (5-10-2014), I read the interview with Dr. Fiona Godlee, BMJ's editor-in chief published in the SUNDAY TIMES OF INDIA. The theme of the interview was "STOP CORRUPTION OR OTHER NATIONS COULD TURN AWAY INDIAN DOCTORS" [1]. Basically, She advises Indian policy makers to punish corrupt doctors and promote honest doctors. This change is required not only in the medical field but also in all sectors of Indian governance.
The modern economy originated from European intellectual traditions and cultures. Countries like India and China have accepted the modern economy without accepting the Western intellectual traditions and culture. The British intellectual tradition is proved to be the best in the world, and they survived due to the intellectual honesty of British intellectuals. Therefore countries like India and China must accept the leadership of Great Britain till the culture of their people has become like Great Britain's culture and tradition by proper education.
The Indian intellectual tradition is not based on social moral, ethical and religious values. It is based on caste divisions. Therefore, this basic weakness allowed Indians to be corrupted. Perhaps this system was good in the pre-industrial age. In the age of industrialization, education and democracy, the old social hierarchy becomes very much invalid. The modern economy evolved in the Western intellectual tradition. Therefore, only those who follow the Western intellectual tradition and culture alone can manage the Indian economy well. Only they can understand all departments of Western tradition and
culture.
Indian culture and traditions were built based on economic principles and these principles are not based on social moral and ethical values. All were made to do routine work like Robots. Not all were permitted to do creative work. Somebody made the system and people accepted and followed. Therefore, this system worked for Indian people in the past. But the modern economy demands people who have got mastery over the Western economy - Western intellectual tradition and culture. The absence of value based tradition in India is responsible for corruption in Governance and other departments.
References:
[1] http://timesofindia.indiatimes.com/Stop-corruption-or-other-nations-coul...
References:
1. John Daniel (V.Sundaravadivel), “Importance of Philosophy and Theology in Education”, Proceedings of National Teacher’s Science Conference, Barkathullah University, Bhopal, September 9-12, 2003.
2. John Daniel (V.Sundaravadivel), “Right Management”, Proceedings of National Teacher’s Science Conference, Barkathullah University, Bhopal, September 9-12, 2003.
3. John Daniel, “Right View”, Proceedings of National Teacher’s Science Conference, Vikram University, Ujjain, September 9-13, 2004.
4. John Daniel, “To unite the World”, New Leader, Chennai, Feb. 2006.
5. John Daniel, “Knowledge Management towards Excellence”, Proceedings of NCBPEE, Pune, Feb. 2007.
6. John Daniel, “Social Information and Communication Theory (S.I.C.T.) and It’s Applications for the Welfare of Humanity”, CLICK-2014, February 12-13, 2014, Sankara College of Arts and science,
Ennathur, Kancheepuram, Tamil Nadu, India.
7. John Daniel, “A Brief History Of Knowledge”, CLICK-2014, February 12-13, 2014,Sankara College of Arts and science, Ennathur, Kancheepuram, Tamil Nadu, India.
8. John Daniel, “Indian Culture - Most Advanced Culture of The World”, CLICK-2014, February 12-13, 2014, Sankara College of Arts and science, Ennathur, Kancheepuram, Tamil Nadu, India.
9. John Daniel,” Importance of Uniting Socio- Cultural Values of India and the World”,CLICK-2014, February 12-13, 2014, Sankara College of Arts and science, Ennathur, Kancheepuram, Tamil Nadu, India.
10. John Daniel, “A Christian Philosophy and Theology based Analysis and Design of Indian and Global Social, Economic and Political System”, Ph.D. thesis, October, 2013, I.I.C.M., Florida, USA.
Competing interests: No competing interests
The editorial by Anita Jain et al [1] written in response to the article by David Berger [2] in the British Medical Journal should surprise no one. It highlights the rampant corruption in the Indian Health Care System. The authors have outlined all aspects of corruption in the medical profession, from inflated insurance claims, manipulation in Drug Trials and falsification of research data, to ‘Kick backs’ and percentages for patient referrals and unnecessary investigations and operations.
We live today in exciting times when science and technology have made many things possible which were hitherto considered unthinkable. The human genome has been sequenced. Stem cell technology is breaking new frontiers and our understanding of immunology has so improved that chimeric organs may one day be available for human transplantation. There has been a quantum leap in medical technology and patient care. However, we also live in times where materialism and corruption have begun to dominate our value system. We have lost all sense of ethics and humanity. The value and sanctity of human life has been reduced, more so in our country where massive increase in population and poverty has reduced the existence of many to a sub-human level. We as doctors have failed to maintain high standards of ethical practice, honesty and integrity. No longer is the doctor of today the revered family friend to whom patients turn for solace and healing. The doctor has become as corrupt as the society he lives in. It would do us well to reflect on the old Biblical teaching, “What does it profit man, if he gains the whole world, but loses his own soul” [3]. The practice of medicine should “embody love and reverence for life” and the desire to help others in need. “Ethics is nothing other than Reverence for Life” [4]. This should be instilled in young medical students in their formative years by teachers who are role models.
Corruption is endemic both in the public and private sector and has become a way of life in India. Children grow up believing that corruption is the way forward and that there is nothing wrong in cheating in exams, marking proxy attendances, or being dishonest to get ahead in life. Many have seen their parents cross a red traffic-light, bribe a Policeman or a Government functionary. Thus the seeds of corruption are sown early in life.
Transparency, good governance, deterrent punitive measures, good salaries (how much is good?) and legal support for whistle blowers have been identified as strategies for eliminating corruption. Anti-corruption bodies in the USA and UK have achieved only limited success with these measures.[5] [6] Physicians and all institutions in USA accepting gifts, kickbacks, free vacations, etc., from drug companies are liable to be prosecuted under the Physicians Payment Sunshine Act 2007.[6] The Pharmaceutical Industry has to divulge to a specific Government Website, a data base, when they make a gift, free dinner, etc., to a physician. This data base is available to the general public for scrutiny. In 2009, Health Care Fraud Prevention Enforcement Action Team (HEAT),[7] a task force against corruption in Medical Practice was established in USA under the Health Secretary and Attorney General. In spite of the passage of this bill, each year the Medical Fraud Strike Force has obtained convictions against several hospitals. Doctors, Nurses and Health Professionals have been convicted for misappropriation of funds going into millions of dollars. Between January and July alone, this year (2014), six hospitals in the USA have been fined more than 177 million dollars for unethical practice and this may only be the tip of the Iceberg. And so the fraud continues despite deterrent punitive measures. Such strategies will provide only limited success and can never produce the enduring change we seek. So, while we vigorously pursue anti-corruption strategies the battle against corruption should also be fought on another front -- at the school and college level.
Social change can only be brought about through children and young students while idealism still dwells in their soul. The battle against corruption in the medical profession will only be won when a new generation of health professionals and young doctors are willing to stand up and spurn the wages of unrighteousness and create a “water shed of change” for ethical practice. If each year 30% of the graduating medical students strive for high moral principles and ethical practice, there will be a domino effect, and medical corruption could be brought to a near zero level. This may take 20 years to achieve but we would have sown the seeds for a new India.
No one can deny that the Private Sector has effected significant advances in medical technology and patient care and a few centers are doing excellent work. The Corporate sector has invested heavily in health care and for them it is big business. It is neither a calling nor a charity. Healthcare is referred to as a medical industry and patients as clients. Since it is a business they see nothing unethical in employing marketing techniques to garner patients. Thus there is a conflict of interest and some hospital may compromise on ethics. The Private Sector must understand that transparency is also in their interest. All they have to do is to ensure ethical practice and this would be the greatest gift to the patients.
It is heartening that a campaign against corruption in medicine has started in India. In this endeavor do not forget the role of young doctors who alone can be the ultimate instrument of change.
Prakash Khanduri
St Stephen’s Hospital
Tis Hazari, Delhi – 110054
References
1 Anita Jain, Samiran Nundy, Kamran Abbasi Corruption: Medicines dirty open secret. Editorial BMJ 2014; 348:g4184
2 Berger D, Corruption ruins the doctor-patient relationship in India. BMJ 2014; 348: g3169
3 King James Bible, St Mark 8:36
4 Albert Schweitzer Reverence for Life. Wikipedia.org
5 Transparency International – UK. www.transparency.org.uk
6 Physicians Payment Sunshine Act of 2007 https//www.gov.track/us/congress/bills/110/32029
7 Fraud Prevention and Enforcement Action Team (HEAT). www.stopmedicarefraud.gov/about fraud/heattaskforce
Competing interests: No competing interests
After the timely curtain raiser by David Berger and then editorials by Anita Jain, Samiran Nundy and Kamran Abbasi in The BMJ, it is quite heartening to note that the noise level on the issue is now fairly high. The indiscreet behaviour of a section of Indian Medical practitioners is making the rounds in Parliament and the newspapers have joined in – making it an issue in which the larger civil society is itching to participate. A divine right to asymmetry of information has given unhealthy protection and a powerful shield to an unscrupulous segment in the profession. That’s been laid bare now. Now that we know it exists, we should focus on its dimensions, cultural and social ramifications with an intent to rub it out. The task may not be very easy and needs incisive analysis as well as action.
One of the major concerns is that the malpractice is threatening to come to centre stage now – given the tolerance that the profession and society has shown to its existence for so long. We need to understand that the corrupt and greedy have a cultural carpet which they have unfurled over a wide area over the past two decades of unregulated market growth in Indian medicare. Although a large group of professionals do not subscribe to this cultural mayhem in the profession, they are generally the work happy, peace loving lot. On the other hand, the misdirected and corrupt dominate at the cost of this decency through their aggressive design and emerge as the only voice apparent. It is important to note that, under the guise of “medicare”, this system has now grown up as an organised institution that disbelieves in all other attributes of a living except limitless money.
Unfortunately, the government in India has taken to a course of blind facilitation and has been appeasing the mushrooming malls of medicare. As a result, the evolving private system with all its cultural baggage is now making fast inroads even into the small townships of the country. This is threatening the entire health system by pushing medical malpractices as the only available “life- line”. People are caught between two evils. One is a non-performing salary savvy public sector and the other, an ill performing private sector that is virtually a seat of cheat and deceit in all its forms. This is growing apace since, in the absence of any effective regulatory system to crosscheck performance and transparency, spiralling profit is guaranteed at the cost of human life and science. Quality of care is the last priority and human beings are seen as a herd of “cases”. Doctors are deployed as intermediaries and instruments to produce money. Another dimension is socio- political. Owning a medicare establishment brings social status and respect for an entrepreneur and provides them with a platform to please the politicians and policy makers in a society where money is often synonymous with political and social power. A vicious cycle goes on and on - perpetuating the dreadful state.
Equally intriguing is the fact that this alternative, yet threatening to be the mainstream culture of corruption in Indian medicare, has become so strong that professionals who decline to participate in this are often teased as out-dated, lily-livered misfits. This often succeeds in making newcomers to the profession obviously fall in line early on. In an overall environment that sans value, youngsters fighting to establish themselves start to believe that malpractice is the only and the right professional way. Nothing can be more frightening than this – sowing the seed of corruption to make the young minds of the future generation morally sterile. The current Indian system is all set to produce thousands of rich traders of medicine and doctors are being used as a canopy.
It is in this ambience that we are hearing the grumbling counter voices. A warm welcome is welcome but not sufficient; action is an urgency and the voice can lead to making some actions fruitful. Obviously, the Indian government needs to come out with specific legislation to contain this spiralling menace. A bill has recently been moved in the upper house of the Indian parliament that proposes to tame this wild horse by tying it down. If this turns out to be true and have an impact, it may be a good beginning. Things are imperfect and a reverse sweep may not have all the elements of measured justice. The important thing will be to implement the laws. The corrupt in the medical profession have a very tight bond with those having the same trait in administration and police – the seats of the translation of law in Indian democracy. A wider ambit of crosschecks by a vibrant civil society is very much necessary now as participants in the movement. Unfortunately, the medical profession has been very tight within its clan, never wanting others in society to peep into its sovereign kingdom. Of course, the king does not wish to be undressed in public. But too much dirt has the potential of seeping beneath and causing disease. Fortunately, awareness regarding the right to information has empowered a larger section of people demanding clarity and conscientious professional behaviour. The meek and timid professionals who want to have a life of dignity need to raise their voice from within now. The skyline is fairly blue and we need to act with courage.
Competing interests: No competing interests
Corruption in India and in other young democracies and developing countries is easy to detect and is commonplace.
In the west we have had centuries to refine our methods and our descriptions.
Lobbyists and publicists have become pillars of professionalism, in some eyes.
Is our western greed any the less ?
Political economist Jeffrey Sachs recently commented, “ The excessive costs of US health care are notorious, but neither party has dared to grapple with the lobbying power of the health care industry, which is after all the single largest industry in the whole country.
America spends about 18% of it’s GDP on health to obtain what other high-income countries get for 12% of GDP. The difference is around $765 billion of waste, fraud and abuse each year, as described in a recent study by the authoritative, government sponsored US Institute of Medicine. “ (1)
A dramatic change in the way health care is delivered in England was enabled by the passage of the Health and Social Care Act in 2012. It has opened the way for private profit making organisations to move into work previously done by the NHS.
Before the 2010 Election, the leader of the Conservative Party had assured the electorate that there would be “ ..no more top down reorganisations of the NHS .“
Had he told the truth, the election result might have been different.
About 200 of the members of parliament who voted for the Act, had connections to private health care providers. (2)
Corporate power exerted by the defence, food, oil, banking and health industries effectively controls western governments.
Most people seldom recognise nor remember this reversal of intended roles, and even more rarely do they associate it with corruption.
Writing at the end of “ NHS SOS “, Davis and Tallis comment on the methods used to get Health Minister Andrew Lansley’s Act, onto the statute book.
“ Andrew Lansley’s wrecking ball is a symptom of a deep corruption in British politics: his act would not have entered the statute book without the subversion of the democratic process and the collusion of many who should have opposed it. “ (2)
Handing over money for services or favours is a banal form of corruption.
In the west we manage things on a far bigger and more sophisticated scale.
1 Our Dangerous Budget and What to Do About It,
New York Review of Books February 6, 2014.
2 NHS SOS Oneworld Publications 2013
Competing interests: No competing interests
It’s good to see an eminent clinician like Dr Samiran Nundy write about the issue of corruption in medical practice in India and for a prestigious journal like the BMJ to feature the same. As the article rightly points out, in a society where corruption is rampant, one wonders whether it is realistic to contemplate removing corruption from medical practice.
Transparency, good governance, professional standards that emphasize ethical practice, decent salaries and opportunities for professional growth have been correctly identified as some of the enablers of a corruption-free medical environment. We are implementing a similar multi-pronged strategy in our own nonprofit hospital to ensure that we don’t fall prey to the environment – we have made a beginning in reporting our clinical outcomes with our caesarean rates (making us perhaps the first private hospital in Delhi to do so), safety is being discussed at multiple levels including the board, all new consultants are inducted with a briefing by me to genuinely put the interest of the patients first, and consultants are being employed on a fixed salary with no financial incentives for generating additional revenue.
While these changes will help, ultimate success even in our small hospital will depend on the emergence of medical leaders who can help create a system where the interests of patients, doctors, hospitals, and payers (insurance companies) are better aligned. This will require doctors to embrace the science and art of leadership practice and move beyond resignation or mere criticism. I look forward to learning more about the planned campaign against corruption in medicine and its launch in India.
Competing interests: No competing interests
Corruption in the medical fraternity is reflective of this malady that is affecting the Indian society overall. Even in an affluent society like US where doctors generally earn well, they are driven by the desire to earn even more (for the groups/ practices they work for and in turn themselves). This has been well demonstrated in many a case studies wherein cost of medical care within a small distance varies a great deal (ref. Atul Gawande and medicare studies). Greed is after all a vice we all are afflicted with regardless of color, creed or nationality! It is good that at least these things are being talked about in India by the doctors themselves. What could be the possible solution is the big question? I definitely do not support having a MGNREGA style public wall (as suggested by the authors) as most of us realize that MGNREGA is a hugely corrupt platform! Introducing medical ethics in the medical school curriculum, emphasizing evidence based treatment which is shared in easily understandable language with the patients/families, and regular auditing of medical practices would be ways to go about in my opinion.
Competing interests: No competing interests
One important thing that many veteran doctors feel is the lack of clinical acumen and lack of enthusiasm for learning the skills. This bad ‘practice’ entails full use of the investigative battery there is for diagnosis and follow up, leading to overdependence. The common maladies that existed earlier still exist but require ten times the investigations in the course of their treatment. The huge shortage of good seasoned doctors as teachers in medical institutions leaves younger doctors less interested in practising medicine as an art form, with no worthy role model to look up to. Less communication and counseling compounds the problem and leads to a suboptimal treatment outcome and further investigations to look into the matter. The herd of sincere and serving doctors have been outnumbered by the doctors eager to cash back their investment in a heavily priced medical degree in the private sector. The alluring greed for easy money is stronger than ‘the oath’. Or should I say they are losing the human touch. At the end of the day, doctors should not forget the basic tenet of the practice of medicine – ‘primum non nocere’ ( First, Do no harm).
Competing interests: No competing interests
Government intervention to restricting corruption of health care market in Iran
Dear Editor
Informal payments for health care can increase health system inefficiency and corruption. Informal health payments can also lead to inequality in access to health care (1). Moreover studies show that the informal health payments can have negative effect on the quality of health care through making rent-seeking behaviors of health care workers and a sense of frustration from knowing the unfair allocation of these payments(2,3).
Informal payments are known in some countries as a major source of financing health care. In such countries a very high percentage of informal payments are made in order to access public health services and in order to receive a higher quality of services. For example, it’s reported that in Hungary that family doctors and some specialists earned between 60 and 236% of their net official income from informal payments in 2001(4). Another study in Hungary in 2007 showed that 9%, 14% and 50% of patients paid informally for their last visit to GP, specialist care and for hospitalization respectively during a year (5). It should be noted, informal health payments are more common in countries where there are imperative unrealistic tariffs along with inadequate monitoring in the health care system. Also informal payments are common where there is a culture of leaving tips or gifts. A World Bank study in Albania (2003) reported that 67% of people who had been hospitalized in the previous 4 weeks had made informal payments for health care services(6). The situation is not so much better in Bulgaria, Georgia, Taiwan and also China.
There are no released official statistics about the frequency of informal payments for health care in Iran, but according to some studies, it appears that informal health payments are common in Iran's health care system(7). As a response to this situation, from the beginning of May 2014 the Iran ministry of health applied a set of reforms in the health care system called "health system transformation plan", and one of its aims was restricting informal payments through increasing the legal wages of health care workers especially doctors(8). However, in Iran, there is a general concern about the consequences of this policy. There is a risk that increases in official fees happen without any reduction in unofficial payments. Because informal payment is a complex and multivariable phenomenon, it can be created in a health system for various reasons, including a lack of adequate responsibility and supervision in the health care system, not just low salary and benefit of health care workers.
Mohammad Meskarpour-Amiri1,2
1. PhD Student in Health Economics, Health Economics Department, Health Management Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran.
2. PhD Student in Health Economics, Faculty of Management and Economics, TarbiatModares University, Tehran, Iran.
References:
1. Thompson R, Witter S. Informal payments in transitional economies: implications for health sector reform. The International journal of health planning and management. 2000;15(3):169-87.
2. Mæstad O, Mwisongo A. Informal payments and the quality of health care: Mechanisms revealed by Tanzanian health workers. Health Policy. 2011;99(2):107-15.
3. Stringhini S, Thomas S, Bidwell P, Mtui T, Mwisongo A. Understanding informal payments in health care: motivation of health workers in Tanzania. Human Resources for Health. 2009;7(1):53.
4. Gaal P, Evetovits T, McKee M. Informal payment for health care: evidence from Hungary. Health Policy. 2006;77(1):86-102.
5. Baji P, Pavlova M, Gulácsi L, Groot W. Exploring consumers’ attitudes towards informal patient payments using the combined method of cluster and multinomial regression analysis-the case of Hungary. BMC health services research. 2013;13(1):62.
6. Bonilla-Chacin M. Health and poverty in Albania: Background paper for the Albania poverty assessment. Washington, DC: World Bank2003.
7. Ghiaspour M, Poorreza A, Arab M, Mahmodi M, Abutorabi A. The Analysis of Informal Payments Among Hospitals Covered Under Tehran University of Medical Sciences(TUMS)2009. journal of hospital. 2011;10(3):1-14.
8. akhondzade R. Health system transformation project, an opportunity or a threat for doctors(Editorial). JAP. 2014;5(1):1-2.
Competing interests: No competing interests