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Use patient power to tackle medical corruption in India

BMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g5156 (Published 14 August 2014) Cite this as: BMJ 2014;349:g5156
  1. Aniruddha Malpani, medical director, Health Education Library for People, Ashish, Tardeo, Mumbai 400 034, India
  1. info{at}drmalpani.com

Educated and empowered patients make it much harder for corrupt practices to occur in the health system, writes Aniruddha Malpani

Corruption (the abuse of power for private gain) seems to be a problem that afflicts healthcare systems the world over. A recent article in The BMJ described some of the problems in India.1

It’s true that the Indian healthcare system is ailing. We have too many patients and not enough doctors to provide personalised care. The result is that patients see themselves as helpless, and some doctors and officials exploit this power imbalance to make money by unfair means.

Traditional solutions have not worked. Regulation is doomed to fail because the regulators themselves are often corrupt.2 Exhorting doctors to become more ethical is not helpful—good doctors don’t need to be told, and bad doctors will not improve because we preach to them.3

Contributing to the stalemate is that we continue to consider the number of patients in India as a problem. Actually, they are part of the solution: patients are the largest untapped healthcare resource.

Healthcare needs to learn from the revolution that has occurred in microfinancing.4 When given money and the freedom to use it as they see fit, even very poor people have come up with remarkably innovative ideas that could never have been planned, designed, or anticipated by bankers—the traditional experts. If we treat patients as experts, they may suggest far cleverer solutions to fix their healthcare problems than doctors have been able to.

The present situation is made worse by the intermediaries who contaminate the doctor-patient relationship. This means that instead of doctors being free to act in the patient’s best interests, they have multiple masters. For example, the family physician who takes a kickback to refer a patient to a specialist will often demand that the specialist perform surgery because it is more profitable. It’s an open secret that to earn more money laboratories and imaging centres offer financial incentives for referrals; and the drug industry compounds the problem by bribing doctors to prescribe their brands.5

One way to fix the problem is to cut out the intermediaries and create direct relationships between doctors and patients based on trust. Healing this relationship will allow doctors to act as the fiduciaries they are supposed to be. Thanks to the internet it has become much easier to do this. Patients are now online, and when doctors are too there will be no need for them to offer cuts to referring doctors—patients will be able to reach out to them directly. If every doctor had his or her own website, this would force them to become open, which is a powerful antidote to the poison of corruption.

We now have a new generation of healthcare entrepreneurs, who are developing clever online solutions that allow doctors to engage directly with their patients. When a doctor’s medical practice is flourishing thanks to loyal and satisfied patients then there is no longer any need to engage in underhanded financial deals.

This may also lead to a virtuous circle. Doctors will compete to be seen to offer more value to patients. This digital leverage would encourage doctors to become more available, affordable, and accessible.

Doctors will always be busy and will never have enough time to educate their patients face to face. This is why they need to invest in creating online educational tools that patients can use to become well informed. These can be cost effective to develop because they are created once and then used multiple times. We need to apply the “flipped classroom model”6 to healthcare so that patients can have more productive consultations (in the clinic and online) with their doctor. When patients are armed with accurate information about their illness, they can form an intelligent partnership with their doctor—this in turn will help to reduce corrupt practices.

We also need to involve other patients.7 Peer to peer education is effective. Expert patients are much more empathetic because they have “been there, done that.” They speak the regional language without medical jargon, and they know how to make the best use of the locally available resources. These expert patients inspire trust because other patients know that the advice being offered is free of vested financial interests. Online platforms where patients act as health coaches for other patients are valuable. Many Indians believe in karma and understand that the best way to help themselves is to help others. Information can be delivered widely and inexpensively, thanks to the internet and the proliferation of smart phones. It’s important that patients trust their doctors, but this trust needs to be earned. Patients can be taught to do their own homework, so they can independently verify that their doctor is giving them sound advice. This will help to keep doctors honest too.

To empower patients, the government needs to provide quality information for the right person at the right time. Ideally, every clinic, hospital, pharmacy, and diagnostic centre should have a patient education resource centre, where people can find information on their health problems. Illiteracy can be a bottleneck, but using video is possible.

This is a huge opportunity for the Indian government. While patients are hungry for information, they are not sure if online information is reliable or not. If the Indian government provided this information, not only would it be trusted, it would also allow the government to show that it was spending its funds sensibly to improve the health of its citizens. It is farcical that the United Kingdom’s NHS provides more high quality health information in Indian languages such as Gujarati than the Indian healthcare system does.

The other big players in the healthcare system also have an important role. Drug companies have damaged their reputations in pursuit of short term profits. By providing reliable information about their drugs, companies can help to improve their image and restore public trust. Health insurers also need to provide information to control the epidemic of overmedicalisation. This will allow them to improve the quality of services they provide, because this would reduce their losses.

Finally, good doctors would be happy—it’s much easier and less time consuming to talk to a well informed patient. Ethical doctors would much rather treat a well informed patient who has realistic expectations of the outcome of treatment. A good doctor and a well informed patient can form a partnership that will ensure that patients get the best possible medical care.

Notes

Cite this as: BMJ 2014;349:g5156

Footnotes

  • Competing interests: I have read and understood BMJ policy on declaration of interests and declare the following interests: I am the medical director of HELP, a non-governmental organisation that promotes “information therapy” in India.

  • Provenance and peer review: Not commissioned; not externally peer reviewed.

References

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