Corruption: medicine’s dirty open secret

Healthcare is a high risk sector for corruption. Best estimates are that between 10% and 25% of global spend on public procurement of health is lost through corruption.1 This is big bucks. Total global spend on healthcare is more than $7 trillion each year. Corruption takes many forms, depending on the country’s level of development and health financing system.2 The United States, for example, lost between $82bn and $272bn in 2011 to medical embezzlement, mostly related to its health insurance system.3 No country is exempt from corruption. Patients everywhere are harmed when money is diverted to doctors’ pockets and away from priority services. Yet this complex challenge is one that medical professionals have failed to deal with, either by choosing to enrich themselves, turning a blind eye, or considering it too difficult. Transparency International, a watchdog on these matters, defines corruption as the abuse of entrusted power for private gain, which in healthcare encompasses bribery of regulators and medical professionals, manipulation of information on drug trials, diversion of medicines and supplies, corruption in procurement, and overbilling of insurance companies.4 This is no dirty little secret. It is one of the biggest open sores in medicine.

India, with rampant corruption at all levels, is prominent in this international field, with a survey by Transparency International in 2013 finding the practice of paying bribes for services in India to be double that found globally.5 The payment of bribes or use of influential connections to get “a little ahead, a little extra, a little quicker” has become ingrained in people’s attitudes.

Resistance is often not an option for those working within corrupt systems. David Berger’s experience of the Indian health system highlights how corrupt practices can steadily erode the trust and respect with which doctors were previously regarded.6 As in China, attacks on doctors may become a more common consequence of perceived corruption in the medical system.7

When devising effective solutions it is important to identify the possible drivers of corruption. India has a lack of external accountability and oversight of both public and private health sectors. Most doctors work in the underfunded and inefficient public sector because it is a secure job with time bound promotions and little supervision. However, those in much better paid private sector jobs are incentivised to generate business for their employers by overinvestigation and overtreatment of patients who are at their mercy both medically and financially. Private medicine has flourished in India because of a weak regulatory climate with no standards to monitor quality or ethics. Using a theoretical framework, Vian suggests that three factors are at play here: opportunity to engage in corrupt practices by dint of being in a position of power in a system with inadequate oversight; financial, peer, or personal pressures felt by officials; and a culture that rationalises and accepts corruption.8 It is therefore a difficult task to weed out corruption from the health system, and it requires action at all levels. Indeed, how is it possible to practise medicine free of corruption in an overwhelmingly corrupt society?

Good governance, transparency, and zero tolerance must form the basis of any anti-corruption strategy. Changes must be implemented in society at large for reform to be sustained. Better governance requires rigorous legislation and functioning administrative mechanisms to provide fiscal oversight. Ethical standards of conduct must be explicitly established and staff held accountable for their performance. Punitive measures should be available to serve as a deterrent. Honest behaviour must be rewarded. These policies may be ineffective, however, unless healthcare professionals are assured of a decent salary and fair opportunities for professional growth.9

A simple yet powerful model for change is presented by the “transparency wall” that appeared in villages under the Mahatma Gandhi National Rural Employment Guarantee Act. Through information sharing, communities were empowered to monitor disbursement of funds under the scheme and prevent malpractice.10 Similarly, the Right to Information Act provides a powerful tool to bolster the involvement of citizens in government functioning and to hold public officials accountable.11

It will be challenging for patients and doctors to take on a system mired in corruption. Simple and effective channels for complaints must be established, and appropriate legal support and protection provided to whistleblowers. Looking deeper, underlying issues such as education and social justice must not be forgotten if the battle against corruption is to be sustained and eventually won. Answers may also lie outside the world of medicine. People for Better Treatment—an organisation set up by an expatriate Indian doctor whose wife died after a medical mishap—is campaigning to hold the medical profession accountable by including people from outside medicine on regulatory bodies.12

Success in tackling corruption in healthcare is possible, even if it is initially limited, as anti-corruption bodies in the United Kingdom and US have shown.4 13 Doctors have allowed sleeping dogs to lie for too long because of fear, lethargy, and complicity. It is time to reflect and hold ourselves and our peers accountable. Professional standards of conduct must be instilled early through ethics training in the undergraduate medical curriculum.14 These ethical standards must be upheld throughout medical careers to influence colleagues and the broader community.

We plan to launch a campaign against corruption in medicine, which will begin with a focus on India. We know that India is not alone, but if we can defeat corruption in India we believe it is possible to tackle it for the benefit of millions of people in other countries with similar health ecosystems.

We urge an international fight back against kickbacks. Join us.