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Corruption ruins the doctor-patient relationship in India
Pharma companies in India are not only bribing doctors with money and luxury goods, but also flying them to foreign destinations and providing prostitutes at their homes. Kickbacks and bribes oil every part of the country’s healthcare machinery, writes David Berger. If India’s authorities cannot make improvements, international agencies should act.
The corruption strangles everything, Sir. It’s like a cancer.”Accompanied by apologetic shrugs and half smiles, statements like this are commonly heard in India. I knew this was the case before I went to work as a volunteer physician in a small charitable hospital in the Himalayas, but what I didn’t realize was how far the corruption permeates the world of medicine and the corrosive effect it has on the doctor-patient relationship.
Although the causes and effects of corruption are complex, a few strands can be teased out. The healthcare system itself is a model of inequity; it is one of the most privatized in the world, with out of pocket expenditure on healthcare at more than 70%, far higher even than in the United States (1).This phenomenon is at least partly the result of the neoliberal World Bank policies of the 1990s, which mandated a reduction in public financing of healthcare, fuelling growth of the private sector (2).The latestin technological medicine is available to people who can pay, albeit at a high price, but the vast underclass, 800 million people or more, has little or no access to healthcare, and what access it does have is mostly to limited substandard government care or to quacks, who seem to operate with near impunity. There is one leveler, however: corruption is rife at all levels, from the richest to the poorest.
One day in the outpatient department I was writing a request for an exercise electrocardiogram at a private heart clinic when the devout young resident consulting beside me said, “Give me that. I have to sign it.” Perplexed, I handed it over, and the story unfolded: all investigations attract a 10-15% kickback to the referring doctor. One day, the marketing executive for this clinic had turned up at the hospital with an envelope full of cash—the commission for investigations ordered in the past few months.
The senior doctor refused it and stipulated that in future the commission was to be paid back to patients, which is why the resident had to sign the form. 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.
Given these practices, it is no surprise that investigations andprocedures are abused as a means of milking patients. I saw onepatient with no apparent structural heart disease anduncomplicated essential hypertension who had been followedup by a city cardiologist with an echocardiogram every threemonths, a totally unnecessary investigation. A senior doctor inanother hospital a couple of hours away was renowned for usingultrasonography as a profligate, revenue earning procedure,charging desperately poor people Rs1000 eachtime. Everyone who works in healthcare in India knows this
kind of thing is widespread.
There is also widespread corruption in the pharmaceuticalindustry, with doctors bribed to prescribe particular drugs. Talesare common of hospital directors being given top of the rangecars and other inducements when their hospitals sign contractsto prescribe particular antibiotics preferentially.
I met a former pharmaceutical sales executive who left theindustry, sickened by the corrupt practices he was supposed toemploy. Working for one of the largest drug companies in thecountry, he was expected to bribe doctors with money andluxury goods. The crunch came when a doctor demanded thatthe company fly him to Thailand for a holiday and then providehim with prostitutes at his home. When the companyrepresentative queried this, his manager told him to comply,and he felt he had no choice but to resign, protesting that hewas “not a pimp.”
It is no wonder,therefore, that a common complaint I heardfrom poor and middle class people is that they don’t trust theirdoctors. They don’t trust them to be competent or to be honest,and they live in fear of having to consult them, which results inhigh levels of doctor shopping.
Lack of trust in doctors, and the costs associated with going tosee them, mean many patients rely on pharmacists, who seemto have a similar lack of ethics, selling inappropriate drugs overthe counter at exorbitant prices to people who often have toborrow the money to pay for them.
Endemic corruption extends to medical studies themselves. Inanother“unvirtuous circle,” students can have to pay very large“donations” (perhaps $200 000 or more, some 20 times theaverage doctor’s annual salary) to get into the rapidly increasingnumber of private medical colleges and to get on to sought afterpostgraduate training schemes. This means that doctors canhave high levels of debt or family obligation when qualifying,which is a strong incentive against working as generalists inrural areas and favors them practising technological medicinefor maximum profit in urban areas to try to recoup theirinvestment.
Many Indian doctors have huge expertise, and many arehonorable and treat their patients well, but as a group, doctorshave a poor reputation. Until the profession is prepared to tacklethis head-on and acknowledge the corrosive effects of itscorruption then the doctor-patient relationship will continue to lie in tatters.
The arrest on bribery allegations in 2010 of the Medical Councilof India’s (MCI) president Ketan Desai (3) and the subsequentdissolution of the council by the president of India (4), wereindicative of the crisis in probity among the Indian medicalprofession. Subsequently, there has been controversy over thesurprise removal, on the day India was declared polio-free, ofthe health secretary KeshavDesirajus, possibly in response tohis resistance to moves to reappoint Desai to the reconstitutedMCI (5,6).
Medicine has globally accepted standards of conduct. The Indianprofession should want to adhere and be held accountable tothese. Currently, however, it seems to be failing in this regard.This is not only bad for India but bad for other countries thattake doctors trained in India. In wanting to draw attention tothese problems, I am holding my Indian colleagues to the samestandards of ethical behavior as I would my colleagues at home.
So what can be done? One place to start would be to reform theprivate medical colleges, the number of which is burgeoning asthe Indian government tries to expand the number of medicalgraduates (7). As long as places are available for sale atastronomical prices at these institutions (8) and as long as theyresort to fraudulent practices and bribery to pass theirinspections,9 then the integrity and competence of their graduateswill remain questionable and the cycle of corruption will remainunbreakable.
If prompt reform is not forthcoming from within the country(and the will seems to be lacking10), then the spotlight needs toturn global. The medical licensing authorities of the UnitedKingdom, the US, Canada, Australia, and New Zealand couldwithdraw recognition from all suspect private Indian medical colleges, sending a signal that there is no longer such a thingas “local corruption.” These countries are popular foreigndestinations for Indian medical graduates, but they do not wantto accommodate potentially corrupt doctors of uncertaincompetence, and neither do the people of India.
(BMJ 2014;348:g3169doi: 10.1136/bmj.g3169)
References:
1 Dutta N. What ails India's healthcare system.HealthSite2012 Aug 18.http://health.india.com/diseases-conditions/what-ails-indias-healthcare-system/.
2 Jilani A, Azhar G, Jilani N, Siddiqui A. Private providers of healthcare in India: a policyanalysis. Internet J Third World Med 2009;8(1).
3 Court extends judicial custody of Ketan Desai by 14 days. The Hindu 2010 May 14. www.thehindu.com/news/national/article429819.ece.
4 President signs ordinance on MCI.The Hindu 2010 May 15. www.thehindu.com/news/national/article430812.ece.
5 Congress, BJP, SP paving the way for Ketan Desai’s re-entry into MCI:AAP. EconomicTimes2014 Mar 1. http://articles.economictimes.indiatimes.com/2014-03-01/news/47799433_1_ketan-desai-health-minister-mci.
6 Dutta N. Ex-health secretary KeshavDesiraju’stransfer—is it justified? HealthSite2014Mar 4. http://health.india.com/healthcare/ex-health-secretary-keshav-desirajus-transferis-it-justified-n314/.
7 Centre to ask MCI to speed up medical college inspection. Deccan Herald 2012 Nov 2.
www.deccanherald.com/content/289800/centre-ask-mci-speed-up.html.
8 Private medical colleges in three states selling seats for crores.IBN Live 2013 Apr 4. http://ibnlive.in.com/news/private-medical-colleges-in-three-states-selling-seats-for-crores/382979-3.html.
9 Medical Council of India ban to hit pvt medical colleges.Times of India 2012 Oct 16. http://timesofindia.indiatimes.com/city/thiruvananthapuram/Medical-Council-of-India-ban-tohit-pvt-medical-colleges/articleshow/16829639.cms.
10 Checking high fees in private medical colleges not feasible: Union health minister. Timesof India 2012 Jun 21. http://articles.timesofindia.indiatimes.com/2012