How to cure cor­rup­tion in health­care

Rx: Only an effective gov­ern­ing body, which in­cludes med­i­cal and non-med­i­cal mem­bers, can stop the cul­ture of kick­backs


COR­RUP­TION IN the health­care sec­tor is old news. Al­most ev­ery­body in the coun­try has been a vic­tim of some form of graft or mal­prac­tice—be it in­flated bills, wrong di­ag­no­sis, or sub­stan­dard treat­ment. So it comes as lit­tle sur­prise when a for­eigner who has worked in the In­dian med­i­cal sys­tem says, “kick­backs and bribes oil ev­ery part of the In­dian health­care ma­chin­ery”.

Yet the ob­ser­va­tions made by Aus­tralian district med­i­cal of­fi­cer David Berger, who has writ­ten an ar­ti­cle in the Bri­tish Med­i­cal Jour­nal on his ex­pe­ri­ence in work­ing with an In­dian hos­pi­tal, has once again sparked a de­bate—both in the public and po­lit­i­cal do­main—on how to fix the ram­pant cor­rup­tion in the health­care sys­tem.

The solutions are ob­vi­ous, sug­gests Sami­ran Nundy, a se­nior doc­tor with Sir Ganga Ram Hos­pi­tal in Delhi. “There is a need for col­lec­tive will and it has to be backed with trans­parency in the sys­tem,” he says. Pol­icy mak­ers have never ad­dressed the is­sue of cor­rup­tion in to­tal­ity, says Nundy. In­stead, ev­ery time a scam is ex­posed, the gov­ern­ment an­nounces new steps, which sel­dom get im­ple­mented. A good ex­am­ple of the lack of col­lec­tive will in re­form­ing in­sti­tu­tions is the Med­i­cal Coun­cil of In­dia (mci), which was em­broiled in a scam in 2010.The statu­tory body was set up to “es­tab­lish and main­tain high stan­dards of med­i­cal ed­u­ca­tion and recog­ni­tion of med­i­cal qual­i­fi­ca­tions in In­dia”. But its for­mer pres­i­dent Ke­tan De­sai was ar­rested for ac­cept­ing bribe of 2 crore from

` Gyan Sa­gar Med­i­cal Col­lege in Pa­tiala. As a knee-jerk re­ac­tion, the gov­ern­ment dis­solved the body while an­nounc­ing in Par­lia­ment that it will bring in re­forms. But in 2013, the gov­ern­ment re­stored mci with­out any re­forms. Like in the mci, cor­rup­tion cases have sur­faced in al­most ev­ery gov­ern­ment health scheme (see ‘Graft files’ on p 39).

Ashutosh Mishra, ex­ec­u­tive direc­tor of the In­dia chap­ter of Trans­parency In­ter­na­tional, thinks cor­rup­tion in health­care is thriv­ing be­cause of lack of trans­parency.In a sur­vey con­ducted in 2006, Trans­parency In­ter­na­tional found that ev­ery year peo­ple from the be­low poverty line cat­e­gory in In­dia shell out over 10,000 crore as bribe for ba­sic

` needs, in­clud­ing health­care. The amount that is be­ing wasted be­cause of cor­rup­tion is close to a third of what the gov­ern­ment plans to spend in the sec­tor (`33,725 crore) in 2014-15.“At any stan­dard, there has been no im­prove­ment since then, ”he adds.

Ab­hi­jit More, an ac­tivist with non--

profit sathi that works on ru­ral health in Ma­ha­rash­tra and Mad­hya Pradesh, echoes Mishra’s sen­ti­ment. He says the gov­ern­ment should make it manda­tory for doc­tors to write down de­tailed pre­scrip­tions with the di­ag­no­sis and the medicines pre­scribed. “Most cor­rupt doc­tors just write the medicines which makes it dif­fi­cult to know what dis­ease the pa­tient is suf­fer­ing from.”

Talk­ing about lack of trans­parency, T Sun­der­ara­man, joint con­vener of public health ad­vo­cacy group Jan Swasthya Ab­hiyan (jsa), says gov­ern­ment health in­sur­ance scheme Rashtriya Swasthya Bima Yo­jna is a ma­jor source of cor­rup­tion and needs re­design­ing. “Un­der the scheme, the ben­e­fi­cia­ries should always be alerted about how much they are pay­ing for treat­ment.For in­stance, smart cards of the Delhi Metro tell users how much money has been de­ducted. The ben­e­fi­cia­ries can then ques­tion if they are over­charged, ”he says.

Mon­i­tor­ing med­i­cal col­leges

The process of in­di­vid­ual cor­rup­tion be­gins early, right at the start in med­i­cal col­leges, with cap­i­ta­tion fees for en­try to the mbbs course in many pri­vate sub­stan­dard med­i­cal col­leges, writes Nundy in an ed­i­to­rial in Cur­rent Medicine Re­search and Prac­tice.

The same ob­ser­va­tion is echoed by Ja­sod­hara Das­gupta, co­or­di­na­tor of Sahyog,a non-profit work­ing on women em­pow­er­ment and health is­sues. Th­ese ex­perts be­lieve cor­rup­tion in med­i­cal ed­u­ca­tion is the rea­son be­hind the wors­en­ing sit­u­a­tion in health­care.

In­dia is the only coun­try where sale of med­i­cal seats by pri­vate med­i­cal col­leges is part of of­fi­cial pol­icy. It means the abil­ity to pay counts more than merit. Apart from the huge cap­i­ta­tion fee, the process of walk- in type of ad­mis­sions is also prob­lem­atic. In such cases, even those who lack in­ter­est in the pro­fes­sion get ad­mis­sion. And the pa­tients bear the brunt of th­ese lapses as they get treat­ment from un­skilled doc­tors. To make mat­ters worse, many such doc­tors un­scrupu­lously in­dulge in un­eth­i­cal prac­tices to make quick money.

The gov­ern­ment, along with mci,did try to en­sure a min­i­mum level of com­pe­tence by moot­ing a Na­tional El­i­gi­bil­ity-cum-En­trance Test as qual­i­fy­ing re­quire­ment for all stu­dents.But the idea was op­posed by med­i­cal col­leges and they got a stay from the Supreme Court in May 2013.

Pri­vate med­i­cal col­leges are also mush­room­ing by the dozen and the gov­ern­ment has lit­tle reg­u­la­tion in this re­gard. Ac­cord­ing to in­for­ma­tion re­ceived from mci, there are 27 med­i­cal uni­ver­si­ties in In­dia.Of th­ese,14 are in the pri­vate sec­tor. Till June 30,there were 387 med­i­cal col­leges, in­clud­ing six new aiims, in the coun­try. Of th­ese,205 col­leges are run by pri­vate play­ers, in­forms Union health min­is­ter Harsh Vard­han, who ad­mits to the prob­lems in the ed­u­ca­tion sec­tor. “We are look­ing into how to im­prove med­i­cal ed­u­ca­tion in the coun­try and mci’s re­form is un­der se­ri­ous con­sid­er­a­tion,” he told Down To Earth. On the ques­tion of mak­ing do­na­tions for med­i­cal seats il­le­gal, he says, “We will see what is pos­si­ble through law.”

Sun­der­ara­man says that cor­rup­tion in med­i­cal ed­u­ca­tion can be eas­ily con­trolled by au­dit­ing and keep­ing records. But it will re­quire po­lit­i­cal will, he adds.

Ban on kick­backs

The other ma­jor is­sue is that the law is silent over the kick­back cul­ture, points out More. jsa has writ­ten a let­ter to the health min­istry

de­mand­ing that kick­backs be made il­le­gal and seen as con­flict of in­ter­est. Sun­drara­man says the gov­ern­ment should in­clude this in the ex­ist­ing Clin­i­cal Es­tab­lish­ments (Reg­is­tra­tion and Reg­u­la­tion) Act, 2010 (cea). The Act is the only effective ini­tia­tive taken by the gov­ern­ment so far to check mal­prac­tices. It calls for reg­is­tra­tion and reg­u­la­tion of all clin­i­cal es­tab­lish­ments and at­tempts to en­sure pro­vi­sion of min­i­mum stan­dard fa­cil­i­ties in all kinds of med­i­cal es­tab­lish­ments, in­clud­ing public and pri­vate ones,and even small clin­ics.

Sun­der­ara­man says that the sit­u­a­tion is so bad that peo­ple do not even be­lieve ac­cept­ing kick­backs is wrong. The new gov­ern­ment re­cently said it is com­mit­ted to the idea of health for all.The health min­is­ter on July 22 told Par­liamment that his min­istry is draw­ing up a panel of re­puted med­i­cal prac­ti­tion­ers and con­sumer law ex­perts to sug­gest mea­sures for in­tro­duc­ing greater trans­parency in med­i­cal prac­tices.

China, which is fac­ing sim­i­lar is­sues, has re­cently taken steps to tackle sys­temic kick­backs in the health­care sec­tor. In De­cem­ber 2013, China’s Na­tional Health and Fam­ily Plan­ning Com­mis­sion in­tro­duced new reg­u­la­tions for hos­pi­tals, physi­cians and med­i­cal prod­uct man­u­fac­tur­ers. The coun­try pro­hib­ited doc­tors from par­tic­i­pat­ing in prod­uct pro­mo­tional ac­tiv­i­ties or il­le­gal dis­clo­sure of pa­tient data. It also banned ac­cept­ing kick­backs and com­mis­sion, and ac­cept­ing in­duce­ments from pa­tients or their families.The guide­lines pre­scribe pro­hib­i­tive pun­ish­ment for defaulters.

Body to check pri­vate play­ers

The need for an effective cen­tral body to gov­ern the sec­tor is more real than ever to­day be­cause of rapid pri­vati­sa­tion in the sec­tor. Ac­cord­ing to the Na­tional Health Pro­file, 2013, the money paid by pa­tients to pri­vate hos­pi­tals for treat­ment ac­counted for 71.62 per cent of the to­tal fund in­flow in the health­care sec­tor in 2008-09.The share is ex­pected to in­crease to 81 per cent by 2015. Thus, ex­perts say, effective re­forms in the mci are im­por­tant to check mal­prac­tices in the health sec­tor.One of the ma­jor re­forms sug­gested by ex­perts is to in­clude non-med­i­cal mem­bers in mci, which is com­mon in Western coun­tries. “In the UK, the Gen­eral Med­i­cal Coun­cil is very tough on cor­rupt doc­tors. Its mem­bers in­clude jour­nal­ists, so­cial work­ers and other pro­fes­sion­als, un­like mci whose mem­bers are only doc­tors and they want to pro­tect them­selves, ”says Nundy. The step, he says, is es­sen­tial to have an effective re­dres­sal sys­tem. There should be trans­parency in the se­lec­tion to re­pose peo­ple’s faith in the health­care sys­tem, says More.

Ex­perts say it is un­for­tu­nate that the coun­try, whose re­searchers are play­ing a piv­otal role in med­i­cal ad­vances glob­ally, is still strug­gling with cor­rup­tion, even in ba­sic health­care sys­tems.


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