Or ‘Overenthusiasm of the Marketing Department
Corruption in Indian medicine is back on the front pages. One would think that there has been an abrupt spurt in corrupt practices or a major scandal. Nothing of that sort has happened. However, there have been some interesting developments for the focus to shift back to what is really a very old affliction. This is an update on recent happenings as the entrepreneurial spirit of the new India plays out in healthcare.
An Australian physician, David Berger, after volunteering for a year in a hospital in the Himalayas, wrote a scathing piece in the prestigious journal, BMJ (formerly the British Medical Journal) in May detailing the corrupt practices he experienced.1 Berger perhaps had the advantage of seeing the problem with the clarity that only an outsider can. While his article had eloquent descriptions of corrupt practices well known to anyone who engages with healthcare in India, he made some critical points worth noting. The first was to establish a linkage between India’s highly privatised healthcare model, the liberalised economy and the booming private medical college industry. The second was that corrupt practices, including the payment of commissions and cuts, severely undermine the doctor-patient relationship in India, as a result of which patients now fear going to doctors. Finally, in a strange twist, he called upon the international medical community to take on this corruption because, as he put it, “If prompt reform is not forthcoming from within the country, then the spotlight needs to turn global.” He suggested that one tangible way of doing this was by “the medical licensing authorities of the United Kingdom, the US, Canada, Australia, and New Zealand” (countries where a large number of Indian medical graduates migrate) withdrawing recognition “from all suspect private Indian medical colleges, sending a signal that there is no longer such a thing as ‘local corruption.’”
This was soon followed by an editorial in the BMJ co-authored by Samiran Nundy, a senior surgeon in Delhi.2 The authors, after lamenting the corruption described by Berger, analysed the drivers of this and remedial measures in some depth. They suggested that good governance, transparency, and zero tolerance must form the basis of an anti-corruption strategy. However, they hastened to add that these policies may be ineffective if healthcare professionals are not assured of a decent salary and fair opportunities for professional growth. They admitted that this is a difficult task in a corrupt society and that the answers may lie outside the world of medicine. They ended with an announcement and a call to join the BMJ in a campaign against corruption in Indian healthcare.
Meanwhile, in Mumbai, the Maharashtra Medical Council (MMC) was hearing two complaints on the issue of “cut practice”. For those who may not have heard this term, it refers to kickbacks and commissions that individual doctors, laboratories, radiology clinics, and other institutions give doctors for the act of referring a patient. The first case filed by Himmatrao Bawaskar, a courageous private physician from Mahad, asked the MMC to investigate a cheque he received by post from a radiology centre, presumably as a kickback for a referred patient. The centre in question filed a case in the Bombay High Court claiming that the MMC had no jurisdiction since a doctor did not own it. The case still awaits a decision. The second case was a complaint against the Kokilaben Dhirubhai Ambani Hospital, the new “corporate” hospital opened by Anil Ambani a few years ago. The hospital had begun a scheme titled the “elite forum” to provide “rewards” to doctors for referring patients. The rewards ranged from Rs 1 lakh for 40 admissions per annum, to Rs 2.5 lakh for 75 admissions. Those joining the scheme needed to sign and stamp a statement. This was perhaps a clever attempt by some bright marketing manager to formalise the kickback system, which now largely operates unofficially and in an opaque manner. Even a hospital of this scale, which had spent crores in advertising campaigns, had to seek recourse to a well-entrenched trade practice. On receiving a show-cause notice, the hospital hastily withdrew the scheme. Both these cases, however, had already brought “cut practice” to the inside pages when the BMJ articles nudged it to the front page.
There are several levels at which one can analyse the all-pervasive phenomenon of corruption in Indian healthcare. These include narrow frameworks such as individual morality to broader ones such as health policy, cultural behaviour, and societal corruption. All these have been dealt with in a fair amount of detail in previous writing.3 A unique feature of the situation though is the total complicity and permissiveness of the medical profession, including professional associations, who have internalised referrals to a kickback-based framework.
Medicine and Entrepreneurship
The professional life of many doctors in India is deeply intertwined with the marketing and entrepreneurial aspects of healthcare. A significant number own hospitals, have personal investments, or are part of all manner of financial arrangements. This results in a certain loss of neutrality and complicity when market forces are at play. For example, hospitals put pressure on doctors to meet “targets” for patient admissions in return for an “attachment”. For admitting these patients, doctors have to pay the going commission rate to the referring doctor, usually a family physician. Such an interplay of dubious mechanisms is necessary because healthcare is not structured into a nationalised scheme where referrals would be based on geography and expertise. To keep the business ticking, investigations, admissions, procedures, and, in general, numbers are imperative. Given the relatively small segment of the population that private medicine is targeting, there is intense saturation and competition. This provides fertile ground for illegitimate methods to keep the cash-counting machines running. Add to this the influence of the pharmaceutical, equipment, laboratory, and radiology industries, all of which also are willing to bribe users to utilise their services.
In the current brouhaha, however, some novel points have emerged. The first, as illustrated by the Ambani hospital case, is that we are now poised to see sophisticated, structured, and even transparent forms of corruption where kickbacks are offered in the guise of well-designed schemes. In this, individual doctors working in such hospitals may actually be pawns in a larger game. Thus “underground” corruption may change to “open” corruption, even acquiring a certain transparency. More importantly, large health industry players rather than individual doctors will be involved. With the entry of several large corporate conglomerates to the market, forms of incentivisation will become more innovative.
The second fallout is that it seems the “international” community, currently represented by the BMJ, is now sufficiently alarmed and actually seeks to intervene by starting a campaign. Given the near complete conspiracy of silence of Indian healthcare professionals, it is very tempting to think of this as a welcome development. But it may not be so unless a critical mass of opinion among Indian doctors takes this up on a priority basis. Appeals without backing are unlikely to have any meaningful impact. I doubt whether a critical number of voices will emerge from the mainstream profession in today’s atmosphere of market medicine. In other countries, the pursuit of science, training and education are important elements of medical practice that neutralise and create an alternative thought current. In India, a large majority of medical professionals are too consumed by targets of wealth, numbers, and strangely with world records to break out of the mould. It would not surprise me if the BMJ’s campaign is portrayed as international interference in Indian affairs. A significant number of responses in the BMJ from Indian authors already reflect this. Remember the jingoistic and pseudo patriotic response to the publication of a high-quality scientific article on multi-drug-resistant bacteria found in patients treated in India not so long ago?
Pressure from Outside Medicine?
As Nundy and his colleagues note, the impetus for change could come from forces “outside” the profession. They give the example of the battle being fought by Kunal Saha, a doctor, under the aegis of a voluntary organisation called People for Better Treatment. If consumers of healthcare recognise that corruption in healthcare is a monster that adversely affects their day-to-day lives more than, say, the telecom scam, one may see more sustained resistance. For this, communities need to appreciate that corruption affects the quality of health services and increases its cost. Therefore it also affects the fundamental right of having access to quality healthcare. If the challenge from society reaches a critical level, it could get a small number of potential allies from the medical profession who are now uncomfortable but silent.
When the Ambani hospital responded to the MMC about its kickback scheme, it had an interesting explanation. Its letter said, “The offering of incentives to doctors, as pointed out in your letter, was a case of over enthusiasm by the Marketing Department.” The MMC’s final verdict on this is still not clear. It could perhaps act on the “overenthusiasm” but that could be easy and temporary. What is more difficult and beyond the ambit of the MMC is prompting a collective self-reflection that, unlike many other countries, we have all been complicit in leading something as important as healthcare into a “marketing” paradigm. When the outrage against corruption leads to outrage against our collective failure to protect healthcare from the ravages of the market, we may move closer to effective steps in the right direction.
1 D Berger (2014), “Corruption Ruins the Doctor-Patient Relationship in India” , BMJ, 8 May, 348, g3169.
2 A Jain, S Nundy and K Abbasi (2014), “Corruption: Medicine’s Dirty Open Secret”, BMJ, 25 June, 348, g4184.
3 S Chattopadhyay (2013), “Corruption in Healthcare and Medicine: Why Should Physicians and Bioethicists Care and What Should They Do?” Indian Journal of Medical Ethics, 10 (3), pp 153-59.