The Author, Manali Surana is a 2nd year Law student (LLB), Children welfare Centre Law College, Mumbai University, Mahrashtra.
What is Corruption?
In simple language, it is an act of misuse of power and being dishonest towards the process that we are part of, usually involving payment of black money in the form of bribe. There is no pellucidity involved and everything happens for the need and desire of illegal money for one’s own private use and enjoyment. There is no field, where corruption hasn’t touched upon starting from politics, which is the most corrupted field to employment sectors, educational institutions, healthcare sector, religious organization, etc. It exists in countries, irrespective of whether they are small or big, developed or a developing nation, government or private sectors.
A pregnant woman walks into a hospital complaining of stomach pain, and the doctors immediately conduct sonography. The doctors “manage” her sonography reports and call it an emergency, only to operate her, do unnecessary stitches and extract money. This whole drama of “sonography” and “emergency” was needless and was done only to fill their pockets with money. Scary isn’t it? This is not the only instance in which doctors have manipulated the patient to make money. Likewise, hundreds and thousands of cases happen every day in Indian medical profession, where doctors, on whom patients blindly trust, make fool out of patients. Be it in urban or rural areas, the malpractices in medical profession in India are rampant and these unscrupulous practices are not only in hospitals but are seeped deep down into diagnostic centres, pharmaceutical companies, asking for cuts from doctors, giving them gifts and throwing parties in return. One can quote innumerable reports pointing to the inhumanity of persons in white coats.
Talking about healthcare, it has become one of India’s largest sector, both in terms of revenue and employment. It comprises hospitals, medical devices, clinical trials, outsourcing, telemedicine, medical tourism, health insurance and medical equipment. Indian healthcare delivery system is categorised into two major components; public and private. The Government, i.e., public healthcare system, comprises limited secondary and tertiary care institutions in key cities and focuses on providing basic healthcare facilities in the form of primary healthcare centres (PHCs) in rural areas. The private sector provides majority of secondary, tertiary, and quaternary care institutions with major concentration in metros and tier I and tier II cities. Some of the major initiatives taken by the Government of India to promote Indian healthcare industry are Ayushman Bharat-National Health Protection Mission, National Nutrition Mission (NNM), Mission Indra Dhanush, Pradhan Mantri Jan Arogya Yojana (PMJAY) and several other schemes.
There are two types of corruption that can be diversified under healthcare sector i.e., Petty corruption and Grand corruption. Petty corruption means the corruption which is done on the small scale or on the low-level. It refers to relatively small amounts paid in order to get services that are either free, or subsidised. While these amounts might be individually small, they amount to a huge burden because they are usually demanded by poor people. The typical petty corruption related to the health sector that people experience are as follows:
- Bribes to gain access (to wards, to enter restricted areas such as labour wards),
- Bribes to jump queues (out-patient department, laboratory sampling),
- Bribes to get free services (for X-ray, medicines, diet supplements),
- Bribes to get admission or discharge from the hospital, or to release bodies from the mortuary,
- Bribes to obtain certificates on medical condition, such as fitness certificates, disability certificates etc., which are required for various purposes such as foreign travel, professional recruitments etc.
Such bribes are usually picked up by the staff in medical institutions and doctors might not be directly involved except in the case of the issue of medical certificates.
Grand Corruption relates to large volume corruption, often involving a team of officials, doctors, private sector agents and politicians. Instances of grand corruption in the health sector are as follows:
- Procurement corruption (to win tenders for supply of pharmaceuticals, medical equipment and hospital supplies, civil construction or repair contracts). This can result in over-invoicing, supply of substandard equipment, supplies etc., sometimes having shorter life span or shelf life in case of medicines, over-supply of some items in excess of requirements. This might also result in excessive preference shown for one of the other brands of a drug, when cheaper generic (and equally effective) products are available.
- Corruption for postings and transfers of doctors and other staff to ‘lucrative’ positions, (where they have access to better private practice, more openings for diversion of medicines, or cultivation of influence).
- Corruption in certification of facilities and the provision of mandatory recognition of departments and medical colleges, following inspection.
- Corruption in admissions, examination marking and passing students in medical colleges, particularly in respect of specialty and super-specialty post-graduation courses.
Grand Corruption can also be integrated with petty corruption. Typically, this happens when profits from bribes taken at lower levels is shared up the ladder, through ‘pre-paid’ arrangements – a lump sum payment to secure a lucrative posting and regular monthly payments, collected from below, channelised upwards with a cut for everybody involved. Newspapers generally capture only massive instances of large-scale corruption. Petty corruption, however, has long been a part of, or rather a way of, ‘normal’ life in many parts of the globe.
An unknown percentage of physicians and others rendering health care services do so unethically, with a wide variety of abuses such as practising without the proper educational qualifications; practising without required licences and registrations; over-charging; negligence; unwarranted or uncertain prescriptions, treatments or surgical procedures; supervising, monitoring or conducting torture; and sexual misconduct with patients. There may be unethical disclosure of a patient's medical history to employers, credit investigators, banks, attorneys and others; and sexual contact may be initiated by the practitioner with his or her patients. Practitioners may accept bribes or excessive fees for expert testimony, and they may make narcotics and other substances that can be misused available to those in their care. They may perform illegal abortions or treat unreported gunshot wounds. The problems of ageing and incurable terminal conditions and diseases are susceptible to medical fraud. Ineffectual cures may be offered for everything from cancer to baldness.
The state of the medical profession which was once a respected line of work but today seems impure. It calls for doctors, the government and the public to act against dishonest doctors and restore the dignity of the profession and work for the welfare of society. The situation has become so bad that patients today approach the doctor with mixed feelings - of faith and fear, of hope and hostility. It goes without saying that such criminal doctors are in a minority. Unfortunately, their number seems to be increasing. Pregnant women have been refused care because they are HIV positive. Hospital authorities have refused to release the bodies of patients who died in their care because the relatives could not afford to pay the medical bills. There are reports of doctors amputating the limbs of poor people at the bidding of the begging mafia. Poor people who resisted the extraction of their kidneys have reportedly been operated upon at gunpoint. The list of such practices is endless.
The beginning starts from medical college itself as MBBS seats are sold for lakhs of rupees. This is merely the tip of the iceberg. Rampant corruption exists at every level, from medical college admissions, getting a degree, to registration with the medical council. Question papers have been leaked and “jockeys” have written medical examinations on behalf of students.
Medical college managements are known to charge unofficial “donations” in addition to official fees. Students have been reported to bribe faculty to get good reports, and doctors have been reported to pay bribes to get registered with the state medical council.
Though India is a welfare state, the role of the government at the centre and in the states in providing healthcare facilities is deplorable. Against the recommendations of the WHO that the total health expenditure should be 6.5% of the gross national product (GDP), India spends only 4.8% of GDP on health. Further, public health expenditure is just 1.2% of GDP, or barely 25% of the total health expenditure; the rest of the money is paid by patients directly to private doctors and hospitals for whom profits may take precedence over their patient’s interest.
Unfortunately, we can’t even rely on justice from the legal system. When prosecutions do occur, only a small fraction of these cases reach the courts. In some cases of medical negligence, the punishment has been notional. Many cases of medical negligence are pending in various courts in the country; in the Supreme Court of India alone, there are some 3,000 cases of medical negligence.
By the 1990s, India had achieved the distinction of being the biggest bazaar for the sale of human organs and the sale of kidneys was described as a cottage industry in India. Such scandals prompted the government of India to enact the Transplantation of Human Organs Act, 1994 but the nexus of doctors and brokers involved in the sale of human organs has never been afraid of the law, which has been violated with impunity. For example, the Gurgaon kidney scamsters, who had been arrested for conducting illegal kidney transplants in the 1990s, evaded punishment and managed to run their trade in kidneys for years, obviously with the connivance of law enforcement authorities. It is known that the main accused evaded arrest by bribing Delhi police officials.
The nexus between corrupt medical professionals and politicians, bureaucrats and the police are one of the major factors multiplying medical corruption. The common man is afraid of exposing wrongdoings – the authorities may hush up the matter and target the whistle-blower instead. Public apathy and fear are also partly responsible for breeding medical corruption. Even if people come to know about unethical and illegal activities in the profession, they turn a blind eye, either because it does not concern them, or because they are afraid of the doctors. For example, many people were aware of the kidney racket but did not report the matter to law enforcing agencies fearing the consequences to themselves.
Social compulsions accelerate the process of medical corruption. A medical professional finds it very difficult to refuse a VIP’s request; it could mean isolation or posting to a remote area. When honest doctors cannot afford to even buy their own houses, but see that their dishonest colleagues enjoy a luxurious life, they may wonder if they are right to stick to their principles.
It is not too late to restrain the medical profession. This calls for a well-coordinated campaign involving doctors, the government and the public. A beginning has to be made by health professionals launching a zero-tolerance assault on medical corruption. The MCI code has to be practised in letter and spirit. The list of things that doctors must do is long. A few of them are refusing to accept bribes, opposing outside interference, stop accepting favours from pharmaceutical companies, following medical ethics and treating patient equally. The government must also support and protect the interests of upright doctors.
Apart from that, the public must contribute to efforts made by medical professionals and the government to clean up the medical system. To restore its noble and distinct status, all sections of society must work together to stamp out the biggest killer in the medical system- corruption.
