The Asian Age & Deccan Chronicle
The real C-word in healthcare
3 July 2014
If there is one thing that gets everyone in this country raging even more in the mid-summer heat, it is talk about sex and sexuality. No surprises then that health minister Harsh Vardhan’s recent statements about sex education and condoms have stirred the pot.
The minister says he is against “crudity” in sex education programmes. He also thinks that “condoms promise safe sex, but the safest sex is through faithfulness to one’s partner”.
We have been down this road before. The debate on what is, or is not, “crudity”, and condoms versus fidelity will continue till the cows come home. Sensibilities vary massively. But while we are on the topic, will the good doctor explain what he considers “crude” in sex education?
Lost in the cacophony is the larger question. What is the most relevant “C” word in India’s healthcare system today? Is it condoms, crudity in sex education or corruption? For most people in this billion-plus country, it is corruption.
Out-of-pocket healthcare expenses in India are among the highest in the world. A medical emergency is a catastrophe plunging families into deep debt, even impoverishment. The situation is exacerbated by the widespread corruption that permeates both public and private sector. In 2010-11, the deaths of three medical officials in Uttar Pradesh sounded the alarm on the organised looting of government funds that crippled the flagship National Rural Health Mission in the state, which has some of the worst health indicators. Last month, the All-India Institute of Medical Sciences (AIIMS) suspended 14 of its staffers and fined 50 others for corruption and absenteeism. The employees whose services were terminated included clerks and housekeepers. But graft is not confined to the lower levels. Private sector hospitals in the country are notorious for prescribing unnecessary tests from private laboratories.
A recent article in the prestigious British Medical Journal, titled “Corruption ruins the doctor-patient relationship in India”, has triggered a frisson by drawing public attention to the ghoulish underbelly of India’s healthcare system, honourable exceptions notwithstanding. In the article, David Berger, a district medical officer in Australia, who worked as a volunteer physician in a charitable hospital in the Himalayas, offers a first-person account of how the system works at the ground level: “I saw one patient with no apparent structural heart disease and uncomplicated essential hypertension who had been followed up by a city cardiologist with an echocardiogram every three months, a totally unnecessary investigation. A senior doctor in another hospital a couple of hours away was renowned for using ultrasonography as a profligate, revenue earning procedure, charging desperately poor people `1,000 each time. Everyone who works in healthcare in India knows this kind of thing is widespread.”
Berger’s observations have created ripples across the public health community the world over but it does not come as a surprise to anyone who has a nodding acquaintance with how the system works in this country.
Writing in the Indian Journal of Medical Ethics last year, Subrata Chattopadhyay, head of the department of physiology at the College of Medicine and JNM Hospital, West Bengal University of Health Sciences, listed the forms of corruption in healthcare and medicine. This could include but were by no means limited to bribes and kickbacks paid by individuals and firms.
The reasons are many — to procure government contracts, leases or licences for the construction of healthcare facilities, for the supply of medicines, goods and services, as well as to ensure the terms of their contracts. There is also a racket to rig the bidding process, manipulate and falsify records, and modify evidence to give the appearance of it being in compliance with the norms of regulatory agencies. There are even cases of “speeding up” the permission to carry out legal activities, such as obtaining institutional affiliation, company registration or construction permits. There are cases of influencing or changing legal outcomes to avoid punishment. The long list includes outright theft and embezzlement.
Mr Chattopadhyay says public assets and instruments in government hospitals may also be intentionally damaged so as to make them unavailable to patients, with the ultimate aim of ordering the services from private clinics in return for commission. Then there are the ever-familiar informal payments even where healthcare services are supposedly free.
Corruption is also prevalent in clinical research. In some private hospitals, physicians have contractual obligations to admit a fixed number of patients to allotted beds and prescribe a number of laboratory investigations (even if unnecessary) to generate revenue.
All this has far-reaching consequences on patient care, clinical research and medical education. So where do we go from here? T. Sundararaman, adjunct professor (public health) at Jawaharlal Nehru University and National Convenor of the People’s Health Movement, points out that most countries which have a functional healthcare system have checks and balances to deal with kickbacks and referrals. Even the United States, where healthcare facilities are largely owned and operated by the private sector, has the federal Anti-Kickback Statute and the Stark Law.
The Stark Law prohibits a physician from referring Medicare and Medicaid patients for designated health services if the physician (or an immediate family member) has a financial relationship with the entity to which the patient is referred, unless an exception is met.
It is not that India has not tried. The Clinical Establishments (Registration and Regulation) Act, 2010, was enacted to register and regulate all clinical establishments in the country with a view to prescribing the minimum standards of facilities and services provided by them. But as of now, the law is not applicable throughout India. Only a handful of states have rolled it out.
The Modi government was swept to power on an anti-corruption wave. It has promised to significantly reduce out-of-pocket expenses on healthcare for the common man, a new national health policy and better regulation of medical education, as well as the pharmaceutical market. It would be impossible to operationalise this grand vision without tackling the most crucial “C” word — corruption.
As a doctor and a seasoned politician who pioneered many health interventions in Delhi, Dr Vardhan surely knows the challenges ahead. Will he make a serious attempt to cleanse the stable?
The writer focuses on development issues in India and emerging economies. She can be reached at email@example.com