I think I belong to a generation of idealistic Indians who were from privileged backgrounds and studied in the best universities abroad who wanted to come back and help this country become a great nation.. In fact I, and more so my wife, felt that we should return to provide the poorest of the poor the best medical care in the world. However I did not realise that the main problems I would encounter were not the miniscule salary or the rather small accommodation that was offered in India but the ubiquitous corruption that one had to face.
In fact my first encounter with corruption in India was even before I came back. When I was a senior registrar in one of England’s best hospitals, a professor of surgery from the All India Institute of Medical Sciences (AIIMS) offered me a job as an assistant professor in his department. I gladly accepted, resigned from my position and waited for the appointment letter. Two months later, I was told the job was no longer available. I found myself sadly unemployed! Fortunately, a few weeks later after I delivered a lecture at the Surgical Research Society in London, I was offered a faculty position at Harvard by a professor of surgery who was in the audience. He kept his word, and this time I got the appointment letter within a week!
I left for the US, with a green card organised for me within three months. Although a bit disappointed at not being able to return to my own country, I resolved to make my career in academic surgery in the US. My wife, however, refused to accept this ‘failure’ and, during one of her visits to India, pleaded with a number of our influential friends and relatives to get me a job here and I was duly appointed to AIIMS—in spite of strong local opposition. The job was wonderful. The patients were inordinately grateful; the students bright, respectful and affectionate; and the medical problems one had to deal with very interesting. If one worked hard, despite the lack of infrastructure, many patients with complicated and advanced diseases could be saved.
But perhaps because I did not ever ask for favours from politicians and bureaucrats and made a lot of noise about any of the misdeeds that were ubiquitous in the hospital, I had great difficulty in getting promoted in the hierarchy and remained a lowly assistant professor for 12 years and only rose up the ranks much after all my contemporaries. I became almost inured to the corruption: it was just one of those things one had to accept and live with, a part of the national ethos. At least the work was intellectually and emotionally stimulating.
In 2014, David Berger, an Australian doctor who was working in Landour, near Mussoorie, wrote an article in the British Medical Journal which blew the lid off healthcare corruption in India. He wrote about the unnecessary tests, the unnecessary operations, the kickbacks that were paid for referrals. This article reopened our eyes, as it were, and set off a huge chain reaction of sorts. Many health professionals in this country, sick and tired of this situation, have decided that something radical must be done to help India get rid of this cancer.
Corruption within the medical industry is estimated to increase healthcare spending by 10-25 per cent. It isn’t just the receiving of bribes for hospital contracts. It includes favours from politicians, prescribing medicines and performing investigations that are not required in exchange for cash, expensive holidays and gifts like iPads and computers from drug companies. The web of corruption is now so intertwined with the profession that doctors, distributors, suppliers and even patients use it to their material advantage. This means doctors who choose to remain honest find it very hard to succeed.
It’s a commonly held medical belief worldwide that the largest amount of malpractice occurs in India. It exists in the form of petty corruption—like being admitted to a scarce hospital bed out of turn—or misdeeds on a much larger scale, like having an understaffed, ill-equipped medical college recognised for teaching by inspectors from the Medical Council of India. In most countries, doctors are not allowed to own shares in pharmaceutical companies and diagnostic centres because of an obvious conflict of interest. In India, there are well-known doctors who own hospitals and who are ‘close to’ pharmaceutical representatives and agents.
This is not to say corruption doesn’t exist in other countries. It does, but in western Europe and the US, the corrupt are punished severely if detected. In India, by contrast, they generally go scot-free. When most healthcare was from the public sector, the corruption was much less evident. After the opening of more and more private hospitals, there has been a major spike in the quantum of corruption and the variety of forms in which it happens. One cannot deny that private hospitals have done a lot to bring quality medical care, but it’s also true that they are driven solely by the profit motive and responsibility to their shareholders. Unfortunately, over 70 per cent of Indians avail of their services because government hospitals are generally so ill-equipped and underfunded by comparison. Many of these private hospitals function on a complex system of retainers for doctors—a practice which in its essence demands that they have to justify their huge salaries, which in the case of star performers may be as high as six crores.
Such retainers are then leveraged by the hospital administration to ensure they more than make up for such salaries in consultations and operations. Every month, private hospitals have finance officers doing the rounds with doctors, asking them to justify their pay cheques. If the amount earned isn’t enough, their salaries are often slashed. In effect, the doctors are highly incentivised—or cornered, to put it another way—to enter a happy axis of corruption where they routinely prescribe expensive investigations and perform operations which a patient might not need.
Another major problem, and a fairly common one, is that of kickbacks for referrals from diagnostic centres and general practitioners to specialists despite such practices being specifically banned by the Medical Council of India. I have been told that after specialists deliver educational lectures for general practitioners in small towns, those in the audience are often more interested in what ‘cut’ they would get for referrals rather than the science being discussed! A similar situation exists with pharma companies and device manufacturers. It is said, for example, that many ophthalmologists use certain lenses for cataract operations and orthopaedic surgeons order joint prostheses only from favoured manufacturers because of the cash they get on the deal—despite these devices being more expensive than others and with no additional benefit to the patient.
These are instances of smaller corruption. The more lucrative way for private hospitals to make money now is to set up medical colleges as business ventures. The system in India is vastly different from those in most advanced countries, which follow a non-profit model of teaching hospitals. In India, many of the private colleges owned by politicians do not even provide a basic medical education. They have ‘ghost’ faculties who only appear during MCI inspections and very few patients—future doctors get a very inadequate training. One of the purposes of a medical institution is to do research: we recently performed a study in which we found nearly 60 per cent of all medical colleges in India did not publish a single research paper between 2005 and 2014.
If the government cannot set up enough medical colleges to produce the large number of doctors this country needs, an alternative would be to allow the opening of not-for-profit institutions, like the best hospitals in the US do. Even in India, the Sir Ganga Ram Hospital where I work is run by a trust and puts back all its profits into improving its facilities. This model could easily be replicated more widely. However deeply ingrained corruption seems at present, there is no excuse for condoning its presence in healthcare, which is based on trust between a patient and his or her doctor. In India, probably more than anywhere else, doctors command a position of reverence from their patients. To exploit this for pecuniary advantage seems to me to be reprehensible in the extreme.
The only silver lining in this rather dark and cloudy scenario is that, in spite of all the problems, we have had some great doctors in this country, like A.K. Basu from Calcutta, N.H. Antia from Bombay and P.K. Sethi from Jaipur. If we strive for a clean system with a focus on producing merit, we will have many more. We might also create a much cleaner system that rewards good doctors so as to lure back many who are abroad. India sorely needs a virtuous band of qualified personnel. Minus corruption, healthcare in this country can get revolutionised. It will become much more accessible, affordable and effective and we may even progress to universal healthcare. We must dream big.
(The writer is gastrointestinal surgeon based in New Delhi)