Abstract
First, a declaration of interest – Dr Desiraju is personally well known to me even though we have not worked together. I approached this book with some excitement and some trepidation as I know the situation on the ground, but had no inclination as to how authors and editors will approach what is an incredibly provocative area.
Medicine is said to be the second oldest profession, and the professional codes and ethical values stretch back millennia. On one hand, altruism and altruistic values are well recognised and. on the other hand, with changes in public expectations as well as changes in society, for example, the impact of social media advances in technology and focussed interventions bring specific challenges with them in the practice of medicine and health care delivery. This volume, with over 650 pages, draws our attention to various types and components of corruption in medicine in India – a country of 1.3 billion with estimated number of medical graduates graduating every year to be over 50,000.
Corruption is defined as the abuse of power for personal gain and often the power is entrusted to that (particular) person or structure(s). Interestingly, globalisation is said to have contributed to the spread of corruption.
The conventional logic of the buyer and the seller in the workplace does not apply to the health sector although politicians and suppliers across the globe pretend that it does. First, buyer has to purchase. He has to avoid disfigurements, disability, debility or death and, in reality, has no choice or an extremely limited one. On the other side of being a seller, the doctor has the role of the mediator, intermediary or seller of pharmaceutical and medical equipment or therapeutic non-medical, non-drug interventions. Hence, professional self-regulation becomes clinical. However, as health care systems get more complex, regulation becomes more problematic and perhaps piecemeal. Unreasonable expectations from the buyer or the purchaser (directly in the case of patients and indirectly in the case of families) and those of the public from medical professionals especially as these include consumerist attitudes because patients and their families are buying health care. The expectations of long working hours with limited resources and increasing, as well as changing, expectations of patients can create further tensions. Increasing workload, especially if the doctors do not feel in control, is likely to lead to burnout. Such a shift in workload and expectations are likely to lead to disaffection both for the patient and the doctor. Ethical shortcuts may follow. Political and bureaucratic interference is strongly evident in many health care systems as often the government is responsible for policy and funding of resources. An additional stressor is the general expectation that physicians will follow decision algorithms and provide evidence-based medicine. With advances in technology and increased litigation and expectations of quick recovery, doctors are increasingly being expected to become technicians adding to further distress. Doctors by and large go into medicine to be healers. However, the scene of practice of medicine in India is of special interest for a number of reasons. With a population of over 1.3 billion, the number of private medical schools has been expanding exponentially over the last few decades with a regulatory control which is often weak or even absent. The health care system focusses very heavily on secondary care which is largely based in urban centres or conurbations and not only controlled by chains of private hospitals but there is very limited primary care and public health care.
Comprising of 41 chapters, this volume is divided into eight sections. From background to corruption in practice, morals, governance along with descriptions of various medical scandals, it also covers beacons of hope illustrating past, present and future of medicine in India.
The commercialisation of medicine (around the world) and of medical education (in many parts of the world) along with health care industry (degrees of involvement vary across the globe) is evident with its advantages and disadvantages. Part of the reason for this commercialisation is expensive tools for investigations and therapeutic interventions. As patients pay, their expectations of services also change and shift. Under these circumstances, when the regulation needs to have teeth, often it is missing completely. In the chapters on regulations, Mathan goes on to suggest that regulations should have three components with three bodies regulating and overseeing these. The three constituents include ethical medical practice, accrediting hospitals and auditing their functioning and (setting) regulating standards of medical education. This is an inherent problem in this split which can put three regulatory bodies at odds with each other and opaque rigid borders between the three. Other authors also recommend openness, transparency and shared principles. All these can happen if corruption is eliminated – as it is a two-way process.
There is little doubt that the consequences of corruption in health care are many for the patient, for the doctor and also for the health care providers. There needs to be a ban on unnecessary investigations and procedures (easier said than done). From personal contacts and experience, virtually every elderly person who sees a doctor is recommended to have a magnetic resonance imaging (MRI) scan and it became rapidly clear that this was not a clinical need but gaining commission following referral to a scanning laboratory. Furthermore, as cultures globally are becoming litigious and doctors more risk aware these proposed banning is not likely to happen. Commissions, kickbacks and hidden fees are not uncommon, whereas public health care had errors of omission. Poor standards of cleanliness in public sectors with prolonged absences of medical staff and lack of facilities in public health care systems create further push towards private health care. Corruption in private medical education appears to have become more evident. This contributes to denying medical care to many, impoverishing the already poor and unnecessary procedures contributes to further poverty and physical complications.
The saga related to national entrance examination to all medical colleges and marked resistance by private medical colleges is moving reading. The courts and the judiciary are doing their work, but the standards of entry and exit as well as those of training in many medical colleges are shocking to say the least. Berger, who had shared his experiences as a volunteer in India a few years ago, reminds us that corruption in health care is universal as evidenced by pharmaceutical exaggeration of prices. Similar observations emerge in this volume from Bangladesh. Medical corruption cannot occur in isolation and is connected to political corruption, human resource management and medical education.
There is an urgent need for openness, transparency, information and educational campaigns, reducing monopolies in health care delivery, eliminating incentives, improving detection of corruption and appropriate remuneration for health care staff across all professions and grades.
This book needs to be compulsory reading for policy makers, medical educators, health care providers and for those who are in a position to advocate for their patients. This volume not only makes one weep for the patients and their carers but also provides hope that things may well change if the will for the change is there. First step in bringing about any change is to acknowledge that change is needed and this impressive volume raises these issues in an admirable and scholarly way. Transparency in decision-making at all levels can enable a reduction in corruption and better care for patients.