Where does the change begin?
K Sujatha Rao
Published online: October 6, 2018
Samiran Nundy, Keshav Desiraju, Sanjay Nagral, Editors. Healers or Predators? Healthcare Corruption in India, New Delhi: Oxford University Press; 2018, 592 pp, Rs 750 (Hardback), ISBN: 9780199489541.
The book Healers or Predators? Healthcare Corruption in India edited by Samiran Nundy, Keshav Desiraju and Sanjay Nagral is a compilation of 41 essays covering a broad array of topics of central concern to India’s health system. As the title of the book suggests, at the core is corruption in medical practice, defined by most authors as “abuse of entrusted power for private gain,” a concern that has been engaging attention in the media and public discourse, albeit in a limited manner.
The book has eight sections. The first section has four essays that provide the background on corruption in India’s health system. The tone is set by the comprehensive essay by Ritu Priya and Prachinkumar Ghodajkar tracing the structural basis of corruption in India’s healthcare from pre-independence times to the present day. In this essay the authors argue that the current Euro-American model of healthcare adopted in India, has created structural imbalances incentivising corrupt practices. These cannot be resolved by good governance alone but require systems and institutions that will democratise and demystify knowledge, enable greater plurality of thought, and make the patient an active participant. They also argue that the demedicalisation of expensive hospital and doctor-centred models and having the public sector lead the system would be ways of reducing corruption.
Following in the same vein and providing the political economy and the sociological, pathological constructs of our society, Shiv Vishvanathan argues that corruption is structural, responding to a “lack”, that is in this case, a lack of access and knowledge where corruption defines “access, price and availability”. He concludes that it is not only individuals but the system that needs to be dealt with by social movements. There are two more essays in this section – by Kaveri Gill and Amit Sengupta—which trace the forces of neo-liberalism and globalisation that have, true to their ideology, over the years furthered the growth of the private sector, commodified healthcare incentivising corrupt practices in the process. They argue that the rapid growth of privatisation and the push towards Universal Health Coverage is the outcome of the growing nexus between policy makers and manufacturers, hospital managers and care givers and the assiduous promotion of insurance and the provider- purchaser split.
The second section on “Corruption in Practice” has 12 essays spanning a wide range – medical education, medical malpractice, ethical issues faced in organ transplantation, clinical trials, public sector service delivery, technology, traditional practice and so on. All these essays allude to the manner in which corruption is systematically eroding the ethical core of functioning, abusing patient trust and exploiting the overall lack of transparency clouding every aspect of healthcare.
MK Mani provides his reflections of eight decades on the growth of medical practice in India from the time when “doctors were respected and well paid” to when he feels “ashamed” of the rampant corruption in the health system and hopes “a time will come when standards of thought and action in society will rise to a level where corruption will become abhorrent to the vast majority of us and honesty will be the norm.” The scams in organ donation, rampant in the US and Germany as in India, are detailed by Vinay Kumaran, in a chilling account of malpractice at every stage indulged in only to profiteer. SV Nadkarni traces corruption in the different facets of government functioning, and also offers some valuable suggestions like medical colleges running a few primary health centres, establishing referral systems, instituting a department of costs and data analysis to enable monitoring of doctors’ productivity and enhancing their accountability for outcomes, use of budget for infrastructure development, and introducing social health insurance instead to pay for services, ending private practice by government doctors, having more realistic personnel deployment policies and so on. Yogesh Jain also laments the institutionalisation of corruption by allowing government doctors to carry on private practice that has since permeated throughout the system. He offers a three-pronged solution that can arrest such corruption–from the bottom by the people, from the top by the supervisors, and laterally, by the peers together making care givers more accountable. Other essays dealing with traditional systems, the nexus of pharma companies, the medical profession, and the government, clinical trials and perspectives from the consumer and technology use are equally rich in content.
The third section deals with Morals, Politics, Legal Issues and Consequences and contains eight essays. While VI Mathan and Abhijit Chowdhury reflect on the moral degradation and fall in ethical standards as the main contributory factors to the increase in corruption, George Thomas argues that the consequences of corruption are denial of care and loss of trust. Arghya Sengupta and Dhvani Mehta have provided a detailed account of the reform of the Medical Council of India through court intervention. They argue that courts have limitations and the process of reform has to be carried out by Parliament in a consultative manner. The fourth section moves on to four essays on corruption in the UK, Srilanka, Bangladesh and Pakistan. Clearly, corruption in the health sector is not peculiar to India and no country seems to be an exception. The difference lies in the intensity, nature, scale and spread.
The fifth section has five essays on Governance and Healthcare Corruption. Here, Meeta and Rajivlochan, and Sunil Nandraj detail how laws and regulations are required to instil an accountability framework. Protocols, focusing on outcomes and patient-centric systems, amending the Clinical Establishments Act of 2010 to include patient rights and civil society involvement enable lending transparency and accountability that in turn will help minimise corruption. In similar vein, the two essays by Abhay Shukla and Rakhal Gaitonde make a persuasive argument that an effective and sustainable way of curbing and minimising corruption is through peoples’ movements, evidence-based policy formulation and greater transparency in policy making.
The sixth section has some personal views on the issue by Kunal Saha, Farokh Udwadia and Ratna Magotra. Kunal Saha recounts his horrific battle with the system for over 15 years to get justice for the negligent manner in which his wife was treated by a private hospital in Kolkata resulting in her death. Such personal experiences of well known practising physicians included in this book have given it credibility, are convincing and more persuasive than any structured household surveys would have been.
The seventh section has two essays on the Justice Lentin Commission of Enquiry by Rupa Chinai and a detailed analysis of the Vyapam scam of Madhya Pradesh by Sandhya Srinivasan.
The last section is entitled “Beacons of Hope” and contains five case studies of institutions that have presumably stayed out of being immersed in the all-pervasive culture of corruption: the inspiring stories of the Banyan Experience of Tamil Nadu, CMC Vellore, the Mahatma Gandhi Institute of Medical Sciences, Sevagram, the Shaheed Hospital of Dalli Rajhara, St John’s Hospital of Bangalore and the personal narratives of Amrita Patel and MR Rajagopal. While this section provides interesting accounts of successes in an otherwise bleak scenario, yet they do not necessarily provide (except for Amrita Patel) their struggles with institutional or individual corruption and how they might have overcome it.
In fact, while the running theme in a majority of the essays is about corruption and declining values, yet many also do provide their reflections on the health system of public policy without necessarily indicating how that has a connection to corruption or in furthering it, a fact that can only be made on assumption or by implication. Nearly all do admit that corruption is not a feature of government systems alone but is hugely pervasive in the private sector as well – in the over use of diagnostic technology, the kick backs, the prescription of drugs, the line of treatment adopted, the unnecessary procedures performed, the faulty admission systems, the capitation fees and so on, and recognise how such corruption is profoundly impacting the trust quotient between patients and their doctors, families and hospital managements, citizens and the government. Despite its all-encompassing corrosive nature, corruption as an issue of primary import continues to be overlooked and not addressed comprehensively enough. It is in this context that the book does a signal service in bringing it all out into the open, providing an opportunity to debate and reflect on these uncomfortable issues that characterise our present state of affairs.
While reading through these remarkable essays, the one thought that kept arising was how can change be brought about and where does the process of change begin? Clearly, today’s corruption is not just about greedy individuals but one constructed upon private capital, disruptive technology and rapidly shifting aspirations of a rising middle class While many authors have offered suggestions of what is to be done to alleviate the current state of affairs, none provide a pathway as to how it is to be done and by whom – the Government, the courts, the doctors, Parliament, the media or the people? It is in providing some answers to this troubling question that a reader is left behind, that the book falls short. It would have been immensely useful if the editors had brought together the various issues and viewpoints raised by the authors and based on their rich experience, discussed them in their concluding chapter to provide the options of “what next”, and if not, the implications of inaction. Given the context of a neo-liberal state, distorted health markets operating in an environment of scarcity of supply, and mixed systems of service delivery that are mostly unregulated and functioning in a fragmented and broken manner, the discussion would have helped a reader steer through the maze of excellent matter that the essays provide. In the absence of such a systemic understanding of corruption, it is easy to dismiss the issue of individual values and ethics.
The book is a good read. Reading the 700 pages is a challenge but one worth taking. It needs to be read and its messages internalised. If it can make you angry enough to want to change the declining standards and question the systems, it would have served its purpose.