Corruption in medical practice: How far have we gone?
Journal of the Pakistan Medical Association
Amin A. Muhammad Gadit (Discipline of Psychiatry, Memorial University of Newfoundland, Canada.)
Transparency International defines corruption as ‘misuse of entrusted power for private gain’; alternately, it is defined as, “sale by government officials of government property for private gain”.1
Corruption in the health care system or the medical practice is widely known, both in the developing and the developed world. Mahajan V2 describes widespread corruption in India that is alarming. His report mentions a number of horrendous issues: pregnant women have been refused care because they were 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, medical seats being sold for lakhs of rupees, medical schools charging unofficial donations in addition to official fees, students bribe the faculty to get good results, government doctors pay more attention to their private patients, pharmacists sell their licenses to unqualified persons to run chemist shops, doctors prescribe unnecessary diagnostic tests and drugs, doctors accept perks from pharmaceutical companies and prescribing expensive medications to patients. Report on Pakistan by Transparency International1 divides corruption in two categories: practices which involve measures that usually lead to monetary gains and others that involve non-monetary forms of corruption, which involve unethical behaviors that are not geared to monetary benefit in the short term but in due course would lead to some form of benefit. A number of features of health care system corruption has been identified in the report, that include: financial leakages, embezzlement, illegal fees, kickbacks, theft of supplies and equipment, over-invoicing, clever book keeping, selling public positions and bribes, failure to base decisions on evidence, preferential treatment to well-connected people, unfair hiring practices, etc. A cross country survey3 of the public gauging perceptions of corruption in public service showed that 95% of the study population perceives that the health care system is corrupt in Pakistan. Another survey3 showed that the frequency of informal payments to public health care providers amongst the users of services is 96% in Pakistan. Anecdotal reports from press and media as well as informal personal communications reveal a number of corrupt practices in Pakistan’s health care system and medical practice. Hospital medical superintendents are known for financial mismanagement, favoring bids that could provide personal benefits, hiring people without merit and not paying heed to corrupt practices of the office staff. The medico-legal certificates are issued upon payment of bribes; medications are used by medical staff and their relatives. Favors accepted by doctors from pharmaceutical industry, even in the form of cars, wedding receptions, foreign trips, land and other luxurious items. Private medical colleges selling seats, government posting and transfers by either payments or using the influential connections, not attending patients in time, ignoring emergency calls, consumption of drugs or alcohol while on duty and much more. Under the context, in 2001, 2.8 billion prescriptions were filled in the United States for an average 9.9 prescriptions per person. It is said that the philanthropy that was once present in modern medicine has been replaced by love of money, which gave rise to an elaborate system of bribery, conflict of interest and deception.4 According to Michael T. Murray “most physicians do not make decisions about which drug to use on the basis of scientific research or cost. They base their decision almost entirely on which drug is the most popular choice of their colleagues.4 Irony of the fact is that children as young as two years old are being diagnosed with bipolar disorder and treated with a cocktail of powerful drugs, many of which were not approved by Food and Drug Administration (FDA) for that purpose and none of which were approved for children below ten years of age.5Similarly, it has been reported that eminent personalities in academic medicine accept huge grants from pharmaceutical companies and would not report the accounts to the concerned universities. The dual practice that is driven by a lack of resources in the public sector and low pay has been associated with the unauthorized use of public resources and corruption.6 Defensive medicine practiced in China in view of law suits whereby numerous expensive investigations are recommended by physicians has been a cause of alarm. This issue at times hints at medical corruption for which effective policies are the need of time.7 Based on the international studies that have shown informal payments having negative effects on health care access, a study8 was conducted on 222 citizens in Albania regarding intentions, past behaviors, attitudes and beliefs about informal payments. People who intend to make informal payments the next time they seek health care are more likely to believe they will get faster and better quality care than non-intenders, but also think they must pay to receive any care at all. People who do not intend to make informal payments are more likely to report that they have connections with medical personnel, which may be substituting for informal payments.
Reverting back to local scenario, corrupt practices are rampant and have often proved detrimental for patients’ safety. The regulatory body and the government have not attended this matter appropriately so far. The recent media reports have alerted the public and the government but in order to curb the medical corruption, lot has to be done. Effective laws and policies by government, continued role of media and strong action by the regulatory body are needed. Above all, it would be the personal motivation of the doctors in remembering the oath upon becoming a doctor, respect for ethics and religion and gaining insight that can lead to the cleansing of the corrupt system.
Though we have gone too far in this regard but there is always a way to return. Are we ready to return?
References 1.Transparency International (TI). Pakistan’s health sector: does corruption lurk? (Online) (Cited 2010 July 10). Available from URL: http://www.u4.no/training/incountry-open/pakistan-materials/health-sector-corruption-pakistan.pdf.
2.Mahajan V. White coated corruption. Indian J Med Ethics 2010; 7: 18-20. (Serial Online) (Cited 2010 July 10). Available from URL: http://www.ijme.in/181co18.html.
3.Transparency International. Corruption in public services; perceived corruption in health sector. Berlin, Germany: Transparency International, 2002.
4.Veracity D. Natural News. Physicians and bribery: a closer look at this common medical industry practice 2005. (Online) (Cited 2010 July 9). Available from URL: http://www.naturalnews.com/009334.html.
5.Angell M. Drug Companies and Doctors: A story of corruption 2009: Source: New York Review of Books. (Online) (Cited 2010 July 9). Available from URL: http://www.biopsychiatry.com/…/drugcompanies-d.
6.Jan S, Bian Y, Jumpa M, Meng Q, Nyazema N, Prakongsai P, Mills A. Dual job holding by public sector health professionals in highly resource-constrained settings: problem or solution? Bull World Health Organ 2005; 83: 771-6.
7.Chen XY. Defensive medicine or economically motivated corruption? A Confucian reflection on physician care in China today. J Med Philos 2007; 32: 635-48.
8.Vian T, Burak L J. Beliefs about informal payments in Albania. Health Policy Plan 2006; 21: 392-401.