Healers or Predators? (Healthcare Corruption in India)

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Despite being one of the fastest growing economies in the world, India ranks among the poorest achievers of good health. The shortfall of India's health achievements com- pared with those of, say, China or Thailand (in terms of expanding longevity, reducing infant and maternal mortality, curbing child undernourishment, eliminating health-cost-induced indigence, and other indicators) is large and has been growing larger. Even within South Asia, Bangladesh and Nepal have overtaken India in health accomplishment, including in life expectancy.

If India's bad record in healthcare is not much discussed in the Indian press, this neglect does not indicate the presence of a tolerable level of healthcare in India, but reflects instead the narrow reach of the Indian news media, with its traditional neglect of elementary education and healthcare. That neglect is, in fact, a contributory factor to the continuation of India's health failure and bad schooling for the population at large, since public discussion is one of the essential requirements for remedying policy failures. Public discussion is particularly important for policy making in a functioning democracy, and it is remarkable that in the public discussion preceding political elections (such as the Indian general elections of 2014), healthcare tends to get extraordinary little attention.

In this collection of well-researched essays on the state of healthcare in India, the editors (Samiran Nundy, Keshav Desiraju, and Sanjay Nagral) have offered us a timely opportunity to understand how badly things have gone wrong in our beloved country. **Contents and Sample Pages**

They have also offered illuminating analyses of the causes and remedies of the observed failures.

What explains India's healthcare debacle? One immediate account is readily available, but we must be careful not to see more explanation there than a deeper scrutiny can confirm. India spends a much lower proportion of its national income on healthcare than do many other nations with comparable achievements in economic development. Seen on its own, this line of explanation is certainly important. The fact that India allocates only a little over 1 per cent of its gross domestic product on public healthcare contrasts sharply, for example, with nearly three times as much by China. We reap as we sow, and cannot expect to get what other countries achieve by allocating much more resources-as a pro- portion of their respective levels of the gross national product-to healthcare.

There is clearly some truth in seeing India's healthcare failure in this perspective, but the story is much bigger than that. The low allocation of public resources to healthcare is merely one of the relevant factors, and important as it is as an account of what ails India's healthcare, the neglect of resource commitment probably hides as much as it reveals. As the studies included in this important collection bring out, India's healthcare failure is far more extensive than the resource story alone can capture.

The entire organization of Indian health care has become deeply flawed in nearly every respect. The story that emerges from these carefully researched studies is that of a comprehensive health care crisis. The editors go further than that, and see in these failures a picture of 'healthcare corruption', which is a more disparaging diagnosis. Corruption is a charge that must not be made lightly. But, alas, these studies bring out why this disheartening depiction is basically correct. In the many-sided failures of Indian healthcare arrangements, the cupidity and greed of the agents involved-at different levels-playa distressingly important role.

There is, to start with, the reflection of a pervasive failure in the widely observed fact that the poor find it difficult, if not impossible, to make use even of those services that are actually available, or can be easily mobilized. Private caregivers will not budge without the promise of payment, and even though some public services are offered freely, many critically important services are denied unless the patient is willing – and able – to offr the demanded sums, which can be unaffordably large for the underprivileged Indians. There are many other failures to which these studies draw attention. Medicine is often hard to get, and spurious drugs are too readily churned out by manufacturers and distributers. That story of culpability frequently extends to medical equipment and implements.

Regulations to restrain pilferage and enforce accountability are recognized as important (as they should be), but are often success- fully circumvented, yielding a financial bonanza for the violators. Laws governing clinical establishments, which exist in theory, remain quite largely unimplemented.

Even at the very top of the operations, the MCI has had what the editors call a 'long and blemished history'. In addition to the duties of supervision and coordination of medical services that the Council is meant to do, but fails to perform, it also has a bad record in its designated role of looking after medical colleges (of which there are nearly five hundred across India). In particular, in the use of the power-and responsibility-to set up new private medical colleges, there seems to be clear evidence of fairly straightforward corruption.

I can go on adding to this dismal picture of health care in India-of the extensive triumph of avarice over public duties and professional behaviour-by drawing on the rich collection of well-researched contributions to this volume. But the readers themselves can get the fuller story from the investigations presented in this enlightening book, and can see how plentiful and comprehensive the failures are that devastate healthcare in India.

I end this foreword by pointing to three general failures in health care in India which may need particular attention. The first is the amazing neglect of primary health care compared with health interventions needed at later stages. There is certainly more money to be made in later interventions compared with simple preventive care and elementary outpatient attention. In the allocation of health resources, there is a massive neglect of primary healthcare, reflecting an inability to understand the critically important role of universal healthcare at the primary level, on which the entire healthcare system has to depend.

A nation's capacity to deliver basic healthcare is perhaps one of the best markers of its concern and responsibility for its citizens. However, as Kavita Narayan, one of the contributors to this volume, states in the opening sentence of her chapter: India's healthcare system is broken. Only a few years ago we read the heartbreaking story of a father and mother committing suicide in the nation's capital. They had lost their young son to dengue after being denied admission to multiple hospitals. In August 2016, we also witnessed the sordid spectacle of a poor man in Odisha carrying the body of his dead wife home because the hospital refused to provide an ambulance. A year later, in August 2017, shortage of oxygen supply resulted in the deaths of a considerable number of infants in a hospital in Gorakhpur in Uttar Pradesh. Newspapers as well as television carry almost daily reports of medical negligence, overcharging, and substandard care. We read reports of the widespread production of spurious drugs by pharmaceutical companies as well the bribery of doctors with trips to foreign countries and other sundry pleasures. There are also drug procurement scams, underhand commissions, and a widespread racket in medical college admissions. Possibly as a consequence of the increasing distrust in the system, there are many more reports of physical violence against health care providers. And even the dry, objective statistics of health indicators, which are some of the worst in the world, essentially convey the same message of the abject failure of our healthcare delivery.

To us the various episodes of denial of basic healthcare are symptomatic of a deep-rooted crisis, and at a time when the trust deficit between healthcare and ordinary citizens is at an all-time low, it is crucial to go beyond the headlines and dispassionately analyse one of the key drivers of the problem-healthcare corruption. Whilst it may be true that the infrastructure is weak, and possibly under-funded, the additional corrosion caused by corruption has aggravated matters. Hence this book.

Corruption has occupied centre stage in Indian politics for some time now, even making and breaking governments. Corruption in healthcare is also beginning to receive attention in the public sphere. Most of the discussion, however, has been superficial and confined to elaboration, moral outrage, and lament. There has been the simplistic explanation that healthcare corruption is just a reflection of the values of the rest of society. There has also been a tendency of the various players to shift the blame to one another. This book attempts to unpeel the multiple layers that contribute to this phenomenon and join the dots to structural and systemic problems. By doing so we also hope to suggest solutions beyond the traditional paradigms.

India is committed to achieving universal healthcare. This is not a particularly recent commitment. The globally adopted declaration of Alma Ata in 1978 recognized the fundamental importance of universal primary healthcare. Successive resolutions of the World Health Organization have reiterated this commitment. The current Director General of the WHO, Tedros Ghebreyesus, in one of his first public statements, was clear in his call: 'All roads should lead to universal health coverage.

It is a truism that universal care will not become a reality unless a well-regulated, transparent, and functioning system is in place. This is, of course, in addition to adequate financial resources and well-trained health human resources at every level. Over the 70 years since Independence, India has established the systems needed, but it is now increasingly realized that paralysing corruption has crippled many of the regulatory agencies, many of the systems, and a substantial part of the practice of the medical profession. This book arises from a conviction that the nature and history of healthcare corruption needs to be well understood if indeed any improvement or reform is to be realized and if we as a country are likely to move towards universal healthcare.

The contributors to this volume are seasoned practitioners, teachers, and researchers, and also include many practicing physicians and surgeons. Theirs is the voice of experience. We have also been fortunate in securing brief accounts from persons who, despite apathy and corruption, have been able, in their particular spaces and disciplines, to make a difference.

There are several broad trends in the way in which corruption pervades the health regulatory systems and the practice of the profession. Rakhal Gaitonde identifies them as being broadly linked to inadequate resources, unequal access to technology, and individual greed. Most prominent is the corruption and bad practice which drives the regulatory councils, the Medical Council of India (MCI) and its sister councils, the Nursing and Dental Councils. Sunil Pandya lays down the background, and details the influence of the General Medical Council of the United Kingdom in the setting up of regulatory structures in India. Amrita Patel writes of her own experiences in negotiating with the councils and the ways in which bad practices are institutionalized. Kavita Narayan calls attention to the fact that issues of bad governance and corruption are present even in the Complementary and Allied Medicine (CAM) sector, better known in India as A YUSH.

There is corruption linked to hospital practice, whether government or private, and these have different manifestations. Doctors in government facilities are notoriously suspect of charging patients for private consultations, of malpractice in purchase of drugs and equipment, and of rent-seeking behaviour in the matter of transfers and postings. S.V. Nadkarni addresses some of these issues and makes a case for better resourced and managed public institutions. Rupa Chinai does a case study of the Justice Lentin Commission of Enquiry into affairs at the government-run JJ Hospital in Mumbai in the mid-1980s, a combination of 'lies, deceit, intrigue, ineptitude, and corruption'.

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