HEALERS OR PREDATORS?

HEALERS OR PREDATORS?
Healthcare Corruption in India

edited by
Samiran Nundy
Keshav Desiraju
Sanjay Nagral
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 Contents

Foreword by Amartya Sen

Introduction

Section I: Background

1. The Structural Basis of Corruption in Healthcare in India

Ritu Priya and Prachinkumar Ghodajkar
2. Socio-Logic of Corruption
Shiv Visvanathan
3. The Commodification of India’s Healthcare Services: Public Interest, Policy, and Costly
Choices
Kaveri Gill
4. Globalization and Corruption in the Health Sector
Amit Sengupta

Section II: Corruption in Practice

5. The Role of the Medical Council of India

Sunil K. Pandya
6. Malpractice in Medical Education
Avinash Supe and Soumendra Sahoo
7. Corruption in Everyday Medical Practice
M.K. Mani
8. Hospital Practices and Healthcare Corruption
Sumit Ray
9. Ethical Issues in Organ Transplantation
Vinay Kumaran
10. The Public Sector and Corruption in Health Services
S.V. Nadkarni
11. The Unholy Nexus: Medical Profession, Pharmaceutical Companies, and Regulatory
Authorities
 S. Srinivasan
12. People in Small Places Don’t Face Small Problems
Yogesh Jain
13. Healthcare Corruption and Traditional Medicine in India
Kavita Narayan
14. Healthcare Corruption: A Consumer’s View
Rema Nagarajan
15. Corruption in Medical Research: Clinical Trials, Research Misconduct, Journals, and Their
Interplay
Sanjay A. Pai
16. Corruption in Healthcare: A Technology Perspective
M.S. Valiathan

Section III: Morals, Politics, Legal Issues, and Consequences

17. Degradation of Our Spiritual, Ethical, and Moral Heritage: A Personal Perspective
V.I. Mathan
18. The Moral Pathology of Healthcare Corruption
Abhijit Chowdhury
19. The Consequences of Corruption in Healthcare
George Thomas
20. Judicial and Legislative Responses to Healthcare Corruption
Arghya Sengupta and Dhvani Mehta

Section IV: We Are Not Alone

21. Global Medical Corruption: It Is Time for Individuals to Act Where Institutions have Failed
David Berger
22. Bangladesh: Great Mysteries in Global Health Masked in Corruption
Md Khairul Islam, Shehlina Ahmed, and Shishir Moral
23. Business Corruption of Personalities: The Case of Sri Lanka
Harendra de Silva
24. Corruption in the Healthcare System of Pakistan
Shershah Syed

Section V: Governance and Healthcare Corruption

25. Patient-Centric Healthcare: Through Institutional Regulation

Meeta and Rajivlochan
26. Regulating Healthcare Establishments: The Case of the Clinical Establishment Act, 2010
 Sunil Nandraj
27. Can Digital Technology Help Curb Healthcare Corruption?
Surajit Nundy
28. Healthcare Corruption: Responses from People’s Health Movements
Abhay Shukla
29. Evidence-Based Interventions for Healthcare Corruption
Rakhal Gaitonde

Section VI: Personal Views

30. My Battle with Medical Corruption

Kunal Saha
31. What Should We Do?
Farokh Erach Udwadia
32. Means and Ends
Ratna Magotra

Section VII: Major Scandals

33. The Justice Lentin Commission of Enquiry: A Case Study—Laying Bare Malaise and
Corruption in Our Health System
Rupa Chinai
34. Vyapam
Sandhya Srinivasan

Section VIII: Beacons of Hope

35. Developing a Health and Social Care System for Homeless People with Mental Illness: The
Banyan Experience in Tamil Nadu, India
Lakshmi Narasimhan, Nisha Vinayak, Kishore Kumar, and Vandana Gopikumar
36. Christian Medical College, Vellore
Sunil Chandy
37. Challenges to Holding a Candle against Corruption
G.D. Ravindran
38. Changing the Paradigm: The Mahatma Gandhi Institute of Medical Sciences, Sevagram
S.P. Kalantri and Anshu
39. Experience with Health Worker-Based Medical Programmes
Binayak Sen
40. In All Honesty
Amrita Patel
41. Palliative Care Shows the Way to True Health
M.R. Rajagopal

Conclusion
Notes
About the Editors and Contributors
 Foreword

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 compared 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. 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 proportion 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 healthcare has become deeply flawed in nearly every
respect. The story that emerges from these carefully researched studies is that of a
comprehensive healthcare 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—play a 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 offer 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 successfully 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 healthcare 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 healthcare in India which may need
particular attention. The first is the amazing neglect of primary healthcare 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.
Primary healthcare suffers in India both from the lack of resources devoted to it, but also from
behavioural corruption. The latter includes the frequently observed absence of public healthcare
personnel in their assigned duties, as well as the distressing frequency with which public sector
doctors direct patients to private medical practitioners for fee-paying services, often delivered by
exploitative—and sometimes untrained—medicine dispensers. The dominance of quackery and
crookery in primary healthcare in large parts of Indian rural society reflects a combination of
policy confusion and extensive behavioural failure, including widespread sleaze.
A second general problem to highlight is India’s hasty and premature reliance on private
healthcare, which goes hand in hand with neglect of public healthcare. The alleged superiority of
market-based healthcare is often invoked without adequate critical scrutiny. Health is a very
special commodity, in the delivery of which the efficiency of the usual market relationships
tends to flounder. When you or I buy a toothbrush, we know what that commodity does and how
it can help us. For a seeker of healthcare, however, the patient may have far too little knowledge
about what the ailment is and what the doctor can—or cannot—do to combat it. The
informational lacuna in general and the asymmetric information—between the buyers and the
sellers—in the market for healthcare provide a rich arena for abuse and exploitation.
Further, when you buy a toothbrush, you need be concerned only with what it will do for you.
In contrast, for healthcare—and the eradication of disease (including communicable disease)—
that we seek for ourselves is important not only for us, but also for others as well. What
economists call ‘externalities’—and ‘public goods’—mess up the efficiency aspects of market-
based allocation.
The usual discipline of market incentives goes extensively wrong in the market for healthcare
both because of externalities and asymmetric information, as Paul Samuelson and Kenneth
Arrow—two of the world leaders of the study of market economics—showed many decades ago.
Health demands a kind of trust relation, and as Arrow put it in an article on healthcare in 1963,
‘the very term “profit” … denies the trust relations’.
Third, as was briefly noted earlier, informed public discussion on healthcare, which is central
to policy making, is peculiarly deficient in India. The dysfunctional and exploitative nature of
healthcare in India survive and flourish partly as a result of the lack of public discussion—and
exposure—of the nature and extent of the failings involved. If the silence on the extensive
debasement of Indian healthcare is a major cause of the persistence of the terrible deficiencies,
the remedy has to depend on enlightening investigations of what has gone wrong—and why.
This splendid, if depressing, book will do a lot to remedy that momentous neglect. We have
excellent reasons to be grateful to the authors and editors of this important collection of
investigative studies.
Amartya Sen
 Introduction
Samiran Nundy, Keshav Desiraju, and Sanjay Nagral

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 healthcare 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.’1
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 AYUSH.
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’.
Doctors in private hospitals are increasingly suspect of ordering unnecessary and expensive
tests, demanding huge down payments before admission. Hospitals are being accused of making
huge profits on drugs. Sumit Ray discusses these issues. Vinay Kumaran focuses on shady
practices in organ transplantation, many of the ills arising from the huge demand for liver and
kidney transplants.
Kaveri Gill, while also acknowledging that corruption occurs in both public and private
hospitals, makes the important point that ‘while corruption in the public system may be
addressed if political leadership and will exists…once the healthcare stem is wholly
commercialized, redress is much more difficult, if not impossible’.
What is probably the most worrying of all aspects of healthcare-linked corruption is the
deteriorating standards of personal conduct and ethical behaviour among practicing doctors, and
indeed, other categories of healthcare professionals. The most deplorable example of this
behaviour—though not an area we have explored in this volume—is reflected in India’s
shocking child sex ratio statistics, a situation which could not have arisen without the active
connivance of doctors and other healthcare staff. India has very weak legal precedent in
malpractice settlement, as Kunal Saha elaborates, and poor and improper treatment must also be
considered as an aspect of individual corruption. That the study of medical ethics is not given
enough importance in undergraduate study and that the MCI does not have a strong record in the
matter of taking action against its members are related issues. Even here, as G.D. Ravindran, S.P.
Kalantri and Anshu, and Sunil Chandy describe, individual institutions can and have taken a
stand and attempted to foster a high level of teaching and ethical conduct.
As part of the larger context in which healthcare exists is corruption related to the
pharmaceutical industry, whether at the stage of clinical trials, or in pricing, or in the
manufacture of substandard drugs. S. Srinivasan and Sanjay A. Pai elaborate on this theme. M.S.
Valiathan, in his brief discussion of the medical devices sector, highlights the ills caused by
inadequate information and the absence of a regulatory framework.
While there are these various manifestations of corruption with which those in the profession
and the lay public are familiar, it is necessary to document them if we are to seek reform to
address the underlying causes. In the opening essay, Ritu Priya and Prachinkumar Ghodajkar
outline what they describe as the structural basis of corruption of healthcare in India. They
identify the extremely unequal access to information between doctors and patients as a key
element of the liability of the system to be corrupt. This information asymmetry is heightened by
a hospital-based healthcare system which privileges the position of the doctor, even with respect
to other healthcare professionals. Modern medical practice in India is again crucially linked to
the pharmaceutical industry, a powerful force for the good, if also for the malign. The point is
made that the way in which health systems have grown in India requires that the ‘healthcare
providers who make choices on behalf of patients are of high professional, ethical, and moral
standards’. This essential truth recurs in several pieces in this volume.
Amit Sengupta, of the Jan Swasthya Abhiyan, holds that ‘neoliberal’ policies which ‘in their
essence involve a transfer of power from public institutions to private enterprises’ are at the root
of increasing corruption in healthcare delivery. Indeed for him the call for universal healthcare is
in itself an abdication of responsibility by the state.
That access to information is a contributor to corruption, is a theme picked up by our
contributors. Surajit Nundy makes a case for the widespread use of digital technology. What he
suggests is that if vast amounts of data related both to the condition of the patients and the
qualifications and record of the healthcare provider were freely available, there would, in effect,
be only a few predetermined data-driven solutions, thereby minimizing the opportunity for
wrong diagnoses and inappropriate treatment. These are fascinating insights even if digitization
on the scale suggested is unlikely to happen in India in the near future. Rema Nagarajan also
addresses the question of inadequate information but particularly in the context of drugs, and the
price differentials between generic and branded drugs.
The question of information availability as part of the larger process of regulation, and the
failure of governments to enforce the law in the matter, is the substance of Sunil Nandraj’s piece
on the Clinical Establishments Act, 2010. Public and private interests alike have been complicit
in keeping the provisions of this law unimplemented. Meeta and Rajivlochan likewise make a
case for better implementation of the law, better maintenance and access to patient-related data,
functioning within a system where the government has the first responsibility.
The issue of corruption in the hospital system and particularly in the private hospital system
recurs in the contributions of Sumit Ray and George Thomas. It is nobody’s case that there is no
corruption in public hospitals. Any system where the demand for services so greatly outstrips the
supply of services is open to corruption. The point, however, appears to be that, in several private
hospitals, the proneness to corruption is institutionalized. Ray makes the point that 72 per cent of
hospitals and 60 per cent of hospital beds in India are in the private sector. There is reason to
believe that these figures are growing. Ambiguous statements from government on health
insurance as a means to pay for healthcare and for health services to be purchased from
providers, all contribute to the growth of the private sector. Even the recent announcement of the
National Health Protection Scheme in the Union Budget is essentially in this direction. If
payment is to be made for providing healthcare, it is natural that both the establishment and the
treating doctor will seek to extract the largest possible amount. Where the establishment is
structured as a company, there is a legitimate drive to increasing profits and dividends.
We have referred earlier to the sad situation of medical education. Sunil Pandya leads us
through the history of the Bombay Medical Council leading to the enactment of the Indian
Medical Act, 1956, by which was established the MCI. It is revealing that the Bombay Medical
Council, in its time, laid down a code of conduct for doctors, specifically condemning the
soliciting of private practice, the entering into a deal with the pharmacists to profit from the sale
of medicines, and to at all times ‘endeavor to increase the public esteem in which he is held by
good and worthy deeds’. The Medical Council of India was established as a council of elected
members and is vested with the powers to inspect and approve medical colleges, medical
courses, and medical qualifications from outside India. All powers were vested in this one body,
whether of setting curriculum and standards, or of accreditation of colleges, or of regulating the
practice of the profession and the conduct of registered doctors.
The long and blemished history of the MCI can be told simply enough. Admittedly, it is a
regulatory agency with a very large mandate. There are currently 472 medical colleges in the
country, with approximately 65,150 seats at the MBBS level2 and approximately 25,000 seats at
the MD/MS level. Much of the history of the alleged corruption in the MCI can be traced to the
decision of government of the early 1990s, allowing for large-scale establishment of private
medical colleges. In her piece on what is known as the Vyapam scandal, Sandhya Srinivasan
goes beyond the headlines to dissect what is probably an extreme example of fraud in medical
education. As long as medical colleges were being established by state governments, the
possibility of rent-seeking behaviour in return for approvals was necessarily limited. With the
introduction of private players, making large private investments in land and buildings, and also
given the urgent requirement of those private players to make a profit, it became immediately
necessary for all approvals and sanctions to be obtained, even if these had to be paid for. The all-
powerful president of the MCI was required to step down from his position over the period
2001–09, when a committee constituted by the Supreme Court of India oversaw the work of the
MCI. Having been restored to his position, the same president was subsequently arrested in April
2010 on charges which, it must be admitted, are yet to be substantiated in court. The reason it is
important to note these developments is because the years 2010–14 saw some moves by
government which, if ultimately fruitless, attempted to stem the rot. A board of governors
consisting of distinguished physicians and medical educators ran the affairs of the MCI for a year
from May 2010. A second board of governors functioned for slightly over two years up to late
2013, when it was decided, largely because parliament refused to further endorse the
amendments to the law which made possible the board of governors, to reconstitute the MCI.
This reconstituted Council is still in office.
Over the three years when the Council was run by the board of governors, government
attempted, through the introduction in parliament of the National Commission for Human
Resources in Health Bill, 2011, to reconstitute the arrangements for the regulation of medical
education and practice. The Bill provided for the dismantling of the MCI and the setting up of
three independent bodies, each of them responsible to the parent commission and responsible
respectively for accreditation, curriculum, and standards and the practice of the profession. The
NCHRH Bill, 2011 failed to secure the endorsement of the Parliamentary Standing Committee
for Health and Family Welfare,3 largely on the grounds that government was seeking to replace
an elected body, the MCI, with several non-elected bodies.
Fortunately for all those interested in the reform of the sector, the Parliamentary Standing
Committee for Health and Family Welfare itself undertook a detailed examination of the MCI
and its functioning. The 92nd Report of the Committee,4 in a searing indictment of the Council,
urged the government to take urgent steps to set aside the Council and put in its place such new
arrangements as is necessary. Discussion on these recommendations, which government could
hardly ignore, has led to the drafting by the NITI Aayog of the National Medical Commission
Bill, which has been moved by the government in the Parliament on 29 December 2017. This
Bill adopts the most important principle of the NCHRH Bill, 2011, namely the separation of
functions currently performed by the MCI. There are problematic elements in the Bill, but from
the regulatory point of view, the recommendation to separate functions can only be regarded as
wholesome.
It would be mistaken to think that matters relating to the MCI are the concern of government
or parliament alone. Arghya Sengupta and Dhvani Mehta detail in this book the types of case
which have attracted the attention of the courts, and the Supreme Court in particular.
We have been fortunate in this volume to have been able to include short essays by such
distinguished practitioners as M.K. Mani, Farokh Erach Udwadia, Ratna Magotra, and V.I.
Mathan, all of whom come from a strong tradition of service, whether in government or in
private hospitals. We cannot help noting their despair. It would not be wrong to say that, in some
measure, this sense of hopelessness provoked us to compile this set of essays on the deeply
entrenched corruption in India’s heath sector. That this despair is also shared in countries in our
region, also beset by problems of large disease burden, limited supply of healthcare services and
massive demand, limited application of medical technology, poor governance, and weak political
will is borne out by the articles by Harendra de Silva from Sri Lanka, Shershah Syed from
Pakistan, and Md Khairul Islam, Shehlina Ahmed, and Shishir Moral from Bangladesh. And,
indeed, David Berger, whose very significant BMJ piece in 2012 dramatically highlighted the
prevalence of corrupt practice in primary care in India, again reminds us that no country is
immune. The recent election by the World Medical Association of its current chair, a fact
referred to Dr Berger, is indicative of what is clearly a global trend.
We must also, however, note that there are many examples of outstanding work led by
dedicated professionals, who have not allowed the decay within their ecosystem to deter them.
Yogesh Jain of the Jan Swasthya Sahyog in Bhilaspur in Chattisgarh is one such medical
professional. Dr Jain and his colleagues in JSS work amongst the poorest people in India, often
handling what he has elsewhere called ‘the diseases of the very poor’ and are witness to the petty
corruption which takes place in the implementation of government schemes, a validation of the
principle that any person in a situation of power over another person will misuse that power. Dr
Jain sees greater community involvement as a possible answer but also recognizes that making
public functionaries accountable is easier said than done.
Two other voices from the ground are those of Abhay Shukla and Binayak Sen. Dr Shukla
again recognizes that enforcing public accountability is a daunting barrier, but sees hope in
mobilization and advocacy of the type promoted by the Jan Arogya Abhiyan and similar grass-
roots organizations. Drawing on his long experience of Chattisgarh, Binayak Sen details the
setting up of the Shaheed Hospital in Durg, Chattisgarh, a truly people’s initiative in establishing
a well-functioning hospital. Dr Sen also looks to people’s participation as a possible way to
ensuring better healthcare.
The book gives space to alternative narratives which though representing a minority, provide
hope. Lakshmi Narasimhan, Nisha Vinayak, Kishore Kumar, and Vandana Gopikumar write of
their work in The Banyan, Chennai, an organization which works with homeless women with
mental illness. The fact that they are women, that they are homeless, and that they are ill—each
of these factors (women, homeless, ill) is crucial to the way in which The Banyan has responded
to its clients. Over the last 25 years and more, The Banyan has created a range of institutions
including shared housing where women with illness live together and run a joint household with
almost no institutional supervision. In more recent years, The Banyan Academy of Leadership
and Mental Health (BALM) has begun training of young professionals to work in the field of
mental health. Pallium India set up in Thiruvananthapuram in 2005, provides much-needed
leadership in the field of palliative care; the remarkable story of Pallium India is told by M.R.
Rajagopal.
Three significant accounts of institutions which have placed service above all else complete
this book. S.P. Kalantri and Anshu write of the Mahatma Gandhi Institute of Medical Sciences,
Sevagram, an institution which has persisted both in maintaining its high standards of teaching
and in its adherence to Gandhian values. Sunil Chandy details the history of the famed Christian
Medical College, Vellore where ‘Healthcare as service, not business has been the dominant
theme of training and patient care’. G.D. Ravindran describes the attempts of St. Johns Medical
College and Hospital, Bengaluru to curb corrupt practices and yet retain staff.
Each one of these stories of struggle, and of remarkable achievement, is a story of charismatic
leaders working outside the government. This is not to suggest that there have not been any
achievements within the government system. We are aware of several exemplary individuals in
state-run institutions including doctors, nurses, and other staff who have carried out their
professional duties honestly in spite of resource limitations and adverse circumstances. It is also
not to suggest that there is no leadership within the government. But what it does suggest is that
the future of universal healthcare must include greater participation of communities, community
leaders, civil society groups and persons, who, even if they do not rank in the official hierarchy,
are trailblazers on the ground.
There are several broad lessons which come through each of these contributions. The most
important of these is that public health must remain a public responsibility and neither the lack of
financial resources, the inability to manage systems, the unwillingness to govern responsibly nor
an unfamiliarity with technology should become an argument or an excuse for outsourcing
healthcare to private enterprise. Corruption arises precisely for these reasons but these are
remediable situations. India is a poor country, but there is still no justification for the fact that for
many years now the total public expenditure on healthcare has hovered between 0.8 per cent and
1.1 per cent of the GDP. It is not that funds cannot be provided. Government has demonstrated
the ability and the commitment to pay as in the introduction of the National Rural Health
Mission (NRHM), now the NHM, in 2005. Government showed a similar commitment towards
primary education in introducing, in 2002, the 2 per cent education cess that funds the Sarva
Shiksha Abhiyan. Equally, it cannot be the case that government is not capable of good
governance or good management practice or good human resources policy and that only the
private sector is capable of these.
As the Economist learnedly observed in June 2017, ‘Health care is largely in the hands of the
private sector, not out of ideology but because the government has long done such a lousy job of
providing it’.
A linked issue, which has not been covered in this book in any detail, is the history in the
current implementation of health insurance schemes. The general conclusion appears to be that
by offering insurance cover only to indoor admission and not for outdoor consultation, the net
result has been both that useless surgical interventions are being performed and that out-of-
pocket expenditure has increased even more, to say nothing of the accompanying corruption in
all these transactions.
This one answer, at least, is clear. Governments at both centre and state levels, must continue
to be the primary player in healthcare, and certainly in primary healthcare. The specious
difference between providing and purchasing care must be called out. Even if government were
to purchase the services, it must still provide those services to the people at little or no cost.
Another major conclusion we can draw is that there is a great deal which the private or non-
governmental sector can and must do. The great healing traditions of institutions such as the
CMC, MGIMS, and St. Johns and the highly professional healthcare delivery through
organizations such as the JSS in Chattisgarh or The Banyan in Chennai, to mention only two
organizations named in this book, deliver a powerful message that non-governmental, civil
society activism, built on a platform of hard professionalism, have a role to play in healthcare
delivery which government, at least in the immediate future, will not be in a position to play. It
also goes without saying that such organizations, drawing as they do on the strength of individual
commitment and dedication to a superior cause, are substantially free of any taint of corruption.
A third broad lesson is that information is power and the access to information determines the
quality of treatment a patient receives. For all India’s remarkable achievements in the sphere of
information technology, communication, and digital applications, access to these technologies is
limited. Owning a mobile phone, if a significant marker of social status, does not reflect any
great access to all that technology has to offer. That is still the preserve of persons who have had
much more than an average level of education. In a deeply divided society, access to technology
has become yet another dividing factor, and one which leads to corruption.
Another important message is that no system of healthcare delivery, whether public or private,
can function in the absence of enlightened regulation. Enough has been said of the state of the
MCI; less is known, at least publicly, of the Nursing and Dental Councils and even less on the
regulatory agencies in the AYUSH sector. It would be fair to note, given human nature, that their
situation is not noticeably better. There is no regulation of any sort over the entire range of allied
health-related training. This cannot, however, be an argument against regulation and we await
the progress of the discussions on the National Medical Commission.
A linked aspect, and which in its own way leads to poor service outcomes, is the need for a
comprehensive overview of the medical curriculum and syllabus. There is very little research of
any standard being undertaken in many medical colleges or universities. Several private medical
colleges do not have the patient load to sustain systematic teaching. It is an open secret that
undergraduate medical education in India does nothing to promote public healthcare delivery.
Even more dangerously, the pronounced tendency at the postgraduate level, and especially in
high capitation fee charging private colleges, is to concentrate only on the allegedly lucrative
specializations such as radiology, obstetrics and gynaecology, and orthopaedics. Across India,
there are only a very few seats in medical colleges, and these are almost entirely in government
medical colleges, in such much–needed disciplines as psychiatry, family medicine, palliative
care, and geriatric care. As long as shortages remain in these areas, there will be exploitation and
corruption.
It is significant to reflect on the fact that about the only medical colleges in India which
maintain a creditably high standard of teaching and research, are the All India Institute of
Medical Sciences, New Delhi, the Jawaharlal Institute of Post-Graduate Medical Education and
Research, Puducherry, and the Post-Graduate Institute of Medical Education and Research,
Chandigarh, all funded by the central government and all, significantly, outside the purview of
the MCI.
There is, however, one question to which there does not seem to be a ready or an easy answer.
Why is it that so many distinguished practitioners appear to believe that the heart of their
profession has been lost? India is a traditional society where persons of learning, teachers,
preceptors, and healers are given respect, as something which is their right and their due. There
are indeed a very large number of doctors in government hospitals and health centres, in private
hospitals and clinics, and in public and private medical colleges who remain true to their calling;
but there is enough evidence to suggest that human nature is frail. It is by no means the case that
it is only the medical profession that has been so affected. The civil services, the world of
universities and higher education, the world of lawyers and the courts, the world of politics and
public representation, all have been so affected, but healthcare is a critical and universal need. It
is our hope in pursuing our idea of this book to focus attention on the malady which seeks to
destroy from within; it is our further hope that through discussion and introspection, we will
learn to improve our policies, programmes, and practices.
 I

BACKGROUND
 CHAPTER ONE
The Structural Basis of Corruption in Healthcare in India
Ritu Priya and Prachinkumar Ghodajkar

In today’s times, corruption in healthcare systems is a global phenomenon. What may, however,
vary is the extent, the nature, the causes, and the consequences of corruption, influenced as these
may be by the social context and the history of the development of health services in a country.
The political, economic, social, and cultural history of a society and how it is influenced by the
international political economy have a direct bearing on how its institutional structures develop.
How the professional classes relate to other sections, and the culture they adopt and evolve is
shaped by all these factors and can only be understood within this larger narrative. However,
each professional domain and service sector also has its specificity of institutional structure and
culture. This chapter focuses on the roots of corruption in India’s healthcare services through an
examination of the evolution of the health service system in the country, with the backdrop of the
larger social, political, and institutional structures.
Transparency International, the global civil society organization fighting corruption, defines it
as the ‘abuse of entrusted power for private gain’.1 In healthcare, the power entrusted in the
hands of the medical professional is twofold: The first is the power to determine what constitutes
expert-legitimized ‘correct’ health-related knowledge and to apply it in practice so as to
determine actions of others, that is, the patients, communities, or governments. The second is the
power to obtain material returns for services rendered and advice given. Corruption in the
context of health services may thus be in the form of irrational practices (malpractice or
negligence) or it may be financial in nature; often it is both. This twofold power of the health
service provider, in effect, increases the probability of its abuse.

Specificities of the Health Sector

The conventional logic of the buyer and seller in a marketplace does not apply to the health
sector. The user often does not have the choice of not buying the services, as it can be a matter of
life and death or discomfort and disablement. Moreover, the user does not choose the product or
service to be purchased. It is recommended by a doctor, who is also the provider or seller of the
services.2 What adds another layer to this is that the doctor is also the intermediary for, and
dependent on the supplier of products, that is, the pharmaceutical and medical equipment
industry. These peculiarities of the sector demand that healthcare providers, who make choices
on behalf of patients, are of high professional, ethical, and moral standards. All healing systems
have realized this and have evolved regulatory mechanisms for ensuring ethical practice
(Chamberlain 2009; Priya 2012). From traditional folk healers to modern medical professionals,
all have professional codes of conduct, which get ritualized as cultural practices3 (Morgenstern
2008; Hardiman and Mukharji 2012; Priya and Kurian 2017).
While evolving institutional mechanisms, the information asymmetry between users and
providers of services, inelasticity of demand for the service, and power of different actors needs
to be taken into account. Over time, the increasing complexity of healthcare delivery systems,
with the involvement of multiple actors, has made health services especially difficult to regulate.
When natural resources formed the base of all or most medicinal products, there were providers
of services with varying levels of formal and informal knowledge who prepared the medicines
for their own patients from mostly free use of local natural resources and purchase of a few
materials that were needed from outside the local ecosystem. Services of healthcare practitioners
were either free of charge (as of folk healers), or recipients of services would pay for the service,
or there were mechanisms by which the providers cross-subsidized across those in the
community who could afford to pay and those who could not, and there were contributions from
philanthropy and the state (Porter 1999; Amrith 2009). The state entered the health services
provisioning field in a substantial way in modern times during the nineteenth century and
increasingly became a powerful actor across the world. Over the period since then, governments
have assumed different roles in different societies.4 Since the 1980s, the role of the nation state
has weakened in social welfare; commercial entities have become stronger and shape state
policies rather than the other way around. They, or the new institutional structures developing
under their influence, operate increasingly on market principles informed by ‘new public
management’ approaches (Osborne 1993; Hood 1991), often contrary to the welfare and service
orientation of healthcare.5 External regulators in the form of accreditation organizations and
insurance agencies as a third-party payer mechanism have further added to the actors involved in
healthcare delivery with complex interactions. They entered the US healthcare scene in the
1950/60s and have acquired a visible presence in India since the end of the twentieth century. An
increase in the number of actors, arguably for mutual oversight and regulation, increases the cost
of care and also the window of opportunity for corruption. Each actor has different objectives
and interests, and possesses differential powers. The resultant power dynamics between them
shapes the structure and culture of health services.
In this chapter, we examine the structure and the processes internal to the health services
system and external to it in the social and political realms to understand the basis of corruption in
healthcare. The chapter argues that corruption in the public and private sectors of the health
services system is linked to, and in continuity with, the legacy of the health services and
professions developed in the colonial period. Secondly, that it is an outcome of the design of a
doctor- and hospital-centred health services structure based primarily on the modern allopathic
system. Since public provisioning of healthcare services to all was unaffordable in the colonial
period as also in the newly independent, low-income Indian republic which had suffered colonial
plunder, high levels of poverty, and gross social inequalities, the services became a commodity
that could be ‘bought’ by those who could garner resources for it. Thirdly, that there was an
absence of accountability of the professionals since the top-down service and knowledge
structure was socially alienated from the majority of the population, and there was no effective
formal regulatory mechanism. Fourthly, the biomedical industrial complex, which includes the
largely private medical industry and with it pharmaceutical, diagnostics, hospitals, and insurance
sectors, has made healthcare increasingly expensive as well as further medicalized and
commercialized. This commercial biomedical-industrial complex has corrupted the health
professionals, administrators, and policymakers, while simultaneously enhancing their power as
experts and their alienation. Fifthly, the delegitimization of people’s prevailing knowledge
resources and medicalization of health led to a lack of cultural confidence to deal with one’s own
health, a greater dependency on the modern expert, the doctor, and thereby gave to the latter
absolute powers, with freedom to abuse them for personal and professional gains. The powers
and their abuse then trickled down to the other care providers and staff in healthcare institutions.
Together, these structural factors have generated conditions for an increasing segment of
healthcare professionals moving away from the expected moral moorings of healthcare providers
and thereby increasing distrust of the profession and healthcare services in society at large. Also
discussed is the fact of the practice of other knowledge systems, including the traditional
indigenous ones, having suffered the same fate, that is, commercialization and irrational practice.
This structural process has been an integral part of the general model of socio-economic
development adopted and pursued as a historical continuity from at least the nineteenth-century
colonial period, with significant shifts in institutional structures of governance at three points of
time, that is, in 1919 and 1935 when the elected local bodies and provincial governments
expanded civilian health services, with Independence in 1947 and with policy shifts towards
liberalization, corporatization, and globalization over the 1990s.
Also significant is that other imaginations for developing the structure of health services was
available at each point of time, but the models of development adopted generated the paths that
have converged to create the present situation of corruption in healthcare. The structure of health
service systems and the socio-political structure interact to create the conditions enhancing or
minimizing the extent and nature of corruption. We schematically represent the structures and
pathways in Figures 1.1 and 1.2.6
FIGURE 1.1 Institutional Structures and Health Culture: Actors and Processes Shaping the Health Services
FIGURE 1.2 Systemic Pathways to Pervasive Corruption in the Health Services System

The Health Services System Structure Adopted and Its Consequences

After Independence in 1947, we chose the blueprint for health services development provided by
the British India government’s Bhore Committee report (GoI 1946). This was preceded by
almost a hundred years of introduction of medical services for civilians into India, primarily
starting with the presidency towns and district headquarters. We begin by examining the colonial
legacy before moving on to the post-Independence developments.

The Colonial Legacy

Modern allopathic medicine entered India as a system introduced by the colonial government,
initially for its own armies and officials and, after 1857, for the civilian populations as well (GoI
1946, Vol. 1). What existed until then by way of health services for the majority was a structure
of health knowledge and provisioning that was bottom-up, decentralized, and largely non-
commercial (Arnold 1993). This was sought to be replaced by a top-down, centralized system
that was dependent on Euro-American urban industrial models and commercial products (Arnold
1993; Priya 1995; Gautham and Shyamaprasad 2010).
From the 1820s to the 1860s, medical colleges had been set up to produce Indian doctors who
were needed to supplement the British doctors serving the colonial rulers and their army (Banerji
1985; Arnold 1993). In the wake of the Indian ‘Mutiny’ of 1857, and later after the formation of
elected provincial and local governments in 1919, there was a fillip given to health services
development for ‘native’ civilian populations, including those in rural areas. Consequently, by
the 1940s there were over 47,000 allopathic doctors in India, of whom only 13,000 (about 27 per
cent) were in government service and more than two-thirds were in the private sector. However,
the 7,650 hospitals and dispensaries that existed were almost entirely of the public services (92
per cent), with missionary and private institutions constituting the rest (8 per cent). They had
already set the tone for the culture of professionals in public services and the hierarchies within
the health services system.
Archival studies show that the question of how to find enough funds for health services, and
how to get enough doctors to work in them, was always an issue for the provincial governments.
They devised various ways to limit costs through placing constraints on expansion of number of
institutions and by creating various mechanisms for obtaining doctors. The latter included
producing ‘Licensed Medical Practitioners’ (LMPs) and hiring them as sub-assistant surgeons
under the Indian graduate doctors appointed as assistant surgeons and British doctors as civil
surgeons. Subsidizing private practitioners to set up medical practice in rural areas, allowing
‘honorary’ private practitioners to practice in public hospitals, and allowing government service
doctors to do private practice were other cost-cutting strategies. Governments also viewed
providing services of the indigenous systems of Ayurveda, Unani, and Siddha as low-cost
options (Muraleedharan 1987, 1992).
The divisions within the medical professionals including graduates and licentiate practitioners
of allopathy, full-time salaried physicians and surgeons, honorary medical officers, civil
surgeons, assistant surgeons and sub-assistant surgeons, as well as practitioners of indigenous
systems traditionally trained in paramparas and those educated in the new teaching institutions
created competitive hierarchies. Inequalities of status, pay, and power of the various categories
led to perceived injustices and justified the adoption of practices that were not allowed by the
rules. For instance, the government medical officers saw the honorary practitioners as usurping
their space, gaining experience and patients from their links with the government hospital and
thereby increasing their earnings while the government doctors who worked full time got less
remuneration (even though they were allowed private practice). The practices of the honorary
physicians, who were not supposed to take any fee from patients in the hospital or to refer
patients to their private practice, were difficult to check for violation of either of these, giving the
government medical officers licence to do the same. The licentiates who could only become sub-
assistant surgeons and had no avenues for promotion, were perpetually struggling for the right to
improve their status by an enhanced training period, increase in salaries, and so on, and thereby
felt aggrieved and justified their ‘diversions’ (Muraleedharan 1992). Thus, going to the
government doctor’s home for private consultation with payment of a fee became an accepted
‘norm’. With new governance structures being created initially by a multinational company, the
colonizing East India Company, and later directly by the British imperial government, there was
social alienation between the state agencies and the majority of ‘natives’. In order to get access to
any government official or any government benefits was a privilege, to be obtained by the
underprivileged sections only by the mediation of a ‘middleman’ (Visvanathan 2011). In the case
of medical services, the public system had created demand, but coverage was limited; the Bhore
Committee records that in the outpatient department (OPD), on an average, one doctor saw 75
patients in an hour! In such a situation, anyone who could afford it was likely to pay to get the
civil surgeon’s services privately.

The Design Adopted at Independence

Alienation and Delegitimization of Lay People’s Knowledge and
Pluralism
Until the early nineteenth century there was state support for the indigenous systems, but by the
third decade of the century the shift in policy articulated by Macaulay’s minutes of 1935 led to
active support to the allopathic system of medicine and withdrawal of support to indigenous
varieties (Mushtaq 2009). The well-entrenched indigenous systems fought back with
collectivization of practitioners into Congresses and Associations, as well as through
‘pharmaceuticalization’ and modernization of educational systems, all modelled on allopathic
lines (Pannikar 1992; Banerjee 2009). The elite moved to ‘scientific’ allopathy and also
continued to use the indigenous systems. However, withdrawal of support by the state and
colonial imposition of formal professional standards in line with the General Medical Council of
Great Britain (that excluded all practitioners other than medical graduates) gradually
delegitimized what was systemically close to people’s knowledge (Arnold 1993; Pannikar 1992).
At the time of independence, with overall optimism around, it was envisaged that healthcare
would be provided to all, irrespective of their ability to pay. The Bhore Committee
recommendations provided the underlying principles and model of health services provisioning
for India. Responding to the demands of the national movement, in 1943 the British government
set up the Bhore Committee to recommend strengthening of the health services for the masses.
The Committee studied the prevailing health services situation, that is, resource constraints, the
low number of practitioners of modern medicine, low proportion of doctors in government
service (one-third, compared to almost two-thirds being in private practice), and the continuing
public acceptance of a large number of practitioners of indigenous medicine systems. After due
consideration, the Committee decided that ‘only one and that the highly trained type of physician
…’ would be allowed (GoI 1946, Vol. 4, p. 60). Private practitioners were to continue and could
serve as honorary teachers and practitioners in medical colleges, and that it would not include
any services of the indigenous systems (GoI 1946, Vol. 2). These decisions faced dissent from
members of the committee who gave written notes, which were obviously not accepted
(Gautham and Shyamaprasad 2010). The Sokhey Committee, which was the Indian National
Congress’s planning sub-committee on health, suggested that initially one youth in each village
be trained as a health worker and then from among these the best be taken up for being educated
as medical graduates, but this too was not accepted (Sokhey 1948; Banerji 1985). Thus was born
a three-tier top-down knowledge and service structure that was meant to provide the ‘best of
healthcare’ to all Indians.
The Bhore Committee had also explicitly taken the decision to develop an ‘ideal blueprint’
and not be constrained by the lack of funds, which would be the responsibility of subsequent
governments to provide (GoI 1946, Vol. 2). However, the budgetary allocations for state-run
health services have been consistently low and have never crossed 5 per cent of total budgetary
allocation as against 15 per cent estimated by the Bhore Committee for its plan (GoI 1946, Vol.
2). Further, the Bhore Committee model mandated priority to setting up of medical colleges and
rapid production of medical graduates.
In the first two decades after Independence, there was a significant increase in the number of
government medical colleges and the doctors produced (Table 1.1).

TABLE 1.1 Trends in Medical Education

Source: Choudhury (2014).

In the first three five year plans, about 50 per cent of the health budget went for specific
disease control programmes and about 25 per cent each for general health services and medical
education. With this proportion of allocation, the pace of general health services development
was not sufficient to absorb the doctors produced (Table 1.2).
Besides there was no systematic effort made to channelize the doctors produced even in
government medical colleges into public health services. Given resource constraints,
infrastructure development was slow. State governments sanctioned less posts than needed as
recommended by the Bhore Committee short-term plan or even for the institutions that had been
set up. Thus, a large section of the doctors produced went into private practice and the
institutional structure for healthcare delivery too shifted heavily towards the private sector
(Tables 1.3 and 1.4). From the 1970s, the public sector growth in medical education slowed
down, as reflected in the fourth plan allocations. In the 1980s, the private sector moved into
setting up medical colleges.
The Bhore Committee, with several members being well-known private practitioners, was
silent on the existing private sector in healthcare or the likelihood of its growth when the number
of doctors produced increased (GoI 1961). In fact, its pious hope was that with the expansion of
public services, private providers would become irrelevant (GoI 1946, Vol.2). As the number of
private practitioners increased over time, by the 1970s and 1980s, they became a powerful
interest group that captured the Indian Medical Association, influenced the self-regulatory body,
the Medical Council of India (MCI), and did not allow any other kind of regulatory efforts.7 The
lack of regulation allowed unchecked deviation from professional codes of conduct.

An Unaffordable Mirage
This issue of an unaffordable model being adopted has come up repeatedly, but what all
governments seem to have done is bypass the issue with ad hoc solutions. After almost three
decades of various third world countries becoming independent and attempting to build health
services for the welfare of their peoples, the World Health Organization (WHO) and UNICEF
were forced to confront the issue and organize the conference at Alma Ata in 1977, where the
declaration of Health for All through Primary Health Care was adopted. It pointed out the
unaffordability of doctor- and hospital-centred health services and proposed instead a system
whereby the primary level of care as close to home as possible was to be made available through
nursing and paramedical staff, utilizing traditional practitioners, wherever available, with
appropriate training. It also posited the ideas of appropriate technology in healthcare and of
dealing with other sectors of development that impact the health status of populations such as
nutrition and sanitation (WHO 1978).

TABLE 1.2 Health Plan Outlays under the First Five Year Plans (Rs in Crores)
Source: Computed after deducting provision of water supply and sanitation, GoI (1976).
*CBHI (2007).

TABLE 1.3 Sectorial Employment of Allopathic Doctors

Source: Duggal, Deosthali, and Wagle (2012).

TABLE 1.4 Public–Private Distribution of Health Infrastructure

Source: Duggal, Deosthali, and Wagle (2012).

However, while Primary Health Care has since then become a reference point for discussions
on developing health services, it has made little dent on the mainstream course of doctor- and
institution-centred healthcare or the biomedical industrial complex.

Low Quality Norms

With low budgetary allocation to health services and misguided distribution of priorities within
them, the quality of public institutions was in a sorry state (Banerji 1973; GoI 1983; Hammer et
al. 2007). Heavy patient loads with resource-starved work conditions (shortages of drugs,
medicines, and functioning diagnostic facilities, inadequate or poorly maintained infrastructure)
and human resource shortages (low sanctioned posts, irrational distribution of available human
resources, poor doctor-to-nurse ratio) are some of the common features of most of the secondary
and tertiary level government institutions. In the 1990s’ economic reform period there was a
further shift of allocations from general health services to techno-centric programmes (Qadeer et
al. 2001). Subsequent efforts by the National Rural Health Mission (NRHM) to rejuvenate the
public system did improve conditions to some extent in terms of increase in infrastructure,
human resources, drugs and equipment, and utilization rates, but even that got only one-third of
its promised budget and therefore had limited results (Sundararaman 2012). While these work
conditions create health services which are of unacceptable standard and quality, fixing
responsibility on those who are actually involved in providing the services becomes difficult,
given the failures at various points in the system.
These contextual factors created work cultures where adjustments, deviation from rational
care, and providing and accepting sub-optimal health services were normalized. This new normal
is practiced with ease as the section of society who could demand accountability from these
state-run health services found an alternative in the rapidly growing private sector. State
insurance schemes like the Employees State Insurance Scheme (ESIS) and the Central
Government Health Scheme (CGHS) with a clientele which can demand accountability have
officially shifted to the private sector (LaForgia and Nagpal 2012). Having different health
services for the rich and poor is in itself a morally corrupt idea, but plugging the leaks or
preventing and rectifying corrupt medical practices becomes more difficult if the user
community is socially powerless.
Education and training in resource-starved hospital/medical college settings makes these
doctors accustomed to cutting corners. Resource-starved work conditions and training
institutions give rise to situations where health workers are forced to adapt and deviate from
what can be considered as rational and appropriate medical practice. Healthcare professionals are
trained under circumstances where they have to make clinical choices in the best interests of
patients that are often at deviance from scientific guidelines. Setting of guidelines purely on
‘universal’ standards without consideration of social and health service contexts is itself
questionable (WHO 2012), but what it also does is create a culture of ignoring standards and
guidelines and taking ad hoc decisions, which becomes ‘normal’. Flouting of expected standards
and norms of rational care and profiteering in providing treatment thus became part of the new
‘normal’.

Unreasonable Expectations from Medical Professionals

The expectation of long working hours in hospitals and constant presence of a single doctor in
the primary health centre (PHC), overload of patients, and inadequate resources for patient care
are work conditions that break the barriers of ethical practice. The extremely low doctor-to-nurse
ratio, and the caring orientation of nurses not being given adequate space in the hierarchy of
health personnel, also leads to unreasonable expectations from doctors in the public system.
The mismatch of education imparted and work expectations further adds to their sense of
inadequacy (Ananthakrishnan 2010). While the education curriculum for medical students
matches international standards, the conditions of work are no match against Euro-American
standards leading to a disjunction between the training provided and work expectations. For
instance, undergraduate education in tertiary level medical colleges and teaching about latest
advances leaves them dependent on diagnostics and high-tech medicine but are expected to
practice without much of these in the government services. Similarly, doctors are not trained in
administration but are expected to perform administrative tasks.
Social hierarchies are evident in the class the professionals belong to and the majority of
patients served by government hospitals. However, no part of education equips the professionals
to understand the social inequalities and develop a sensitivity to such issues or about their
behaviour with patients of all classes, and the ethics of clinical decision-making in such
situations.
 Political and bureaucratic interference in their day-to-day functioning leaves doctors feeling
that their professional expertise is not adequately valued. Moreover, they are accountable to the
political and bureaucracy ‘bosses’, not to the patients and communities they serve. Linked to this
is the absence of transparent processes of recruitment, transfer, and postings (Purohit et al. 2016).
With huge bribes to be paid at each stage, the culture of corruption is well set in the public
system.
This professional class is also not free from the general desire of upward social mobility like
any other professional or social group. Aspirations of upward social mobility of the professionals
who come predominantly from the middle class and the aspirations of professionals who were
well-performing students in school have also shaped the principles and modalities of professional
practice (Seetharaman and Lograj 2012; Kuriakose 2015). There is also an element of the
professional aspiration of practicing technologically advanced medical care in doctors moving to
the private sector or going abroad.
Distancing oneself from an anti-technology position but in favour of the rational use of
technology, one finds clear evidence of misplaced faith in medical technology. Technological
advancements coupled with a hype created about consequent outcomes through the marketing
influence of the pharmaceutical and medical instrumentation industries has rapidly changed the
nature of healthcare services. Diagnostics have carved out a whole nexus, where the less
unethical prescribing doctor thinks this is least harmful as intervention for the patient (relative to
unnecessary therapeutics), and for the more corrupt ones, it allows for a full package of
malpractice in collusion with the diagnostic laboratories. All these factors have also contributed
to irrational care or corrupt health care8 as the ‘new normal’.

Influence of the Private Sector

The Medical Industrial Complex
Our planned development model in its vision for planning and developing health services in
India did not evolve sufficient institutional mechanisms to have pharmaceutical and medical
instrumentation industries work for locally relevant health needs (Priya 2013; Chakravarthi
2013a, 2013b). The government neglected and relinquished whatever little control it had through
public sector companies like Indian Drugs and Pharmaceuticals Limited, Hindustan Antibiotics
Limited, and the Haffkine Institute. There has been a lack of a public health perspective for
regulation of pharmaceutical and medical instrumentation companies due to their being under the
ministry of chemicals and the industries ministry respectively rather than that of health. Our
private sector in pharmaceuticals has, due to the Patents Act, 1970, been able to produce
medicines at a relatively low cost, but epidemiological rationale and public health priorities
easily get undermined with the priority of the other ministries to more production, profits, and
economic growth. Healthcare providers then become targets of marketing strategies of these
industries and their products in their attempts of doing more business, and of the unethical
practices on which much has been written (Verma 2004; Srinivasan 2011; Goyal and Pareek
2013).
The pharmaceutical and medical equipment industry, the medical insurance and corporate
hospital chains, all these form a formidable component of international financial lobbies, with an
estimated value of health care globally being USD 7 trillion (Deloitte 2015). Currently, in India,
50 per cent and 80 per cent of the out-of-pocket expenditure in the private and public sector
respectively is found to be on medicines and diagnostics (GoI 2009) and about 25 per cent of
illness episodes go without treatment due to financial constraints or lead to indebtedness and
impoverishment (NSSO 2006).
Insurance then steps in to make the unaffordable care seem affordable for those who can pay
premiums—only at best about 25 per cent of the Indian population, as per a market study
conducted by the Confederation of Indian Industry (CII-McKinsey 2002). Schemes for the
subsidizing of medical expenditures are then evolved as ‘social insurance’ by the central and
state governments to provide for the poor and give a large business base to the insurance
companies for channelizing public funds to private providers (Selvaraj and Karan 2012; Planning
Commission 2011). The emerging big hospital–customer relationship is also conducive to
insurance companies as the entities for negotiation are less for the same volume of business.
Supply creates its own demand, opening the gates of irrational care and corrupt medical practice
by the ‘doctors as intermediaries’, with users suffering the iatrogenesis and economic costs that
has been evidenced most clearly in the US context (Kohn et al. 2000; Starfield 2000;
Himmelstein et al. 2009).

Rise of the Commercialized Professional

At the time of Independence, about two-thirds of the doctors were in the urban private sector
(GoI 1961), largely in single doctor clinics as family physicians or in the few private hospitals.
Much of the private sector clinics and hospitals were owned and run by doctors. The nature of
medical practice was of family physicians where the relationship was of a personalized nature
with continuity of care.
The 1970s and the 1980s saw significant changes in the private sector, with its rapid
expansion and beginnings of a shift from clinics to nursing homes and hospitals which
accelerated further in the 1980s and 1990s. It also witnessed the entry of non-doctor ownership
of hospitals with investor-led corporate group ownership emerging in the healthcare industry.
Most doctors became merely workers in such hospitals where the terms and conditions were set
by the hospital management with financial concerns often overriding rational and ethical
professional practice (Mathur et al. 2015). Specialists became consultants and practiced in
several hospitals. The nature of practice thus changed from that of family doctors to consultants
offering services in big hospitals with a consultant–client relationship. This decreased the
possibility of continuity of the doctor–patient relationship and care.
Corporate hospitals with their five-star hospitality services have changed the notions of what a
hospital can or should be. Hospitals are no more places of providing the health services that are
needed for the patients in a comfortable setting but have become sites also for fulfilling desires
of hospitality services in a luxurious ambience. Unfortunately, such role models of delivery of
health services are unsustainable without overpricing and irrational and corrupt practices.
These hospitals have ensured their profits by giving doctors targets to be fulfilled through
available patient loads or by increasing patient numbers (Kay 2015). This has pushed doctors
into malpractices of over-diagnosis of problems in patients and over-prescription of diagnostics
and therapeutic procedures (Gadre and Shukla 2016). Apart from giving targets to consultant
doctors, business models are moving patients from general practitioners and small hospitals into
these multispecialty and/or corporate hospitals (Lefebvre 2010).9
Secondary-level hospitals/nursing homes have been shown to be financially non-viable with
ethical practice and needing external support such as subsidy by the state (CII-McKinsey 2002).
The entry of the corporate sector has further escalated the profit-oriented business practices in
the health sector. The sheer scale of investments needed for building and running a hospital and
for providing these technologically advanced and hospitality services demands commensurate
returns. Financial viability and aspirations of upward social mobility push even the hospital
owners and doctors into corrupt practices. There is a thin line between technologically advanced
medical care and irrational use of technology, the commonest examples being use of injectables
and intravenous fluids. The scale of corruption multiplies in the case of unnecessary MRIs, CAT
scans, hysterectomies, cardiac stents, and bypass surgeries (Tayade and Dalvi 2016). Ruthless
profiteering practices in the healthcare sector have vulnerable and weak patients at the receiving
end with inelastic demand for rational medical needs.
Profiteering and corruption thus involve a wide range of practices, some of which have been
discussed in subsequent chapters of this book. Besides practices of inflating the narrative on
disease conditions when a patient is admitted, extending stays, ICU admissions, that have been
well documented, the new low of corrupt medical practice can be seen in the form of ascribing
disease to make patients out of healthy persons and, in many instances, declaring them lifelong
patients. Laboratories and diagnostic centres involved in cut practice and kickbacks are ready to
conduct ‘sink tests’.10
Competition for survival and increasing profit margins among corporate and other private
hospitals requires attracting more patients by evolving mechanisms of cut practice and financial
kickbacks. Increased number of partners in the net profit was accommodated by increasing the
cost of care. The kickback channels involve referring practitioners, diagnostic laboratories and
radiology centres, pharmaceutical and medical instrumentation retailers/wholesalers, and
hospitals.
Opening up of medical education to the private sector further aggravated the problem. The
shortage of doctors was used as an argument to open medical education to the private sector.
Increasing the number of seats in existing government colleges and encouraging setting up of
private colleges served the purpose of fulfilling middle-class aspirations of becoming
professionals. Private medical colleges did increase the number of doctors available, but this
contributed less to balancing rural–urban differences and more to increasing private sector
doctors clustering in urban areas and increasing their competition. The brain drain of these
highly qualified medical doctors was conveniently ignored. These non-resident Indian (NRI)
doctors then become reference or comparison categories for their peers here, both in the use of
technology and in incomes earned (Baru 1998).
The admission process in private colleges initially added capitation fee to medical education,
but this has since grown into a large-scale nexus of corrupt arrangements to ensure seats for
those who can pay hefty sums for admission to both public and private colleges (Baru and
Diwate 2015).
The greater competition among doctors and private hospitals has neither improved the quality
of medical care nor brought down its cost. The heavy investment in medical education gave
legitimacy to their attempts of recovering those investments through their private practice.
Profiteering through medical practice thus got wide acceptance as there were compelling
economic grounds.

The Profession’s Relationship with Society

The Doctor–Patient Relationship
The Bhore Committee’s discrediting of the worth of the other systems of health that were widely
practiced in India, reposing faith in a hospital-based, doctor-centred health system with modern
medicine as its medium, state legitimized and sponsored, strengthened the colonial legacy and
cultural ethos of medical practice, with its power relationships between healthcare providers and
patients. The nature of modern medicine at that time was that of the doctor and nurse being
providers of care and the patient being a passive recipient. Control over the culturally alien
medicine and paraphernalia of medical practice gave immense power to the doctors over the
patients (Arnold 1993).
By the late twentieth century, the doctor–patient relationship was getting transformed into a
consultant–client relationship where the patient has now become a customer. A hospital–
customer relationship is being constructed by the nature of hospital management practices. The
doctors trained are also less confident in practicing independently, given technological advances
and the precarious nature of the practice and its vulnerabilities, as well as poor hands-on training
during their undergraduate education in low patient load hospitals of many private colleges or
usurping of the ‘clinical material’ by the enhanced number of postgraduate students
(Ananthakrishnan 2010). Professionals, given the dynamics and vulnerabilities of medical
practice, are increasingly preferring being consultants in the big hospitals since individual
practice is difficult and they get the protection of powerful corporate hospitals.
The image and fame of doctors is increasingly being replaced by that of a hospital brand
image. The image and corporate brand value of the hospital, in the competitive market, is
enhanced by adding more specialization and super-specialization services and by adding recent
technologies (Poduval and Poduval 2008). The competition for enhancement of brand images
has led to addition of unnecessary and costly technologies which are then forced upon patients,
often through doctors who are also not well trained in their use. This trend in the corporate
hospitals creates pressures on the smaller hospitals and nursing homes to follow this path of
technological upgradation in diagnostics and procedures, whether or not it is relevant for their
patients and irrespective of whether it is cost-effective or not. The financial and iatrogenic costs,
of course, are then transferred to the patients through rational and irrational, ethical and unethical
practices.
In such a situation, when healthcare providers expect higher margins of profits and income,
patients also demand results for their investments and failure of treatment become unacceptable.
The unethical and irrational practice by medical professionals has undermined the trust and
respect they enjoyed. The misplaced faith in technology and trust deficit is resulting in
widespread physical attacks on doctors and health workers,11 failure of treatment being viewed
as caused by the doctor’s negligence or error (Anand et al. 2016).

The Social and Governance Structure: Its Implications for Power

Imbalances and Weak Regulatory Frameworks
The web of the huge unmet need for rational medical care; inaccessibility of
doctors/specialists/healthcare providers; lack of effective regulation on qualifications required,
nature and composition of professional practice; lack of mechanisms to decide and regulate
pricing of services and products; and the influence of the medical industrial-insurance complex,
all creates a fertile ground for corrupt medical practice. The lack of accountability to the user and
the society at large, and the sense of helplessness of users, expresses itself through this violence,
or the poor just stay away and suffer without treatment or end up under debt (NSSO 2006). A
consequence of the high-cost systems design has been that the public system never gives
adequate coverage that would have created stakes and support for it in the population at large.
The costs added to patients’ expenditures by corruption further undermined its value. People
found alternatives in the use of the private sector and other systems, so that there was little
political pressure to retain and strengthen the public services (Qadeer 2000).
On the other hand, the powerful private sector interest groups of medical professionals and the
medical industrial complex were able to influence policymakers, whether politicians,
bureaucrats, or expert groups.

Corruption in Policy
Corruption is not just limited to clinical practice, but extends to policy making. Here the nature
and scale of corrupt practices at the highest levels of health technocracy is different and has
implications for larger numbers of both providers and recipients of health services. These
decision-making processes are not available for public scrutiny and often not based on context-
specific scientific research. The technological choices in government services do not always go
through a scientific process of deliberation like health technology assessment by involving all
stakeholders in a transparent manner; for instance, in the case of vaccines and immunization
programmes (Banerji 1999; Puliyel 2014). Utter disregard for an epidemiological perspective in
planning health services and for technological choices in healthcare has allowed commercial
interests of health technology industry to exert their influence (Sathyamala et al. 2005;
Jayakrishnan 2011). Professional aspirations of practicing technologically advanced medical
practice has also undermined the epidemiological rationale and public health perspective in
making these technological choices and health service planning. The complete absence of
mechanisms to avoid conflict of interests in decision-making in healthcare policy decisions has
allowed corrupt practices of enormous scales of both monetary and non-monetary types (Baru
2012). Health system strategies like privatization of public services, public–private partnerships,
contractual workforces, and user fee for services have opened new possibilities for corruption.
These policies allow government doctors and healthcare administrators to take their share in
profiteering business mechanisms. The healthcare workers who cannot take part or have less
scope in this well-oiled system of financial kickbacks and bribes then attempt to take their share
by avoiding/delaying their work responsibilities or through insincerity in the work that they do or
by coercive demands from patients to pay them for services.

Nemesis for the Profession

The violence against doctors, with its underlying distrust and loss of respect, doctors increasingly
being reduced to workers, earning surpluses for the hospital investors/shareholders and insurance
companies; clinical concerns and patients interests being undermined in medical practice—these
conditions must bring a more concerted and creative response from this enlightened profession.
The alienation between the system and its users, and between the doctor workers and the system
they run must be acknowledged.
Illich (1977) and others have pointed out the deeper malaise in the Euro-American health
service system of modern times. Members of the profession are themselves recognizing some of
its symptoms, which have been articulated in writings of Berger (2014), Jain et al. (2014), and
others. It is obvious that among the practicing members of the profession there are varying
degrees of complicity with the system and its corrupt ways. However, what the most non-corrupt
doctors are at best able to do is maintain their own integrity, maybe with some sacrificing of
possible financial gain (Gadre and Shukla 2016).
It has to be recognized that effective regulatory mechanisms, or rather a set of mechanisms,
are necessary for all professions, and the lack of these has brought the medical profession to this
pass. Therefore, building regulatory systems anew must become a serious concern of the
profession. A collective rethink is required on what are the essentials of a medical professional:
How can regulatory mechanisms be patient-centred rather than protecting the medical
professionals and institutions? How can they create an ethical balance between patient interests
and those of the professionals? What have been the consequences of failure of the self-regulatory
mechanism (the MCI), reluctance to or opposition of other regulatory mechanisms by
professional associations, and absence of grievance redressal mechanisms for users (Phadke
2010; Sharma 2015; Vora 2016)?
It has also to be recognized that mechanisms such as monitoring and supervision, peer
reviews, medical and death audits, fail or become irrelevant in resource-starved institutions or
when the primary objective of the institution is to earn more margins of profits. How can their
objective of reviewing systemic and clinical errors be met under such conditions?
Also to be considered is what mechanisms can be created such that the prescriber has no
interaction with the supplier of products and subsidiary services? Institutional arrangements such
as of the Tamil Nadu Medical Services Corporation Ltd. (TNMSC) should be examined for
answers. Disregard of institutional systems design issues for transparent policies and decision-
making by health bureaucrats and doctor administrators encourages corrupt medical practices.
Therefore, what is also required is a serious re-examination of the design of health services to
make it an optimal, low cost but rational and quality service system. It is probably time to go
back to the Alma Ata Primary Health Care Approach (WHO 1978) to design for a better future.
Multiplication of efforts by collectives of doctors to create alternative ways of envisaging and
creating institutions rooted in local contexts, such as the Jan Swasthya Sahyog at Bilaspur,
Shaheed Hospital in Dalli Rajhara, the various community experiments at Christian Medical
College Vellore, and the work on integrative medicine of the Foundation for Revitalisation of
Local Health Traditions could provide learnings for appropriate designing of healthcare systems.

Regulatory Mechanisms for the Health Sector

India is a country with a large—yet the most unregulated—healthcare service sector in the world.
Since 1934, the MCI has been responsible for regulating medical education and practice to
ensure quality and ethical standards. Post-Independence, some states brought in regulations for
licencing private hospitals and nursing homes (such as the Bombay Nursing Home Act, 1949 and
the Delhi Nursing Home Act, 1953), the Consumer Protection Act, 1986 was applied to health
services, and the central government framed the Clinical Establishments Act, 2010 for
registration of all entities providing clinical services and stipulating minimal standards. The
experience with the registration/licencing route of regulatory mechanisms has been that they,
while putting a formal stamp on the dominant forms of health knowledge and standards of
infrastructure for educational and clinical settings, do little else to ensure quality and ethics of
practice. The legal route provides some redress to patients, but tends to undermine the element of
professional judgement and human interaction in the doctor–patient relationship.
The Medical Council of India12
As a professional self-regulatory mechanism, the MCI is mandated with three core tasks: to set
the curriculum for medical education, to set minimum standards for medical colleges and ensure
adherence to them, to regulate medical practice in accordance with a professional code of ethics.
Over the decades, the MCI has repeatedly been found short of fulfilling its responsibilities. Its
failures have had serious implications for the health of the people, for the health of the profession
itself, and for the relationship between the medical healthcare providers and the people. The
MCI’s failures can be summarized as follows:

1. To create a curriculum that produces doctors suited to working in the Indian context,
especially in the rural health services and poor urban areas. This is one of the major barriers to
good quality and functioning of the public system.
2. To guide the setting up of medical colleges in the country as per need, resulting in
geographical maldistribution, with clustering of large numbers in some states and in some
metropolises with absence in several other states and regions.
3. To oversee and guide the Continuing Medical Education (CME) in the country leaving this
important task in a rapidly changing technological scenario entirely in the hands of the
commercial private industry.
4. To create a transparent system of medical college inspection and grant of recognition or de-
recognition.
5. To instil respect for a professional code of ethics among medical professionals.
6. To take disciplinary action against doctors found violating the code of ethics.

The major problems with the functioning of the MCI has been corruption in the registration
and inspection of colleges, looking to the first world for curricula with a straightjacketed
framework, no process of consultation outside the expert groups and elected office bearers,
rigging in council elections at state and national levels, delays in action in case of complaints
against members, lack of stringency in disciplinary action against those found guilty, and non-
compliance with punishment even when it has been meted out by the enquiry committee. While
mandated to ensure ethical conduct of the registered members, it has not yet included ethics in
the course curriculum or made any other efforts at orientation to issues relevant to ethical
conduct.
The corruption detected at high levels in the MCI have discredited it in the eyes of the general
public and the medical community at large. The government stepped in and removed the elected
members to constitute a Board. The malaise had sunk so deep that it was thought that a complete
overhaul was needed. In keeping with the trends in the UK, Australia, and other countries, the
Ranjit Roy Chaudhary Committee set up by the MoHFW in 2012 had suggested an independent
National Medical Commission. The Parliamentary Standing Committee on Health and Family
Welfare for 2016–17 (Rajya Sabha 2016) gave the issue high priority, heard various sections
involved, and invited health systems experts to give their views. Its report on ‘The Functioning
of the Medical Council of India’ is a strong indictment of the organization’s functioning until
now, and it endorses the Roy Chaudhary Committee’s structure for a National Medical
Commission (NMC).
The Proposed National Medical Commission
The present proposal is to establish an independent body as an NMC, with four separate,
independent Boards under it, each of which would solely focus on its mandate: (i) undergraduate
medical education, (ii) postgraduate medical education, (iii) accreditation of medical educational
institutions, and (iv) medical registration and code of ethics. These would be constituted with
medical and non-medical members (Rajya Sabha 2016). In addition, there is a proposed Medical
Advisory Council (MAC) that has ex-officio members of the NMC as well as nominated
representatives of all states and heads of IITs, IIMs, and the UGC.
While broadly agreeing with the proposed structure, we would suggest a few other
components for effective functioning and to overcome the limitations experienced with the MCI.
One, that there should be a fifth organizational structure headed by a retired judge for dealing
with complaints and meting out the quantum of punishment, to ensure no conflict of interest
influences the disciplinary decision. Second, the office bearers should all declare their assets
when they take their oaths and annually till the end of their tenures. This is critical to rebuild
trust in the institution and to ensure that only socially committed persons become office bearers.
Third, ethics of the medical profession are hinged on a complex doctor–patient relationship and
regulatory mechanisms must take this into account. Therefore, it cannot be only a
bureaucratically controlled structure but needs socially committed medical professionals of
unquestioned integrity who should be identified through a transparent process to head the NMC
and its constituent boards. The MCI experience shows that structural checks and balances must
be built in to ensure that monopolies and nexuses do not form.
Besides this, the composition of members must include doctors who are in-service providers
of services at primary, secondary, and tertiary levels in the public system, so that issues they face
are given due consideration. Experience of innovative undergraduate teaching suited to resource-
constrained settings should be an essential attribute of those who are selected for the UG Board.
The NMC and MAC must include a sufficient number of experts of subjects such as public
health and health systems research, health systems management, law, ethics, and the social
sciences for the societal concerns related to healthcare to get due attention rather than the
professional medical interests alone.
Since the self-regulatory bodies of other health professionals—the Indian Nursing Council,
Central Council of Indian Medicine, and Central Council of Homeopathy—are also riven with
similar problems (Sharma 2013; TNN 2010; The Hindu 2016), it is probably necessary for any
effort against corruption in the health services to conduct a thorough review of these
organizations as well.

Other Regulatory Measures

Empowering the users of services, such as through the Consumer Protection Act, 1986
(COPRA), is an important step to hold the service providers accountable. However, it leads to
high levels of defensive practice and a breakdown of the doctor–patient relationship (Bhat 1996).
Viewed differently, it can bring much benefit if service providers realize that a good doctor–
patient relationship will prevent the use of COPRA, and the onus of creating a good relationship
lies with the professional.
Control of elected local bodies under the 73rd and 74th amendments to the Constitution, and
community monitoring arrangements, such as under the NRHM, over the health personnel
including doctors in rural service are other important measures with potential to empower users.
However, they have proved to be of limited effectiveness, even where allowed to be
implemented, because of the knowledge and power asymmetry (Khanna 2013). Therefore,
complementary measures are required to move towards knowledge democracy, that is, the
acknowledgement of people’s knowledge and perceptions in decision-making about healthcare.
Insurance systems and the Clinical Establishments (Registration and Regulation) Act, 2010
are recent additions as regulatory mechanisms, and a National Health Authority has been in
discussion (McClellan 2013; Pandey 2013; Shiva 2015; Shukla et al. 2010–11). All three are
based on the New Public Management approach with centralizing authority and little democratic
check mechanisms. Easy to influence for setting standards that work for the corporate sector and
other large institutional providers of healthcare, such centralized mechanisms can only squeeze
out the small establishments and single providers, and widen the gulf between the healthcare
providers and the majority of users of services. The income needs of providers, which have
moved from livelihood needs to profiteering and corrupt practices, are only legitimized and
further entrenched in the system through the distancing of accountability mechanisms and the
insistence on higher standards of infrastructure and human resources.
Decentralized healthcare, with multiple foci of knowledge and decision-making, bottom-up
approach to development of healthcare systems, de-commercialization of healthcare by low-cost
technologies, public systems of financing and provisioning (by state and philanthropy), and
regulatory mechanisms that are conducive to such healthcare could help in reversing the tide.
Mechanisms for addressing users complaints and taking disciplinary action against healthcare
professionals and establishments, even when restructured to create a larger accountability
structure beyond self-regulation, will be effective only when complemented by the other
structural changes. An ‘architectural correction’ of the social, knowledge and technology, as well
as cultural moorings of the medical profession and other care providers is called for. That in turn
requires a shift in societal perception of healthcare as a service for individual and community
empowerment, and not an economic sector to generate more GDP. Will the political economy of
the private corporations in the pharmaceutical, insurance, diagnostics, and health services sectors
allow this is a moot structural question. Changes in societal values are known to change the
behaviour of structures, and values change with large-scale social movements. Will enlightened
self-interest prevail or will we have to wait for a social movement, or will both come together for
a better future for the profession remains to be seen.
***
Thus, the structural causes internal to the health sector lie in the design of the health services
system, related to the political economy of the public–private proportion and roles in the service
system and manufacturing. Integral to this is the politics of knowledge within the modern
scientific paradigm and in relation to the pluralism in health knowledges and how they empower
or disempower people. The politics of governance in relation to the social context of users and
their role in decision-making and accountability of the system to them creates the institutional
structures that enable societal checks on the professional systems. This chapter argues that it is
the imbalance in these three dimensions of the politics of health that has systemically created the
conditions for the actors to engage in corrupt practices and discouraged the ethical practice of
healthcare. The imbalance between the public and private sectors with high degree of
privatization, the unregulated nature of the healthcare sector, and its alienation from the majority
arises as a historical process of development of health systems and that a historical analysis gives
a greater understanding of the causes and the possible solutions.
Our analysis shows that the possibility of checking malpractice as well as financial corruption
in the health services requires an in-depth enquiry into some basic questions. The first is the
contradiction of an alienated system on which people are increasingly dependent. This paradox
in the architecture of the health services system will have to be resolved if the trend of violence
against doctors is to be checked. How can the gap between the professional system and its users
be bridged?
Secondly, for good, standard healthcare for all, financing will have to be of the order that the
Bhore Committee asked for, that is,15 per cent of all public expenditure. The question is: where
would this come from? In the Indian context, clearly, it has to be largely supported by public
funds, that is, state and philanthropy. How is the fund to be optimally utilized? What is the vision
of ‘good healthcare’—high quality to mean least intervention, low cost but effective measures
and technologies or a high-end, technology-centred, luxurious healthcare? What structures will
be needed for provisioning—public sector alone, public sector as setting standards and leading
with the private sector as follower, or the private sector in the lead position?
Thirdly, how is regulation of the health services to be made a serious public and professional
concern? Will the profession correct itself or will it require strong mechanisms to enforce
societal controls? If the latter, the profession will have to be ready to welcome such measures
rather than contesting them.
How we respond to these questions will determine how the future of healthcare services
unfolds. The hope that some positive change can happen comes from several sources. Even as
the medical industrial complex asserts its dominance, recognition of iatrogenesis and
unaffordability of the present model is gaining ground. In a grim situation, hope lies in
democratization of knowledge systems happening due to the coming of non-communicable
diseases (NCDs) as the big epidemiological picture and their need of long-term care that has
brought even the medical profession to recognize the value of self-care, complementary and
alternative medicine (CAM); therefore, a degree of de-medicalization and moving away from
doctor- and hospital-centred models. That is the hope for moving towards professionals
encouraging and supporting self-care and closer provider–patient/community relationships which
would be more conducive to ‘caring’ as central to service delivery, with greater transparency and
thereby less corruption.
Disowning or deserting of public institutions by the public that they were supposed to serve,
especially by the socio-economically powerful by creating their own alternatives, has allowed
degeneration of public services. Unless these public institutions are reclaimed, their services
used, and they made accountable, the situation is unlikely to improve. Hope comes from the fact
that services of the public system are still trusted more than the private, but it is the hospitality
component that gains ground in the latter. As the experience of the NRHM showed, people will
turn to the public system if its availability and reasonable quality are ensured.
However, if we keep aspiring for the mirage of creating health services as per the Euro-
American models of healthcare, we will constantly have an increasing demand and a shortage of
supply. Our tracing of the history of India’s health services development demonstrates that this is
what creates conditions conducive to increasing corruption. ‘Good governance’ alone cannot
check the pervasive presence of corruption. We need to evolve a bottom-up structure of health
services that optimizes all the available resources (knowledge, human resources, natural
resources, and productive capacities) and institutionalize processes that facilitate accountability
to users and expression of people’s own agency.
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 CHAPTER TWO
Socio-Logic of Corruption*
Shiv Visvanathan

The Necessity of Corruption

I remember meeting a Jesuit priest named Rudy Heredia at a conference in Mumbai over ten
years ago. He asked me about the cybernetics of suffering. The question intrigued me and the
term fascinated me. I eventually felt suffering needed more than cybernetics, but toying with the
idea I realized that the idea of cybernetics as a metaphor for communication and control systems
was more relevant for understanding corruption as a systemic phenomenon, in terms of its
connectivity, meaningfulness, and communicative performance.
Corruption inspires a political correctness. One is forced to see it as pathological rather than
logical; in fact, there is a theology to it, which defines it as ethically wrong, economically
damaging, and politically corroding. The entire sociology of modernity—from Max Weber to the
World Bank documents and Transparency International reports—see, corruption as a violation of
modernity, development, and democracy. Corruption is the one disease that is perpetually
epidemic, and that everyone seeks to reform and eradicate. The question few ask is why despite
all the moves against corruption, reforms have come to naught. Why does reform become a
compost heap for more and more corruption?

II
The literature on corruption is reminiscent in some ways of the literature on the Holocaust. When
the Polish émigré sociologist Zygmunt Bauman wrote his classic book Modernity and the
Holocaust (1989), he contended that to get the story right, one must get the categories right. In
the case of the Holocaust, Bauman argued that one must begin not with what sociology can say
about the Holocaust, but with what Holocaust narratives tell you about the state of sociology. For
decades, social science had simplified the Holocaust into a Jewish problem or a German
problem, or reduced everything to pathology such that the everydayness of the Holocaust could
not be grasped. Sociology in fact becomes a way of sanitizing oneself against the truth of the
Holocaust.
The narratives of corruption create similar problems. For the modernist, corruption is a
carryover from a traditional society. For an ethicist, corruption is a failure of individual morals.
For technocrats, corruption is a problem waiting for the right fix. It is seen as a temporary
phenomenon, a hangover of a delayed development sequence. Authentic modernity, they argue,
should sanitize corruption. For political crusaders like Anna Hazare, all that corruption requires
is the right political legislation and the correct dose of political will. For ethicists as well as
social engineers, corruption is a problem waiting to be solved.
Yet a sociologist looking at the fate of reform or the great archives of corruption reports
seems to come to another conclusion. Every cycle of reform merely adds an epicycle to
corruption. Reform seems to be the compost heap where corruption stories seem to have no
ending. The first steps of a legislative reform are clear, and then tiredness sets in. After a while,
things are back to normal and the crusader has been forgotten or has quietly joined the club.
Corruption generates an unending textuality, a perpetual machine of archives of reform which
regurgitate the old categories and then return to status quo. It is almost as if the waves of reform
are needed to recharge the potency of corruption. Each year produces a new World Bank or
United Nations report; each year inaugurates a new Transparency International report on
corruption rankings, but corruption proceeds as triumphantly or as mundanely as before.
What I want to state is that the problem of corruption cannot be framed only as a lie or as
pathology. The reports on modernization and reform refuse to face the lie about themselves
because corruption argues that modernization produces a false theology of corruption. The
moralizing nature of modernizing sociology cannot accept the necessity of corruption. To put it
paradoxically, corruption is a lie whose truth has come to stay. Let me be more blatant. I want to
argue about the necessity of corruption. I want to perform this exercise as a thought experiment
into the ironic ways we look at society. It is not that we cannot fight corruption. It is just that the
way we define and battle with corruption perpetuates it as a system. By personalizing and
demonizing corruption, we distort it. We need to look corruption in the eye, and one cannot do
that through the lenses of human rights, rational choice, or management theory. In fact, the irony
is that corruption perpetually distorts its own logic as a story. Corruption like a wily octopus
shoots out the ink of scandal to blur its paradigmatic essence.

III
I want to begin by arguing that corruption is a form of knowledge. It is a form of knowledge
defining access. Corruption is an ethno science of modern power. If one looks at the modern
state, the apparatus of the bureaucracy, one sees remoteness and indifference. The modern
bureaucracy speaks a language indifferent to people. The clerk as a middleman, however,
translates it into dialects that people can understand. Corruption is a way of coding and decoding
bureaucracies by pricing knowledge and access to them. The corruption economy is the first
major knowledge society. Corruption defines access, price, and availability. The Kafkaesque
bureaucracy without signs now becomes a humanized entity. One sees this in the dialects of
people in words like ‘contact’ and ‘approach’ that capture the nature of entry. Corruption began
as a frame, as a way civil societies, communities created an ethno science of management to
create access to the corridors of modernity. Systemically, corruption defines the rituals of access
to power especially in bureaucracies.
The Weberian narratives portray what one calls an immaculate conception, or an immaculate
misconception of corruption. A bureaucracy is an embodiment of rationality, evoking speed,
efficiency, predictability, technical control, and impersonality. The bureaucracy was the epitome
of modernity. It was seen as value neutral, and therefore a mere technical instrument used to
transport information, fertilizers or organize concentration camps. As a purely instrumental
weapon, it could be used to help development, or to erase people. The problem that Max Weber
did not consider was what happens when a bureaucracy gets subverted.
 I want to replay the everyday drama between the citizens and bureaucracy in a sociological
sense and read it as a two-way phenomenon. The citizens seek access to it and the bureaucracy as
State seeks to classify its citizens. The state, in approaching citizenship, classifies and maps
citizenship. Two of the great Weberian codes are the opposition between public and private, and
between formal and informal. No bureaucracy can do without these two oppositions and
corruption is a process which basically arises when one conflates these oppositions. Ethics and
sociology seem to legitimize this classificatory exercise. The opposition between public and
private is enshrined in modernity, and corruption is basically the illegitimate use of public goods
for private ends. Yet the two oppositions create a Manichean world, a power system that
bureaucracies seek to perpetuate. This distinction between formal and informal anchors the
discourse on corruption. But few realize that 70 per cent of India is in the informal sector. The
formal is the domain of citizenship, of expertise, of entitlements. The informal is the domain of
the less-than-citizen and less-than-bureaucratically formal. This asymmetry between
vulnerability and its citizenship, its need for access and the grammar of bureaucracies has never
been understood. The bureaucracy represents the exercises of a textual world. Re-read in a
hermeneutic sense, corruption can be redefined as the price the informal pays to the formal and
the oral pays to the textual literate world. Corruption is the attempt by the informal and the
private to wrestle with the formal and the public. It is a battle between two dialects for power, for
defining reality. As long as the formal dominates, modern corruption will remain a pathology.
I think one has to reverse the idea of the social contract, which, by being rights-based fails to
understand the nature of our societies. In fact, between the idea of rights and markets we literally
seem to exhaust the imagination of how to reform corruption. Manmohan Singh, and earlier
Kaushik Basu, showed the possibilities of this imagination which sees corruption as a market
with a demand and supply side, a transaction between bribe-giver and bribe-taker. Reform now
seeks to influence both sides through either incentives or punishment. In this perspective, the
bribe is symptomatic of the disease.
In our analysis, the bribe is a much more fundamental phenomenon. It is structural, not
transactional. The bribe rather than the vote is the basis of the social contract through which
modernity was forged. To shift metaphors, it was a Machiavellian resolution of a Hobbesian
problem. If one looks at it ethnographically, a bribe is more fundamental than the vote and sadly
it has been a form of exchange anthropologists like Marcel Mauss, Levi Strauss, and Marshall
Sahlins paid little attention to. The vote in an electoral system is closer to a bribe, as part of a
potlatch of gift giving. In return for shawls, food, cycles, and other such things, we vote for a
party to sustain a transaction called electoral democracy. I want to argue that the bribe is a deeper
phenomenon. A bribe is a ritual that resists the panopticon. The panopticon as a system of
surveillance and control is built on the visual grammar of governance. Corruption resists light
and scrutiny. It is optically veiled, prefers shadows and the backstage. It summons the senses and
identities in a radically different way.
The modern corruption system is a challenge to modernity and the social sciences. Modernity
operating in terms of the pattern variables, to use a telegraphic expression, confines corruption to
a world where collective, the nepotistic, and the patrimonial dominates the individual.
Corruption subverts the ideas that the individual is the locus of ethics. Here, the corrupt self-
behaves like an elaborate network. Secondly, it shows that the grammar of reinvented tradition
can facilitate state building. Corruption as ethno science, along with jugaad as improvization
under scarcity, are two collations of knowledge created for restrictive conditions.
Governmentality is now the tacit contract between tradition and modern idioms which allow the
Janus face of modernity. At one level, it speaks the language of the rule of law and at the other it
speaks the dialects of corruption. The coexistence of the two also shows why reform does not
work. In fact what one sees is complexity and complicity. One often witnesses ministers
inaugurating seminars on corruption, creating a facade of reformist structures, which in turn
creates new markets through regulation, audit, and accountability. The more reform one requires,
the more extractive the system gets. The facade of institutions promises a reform of corruption
while social dynamics feed aid and reform into the corruption machine. As an inverted
sacrament, it is immersed in ritual. A bribe demands its own ethnology. Each bribe goes back to
the original bribe that forged modernity. The bribe was the ritual of entry whereby the informal,
the oral, and the marginal negotiated the beginnings of the citizenship with the state.
Paradoxically, the bribe, in creating modernity, appropriated modernity partly.
Corruption is not a mere transaction of costs. It is a theory of subversion through transaction.
The modern appeared familiar to the traditional through the middleman speaking the dialects of
nepotism and kinship. Tradition seemed accessible to the modern through the ritual of entry. One
has to understand the deeper processes of ritualization and initiation.
The first is bowdlerization. Bowdlerization is an act of simplification, of ruthless
reductionism, which captured or sought to capture the essence of the complex, alien, or a new
phenomenon. Bowdlerization corrupts the nature of modernity. The Bowdlerizer simplifies to
provide access or familiarity. It is part of the tutorial college mentality that haunts education and
modernity. We opt for phenotype over genotype, summaries over reading, and headlines over
essences. Bowdlerization is cheap, populist, and creates a web of familiarity, which we reinforce
through kinship and nepotism. Bowdlerization is an instrumental way of appropriating reality
where access and presence become more important than understanding and enjoyment. The
bureaucracy, like the modern West, is available as an instruction manual. Who wants
Shakespeare when you can buy an English language certificate? Corruption captures, exploits
this ambivalence towards modernity, turning it into a seductive enterprise. Corruption is a partial
re-colonization of modernity through the idioms of patrimonialism.
Subversion through translation needs consolidation. Corruption has to be seen as a collective
process, as a chain of being. There is a trophicity to the ritual of bribe. The idea of trophicity in
biology allowed for a chain of being of creatures, all of which lived nutritionally off the same
bundle of energy. It could begin with man, proceed to the waste consumed by scavengers both
human and animal, and then proceed to the dung beetle and other insects who demand less
energy from a system. All of them live off the same packet of energy, at different levels. It is
collectivity operating at different levels of a sequence while replenishing itself. Given the trophic
interconnected nature of process, to look at individual ethics is naïve.

IV
Viewed differently, corruption is a structural problem that modernity creates for certain forms of
vulnerability. Three sociological texts seek to indirectly understand this. Anton Blok, the Dutch
sociologist, writing about the mafia of the Sicilian village claimed that the mafia began as
interlocutors, intermediaries, translators between the modernizing state and the peasantry. The
mafia held both hands in a spirit of entrepreneurship and then tightened its lethal grip on both.
Here corruption is presented as a case of incomplete modernity, a distorted example of problem
solving.
Robert Merton in his classic study of the party boss shows that the boss performs a function.
He translates the demands of bureaucracy to the ethnic migrant, he humanizes welfare. The party
boss is human face of the modern welfare machine. Merton treats the party boss as a passing
phenomenon, where corruption facilitates modernization.
Both these classic pieces of sociological writings understand the role that corruption as a
process performs. It facilitates entry, assures survival at a price. In a Hobbesian world, it
provides a survival kit, an ecological niche at an extortionate price. For example, the homeless at
least get a home through the land shark renting out the street for the right. It also expresses this in
local idioms and dialects.
The third tract that I wish to cite is about the role of corruption in total institutions. Max
Weber in a lecture (See Beetham 1974) on the failed 1905 revolution claimed that in the age of
authoritarian efficiency, freedom lies in the interstices of inefficiency, and corruption is one form
of inefficiency. Erving Goffman’s work on total institutions and even the ethnographies of the
concentration camps have shown that corruption in total institutions allows for the ecology of the
informal, and thereby guarantees the rudiments of survival. Corruption often provides the
ecological space for freedom in an authoritarian system.
Between Blok, Merton, and Goffman, one would like to suggest that corruption is an attempt
to alter the cybernetics of that man–machine system that we call State or modern bureaucracy, by
modifying its language, its idiom, its symbolism, its processes of control. It is a reciprocal
encounter where the modern taxes the traditional for entitlements, and the traditionally
vulnerable creates resistance to power. The asymmetry is recognized and yet preferred. The
consequences are often zero sum games.
Probably the worst form of extortion one can think of is bonded labour. In terms of political
economy, bonded labour is the extractive price the tribal or peasant pays a landlord for
borrowing a bag of rice, or a sum of money. Bonded labour is the price a barter economy pays a
money economy, or an oral society pays a written one, for a minimum transaction. It is the
extractive process of entry into a money system where tribal is reduced to bare life. Bonded
labour reveals the extractive limits of the informal economy. Corruption is the medium of
informal citizenship, even in the form of hafta paid to cops and land sharks; it is the extractive
price that creates pathologies of the informal economy. Yet corruption in an asymmetrical alien
system at least allows for survival.
Central to this transaction form is the middleman. The middleman is the mediator who
facilitates transactions across diverse systems, converting bureaucracies into market transactions,
where information, power, access, time are all commoditized. In India, such a role was played by
the dalal and the tout. The dalal was a more traditional role, extractive, coercive, and yet
sustainable. The tout is a dalal in a non-ritualized sense. He has no institutional role. Viewed
within a bureaucratic economy, he facilitates speed, access, entry, and resolution in an alien
bureaucracy, especially in a society which is both marginal and illiterate. Corruption is a ritual
and the bribe is the price that the alien, the marginal, pays for familiarity, the temporary
everydayness of citizenship which the modern system does not permit the hawker, the migrant,
the scavenger, the nomad, the forager to have. Corruption, by providing illicit access to water,
electricity, space, creates a temporary form of citizenship as the marginal wait to be regularized.
The middleman as gatekeeper has often embodied the coerciveness and entrepreneurship of
corruption. Corruption is an attempt to create a scarcity around entitlements and then create a
service economy to cater to it. People do not mind paying it because that is the only form of
access. A bribe, more than the vote, becomes the first act of citizenship at a time when the state
is inaccessible or difficult to access. Corruption is the basic price of citizenship that the marginal,
the informal, and the illiterate pay for a simulated citizenship. Corruption creates a hope in
temporariness that marks the liminality of citizenship in India.
Once we see corruption as structural and normal, one must confront the scale of the activity.
Corruption turns the state as a bureaucracy into the inverted commons. The Kripalani Report,
one of the earliest reports on corruption in the railways, shows how the railways had been
fragmented and strip-mined into separate markets for cushions, bulbs and electric wire, and
bathroom fittings. During its various field visits the Kripalani Committee was met by protestors
asking the committee to return home. What the committee elaborated in ethnographic detail and
naive askance has become a fact of life. Between Party and the State, every asset of nature from
coal and forests to land and water has been fragmented into auction blocks and sold to various
bidders. In fact, this revelation comes out starkly in the fodder scam, where guilt is a chain of
being. To use a socio-biological metaphor, the corrupt man is not an individual termite; it is the
entire termite economy that is corrupt. Corruption is no longer about individual ethics, to bribe or
not to bribe, because corruption is structural. It is vertically and horizontally integrated. There is
trophicity where different groups in the ecology of corruption claim a different section of the
spoils. It is not an individual, but a network that has to be sustained and fed. One reason why one
cannot arrest an isolated individual is that corruption involves an entire chain of complexity. It is
almost like a jajmani system in its mirror of obligations. I think we are naive to call Coalgate,
2G, Commonwealth Games, or Jagan Mohan Reddy scams. Actually, there is no sense of scandal
or outrage. Coal, medicine, forests, dams, in fact every major natural resource and each
concerted act of development politics is part of the normalcy of state-building.

V
What one has to understand is the stages through which corruption evolves. Corruption began as
a necessity, a response to a lack, whether it was a lack of knowledge or a lack of access. It
fulfilled a need. However, the nature of corruption as a service economy changed over the years.
It responded to scarcity by creating markets. Yet the grammar of each stage was different.
One can discern stages in the political economy of corruption. Firstly, there was the
criminalization of politics, where politics through corruption provided opportunities, access to a
spectrum, from the dominant caste to the downtrodden. Electoral democracy and politics become
processes for entrepreneurship. In the first decade, there was still a separation of powers. The
politician and the goon, or gangster, were separate entities. The politics of electoralism combined
violence and finance as the two arms of political activity. The goon became politician. This
raised a liberal uproar over the number of politicians who had murder or rape charges against
them. It was a stage when we were proud of our democracy but had not examined the political
economy of electoralism. It took decades before we realized that the political economy of
electoralism could threaten the foundation of democracy and governance. The appropriation of
democracy through corruption was to prove one of the ironies of the Indian polity. As Jagjeevan
Ram admitted casually, all it took was an order of Harrier jets to finance elections at the national
level.
The criminalization of politics took a second step with the criminalization of the state.
Corruption is a form of state-building. It is a process which in turn incorporates three steps.
Firstly, it invokes the inversion of the commons and the hypothecation of nature to the state. The
state merely becomes an auction block, where nature as forest, mine, the river is strip mined by
contractors. The state then becomes an inverted commons, which itself is available for strip
mining. Development in many countries becomes a way of strip mining the state as an
aggregator of assets. Finally, the state itself becomes a criminal agency suppressing other forms
of criminality in the name of order. The fascists under Mussolini suppressed the mafia to indicate
they would be the source of crime. In India, under the Emergency, petty theft and dissent were
criminalized, while Sanjay Gandhi became the sole agent for the state. The Emergency
epitomized the criminalization of the state under Sanjay Gandhi. It opened up the
deinstitutionalization of every major structure, from banks, courts, and media, to parties,
destroying the normative base of our institutions.
The third step is an internal form of restructuring. Following the work of Mary Kaldor, we
shall call it baroquization. In her Baroque Arsenal (1981), Kaldor observes that generals always
fight the last war. The major weapon of World War II was the tank, and major investments were
undertaken to improve it. Unfortunately, more and more is being spent on empowering it less
and less. Baroquization is a process by which a system becomes more ornate, complex and less
responsive to inputs.
The corruption system is a baroque entity. It delivers less and less as more and more is fed
into it. Reform in fact adds to baroquization, making corruption a more complex process. By the
final years of socialism, corruption has baroquized into a set of extensive quota-rajs. There was a
sense that markets were clogged. Liberalization became a process where new markets had to be
created for corruption to expand. It was the Indian mafia that moved to Dubai creating
conglomerates that included terror, match fixing, airlines, and Bollywood. Dawood Ibrahim was
only a metaphor for this spectrum of activities.
Corruption, by this time, was seen as a form of governance composed of knowledge systems
and a service economy. The language of expectations has become commonplace in its idioms,
the words like ‘contact hai’, ‘approach’, ‘kuch oblige kar sakte hain’ indicated it had become a
new jajmani system, where the corrupt service their patrons at a price. For many, it provided a
system of familiarity, delivery, even speed and access to an alien bureaucratic system. In a
democratic system, elections were seen as a circulation of corruption. Many Dalit and OBC
(Other Backward Classes) politicians when asked about corruption often remark: ‘It is our turn
now’. Corruption becomes a form of distributive justice to politicians like the Mulayams, the
DMKs, and the Mayawatis. It becomes part of a new social contract, where between bribe and
vote we create a new political economy. In fact, one often asks what is the economy or society
that institutions like Transparency International are rating. One wonders what numbers reveal
about such processes.
My argument is that we recognize the everydayness of corruption. Our newspapers create the
facade of a morality play about governance which creates a split between front and backstage.
The front stage is the stuff of governance scripts; the backstage unravels the culture of the
corruption economy. The schizophrenic nature of modern governance is what we need to
recognize. In fact, it is present in the way we run our cities. Our planners talk of slums as the
source of corruption. Newspapers report on how the informal economy taps into the formal for
electricity and water. Yet if we look at the unintended city, the formal cannot last without the
informal, because it is the latter that provides cheap services that allow the middle class in the
formal to exist. A slum might be a source of crime, but it is also the source of domestic servants
and the whole network of hawkers and scavengers who help sustain the formal economy. The
irony is that the informal in servicing the formal also accepts the double-edged contract where it
provides cheap service, while being dubbed as potentially criminal. Our domestic servants
provide cheap services while living in illegal hutments. Our hawkers provide cheap vegetables
while paying hafta to the cops. There is a double split here that we have to recognize. This is
corruption of the informal economy, full of an array of micro-transactions mediated by cops and
clerks, which is about the expensive nature of citizenship for transients and marginals, where
corruption is the way of extracting the surplus from subsistence and its desperate need for formal
entitlements. This is the world of micro power, the corruption of little trophicities. This deals
with the trials of citizenship.
There is a second tier of corruption, where corruption is a grammar of state building. This is
corruption on a larger scale; it is a strip mining of the state and its resources by interest groups of
various kinds.
The plundering of the state and its assets (Phase 2) and the extortion of the citizen (Phase 1)
are tied together by two dynamic and modern procedures. The first is development, and the
second is electoral democracy. These two machines connect and prime pump the system.
Development is a way of creating new markets for corruption, and globalization is only an
extension of development by other means. Elections provide a circulation of corruption, and
allow corruption to be a form of distributive justice.
What we have is a corruption machine and a policy machine tied to the formal economy. The
idea of corruption is the differential success between two overlapping systems.
The picture of India one sees is a bit like what has been visually depicted in Figure 2.1. The
scale of the corruption economy is mind boggling not just in numbers, but the variety of services
it contains and offers. It is almost as if corruption as an economy, as a way of life, claims most
terrains of the human.

FIGURE 2.1 Domains of Corruption

 My argument can be presented in simplified terms. I believe corruption is a distinct form of
exchange, like the gift, like the contract. It has its own logic, deserves a distinct anthropology,
and to reduce it to a fragment or a pathology diminishes its being.
Corruption is a form of anti-commons or an inverted commons which creates new rituals of
access and prices them. It deserves to be understood as a knowledge system and a service
economy with a distinctive ethology of rituals.
Reforms which seek to witch hunt a few individuals in the style of Arvind Kejriwal, or create
summer schools to eradicate corruption in the World Bank style, fail to understand the cultural
roots of corruption. In Karl Polanyi’s terms, corruption is an embedded system both as ecology
and economy, and also as a belief system. Therefore, one needs a sense of reform beyond
managerial models of the punitive and market models of the incentive. To reform corruption, one
must seek to change more than corruption.
Since corruption is an anti-commons, one must seek to recover the idea of a commons in a
market economy. A commons was a way of resisting enclosures. The corruption economy seeks
to recolonize bureaucracies as a set of restricted enclosures.
Fighting corruption demands a return to the commons as a way of conceptualizing life. The
commons seeks to decommoditize life, creating zones where commoditization does not operate,
or operates loosely. The return of nature into the constitutional system not as a resource, but as a
way of life, is the first step to corruption reform. To redeem the violence done to the informal,
one needs the liberating cocoon of the commons, which should be extended from nature to ideas.
Once the sea, the forest, land, and waters are seen as a commons, the decommoditization of life,
of which corruption is an alien part, begins. An opening of the constitutional commons would
demand a wider implementation of what has of late been called Madhav Gadgil’s GO/NO GO
policy.
Gadgil’s scheme is a classification which recreates zones of control where nature is not
subject to development, where for reasons of ecology, civilization, community values, areas of
land, minerals, sea, forests are decommoditized and saved from corruption. The panic over the
Gadgil model was read narrowly as a no-go to growth. It was actually a brilliant move to fight
corruption by remapping India. The Gadgil plan should be extended to intellectual property, to
medicines to emphasize de-branded generic medicines. An attempt to extend the commons rather
than a rights-based battle against corruption sums up the wisdom of India’s social movements.
An anthropology of corruption as a delivery system which understands its logic and semiotics
is necessary. Corruption empowers and humanizes to a point. It renders the alien familiar; it
allows new entrants, migrants, ethnics to domesticate the system. What we need to create are
organizational systems that mimic the style, language of corruption, and recode it as an
information delivery system. Corruption models should be extended which should show us new
ways of accessing the system, of improvizing solutions where none were seen to exist.
Management and legal systems should seek to simplify rules and decriminalize the economy.
The economy should begin not with the macro-bureaucracies but with micro-systems like the
municipal corporation, the police station, and the local hospital. Right to Information (RTI) must
be used to simplify systems, to challenge delay. One must pass legislation whereby services can
become vending systems. It is certificates and clearances we need to vend in India, not Coke and
Pepsi. The micro reform of these systems is what we have to devise. The macro battles of Anna
Hazare and Arvind Kejriwal should be applied to electoral or developmental systems.
Moreover, we need experiments in civic epistemology. A police station could possibly
combine with other community services to form new hybrids which combine functions. Human
Rights groups and NGOs working at local levels should share offices with the police. One needs
to create wider community solving mechanisms for law and order where the police become party
to a wider area of problem solving.
My argument is that technocratic and managerial solutions to corruption are no longer
adequate. We have to break the current corruption discourse and deconstruct its links to electoral
democracy and development. The real possibilities lie with social movements. The sadness of
these movements is that they also repeat the split between corruption and the logic of democracy
and development. Those who criticize corruption rarely question the current models of either
democracy or development. We need a synthesis of the two. The closest we came to it was with
the Mazdoor Kisan Shakti Sangathan under Aruna Roy and Nikhil Dey. The RTI Bill had set the
stage for a simultaneous critique of corruption and development. The tragedy was that the Anna
Hazare movement in its excitement and rhetoric has forced a return to stereotypes. It attacks the
corrupt politician or demands rhetorical legislation but shows little sense of everydayness. The
everydayness of corruption continues blissfully. A mere punishment of some people does not
affect the process, and unless we look corruption in the eye and go beyond the sense of scandal
and spectacle, we cannot confront it.
I think this is where theology comes in. It looks at belief and rituals and their connectivity to
life. One’s sense of God gives one a sense of society. Maybe it is time for a new theology of
corruption. Decades ago, both the liberation theology movements and the remarkable network of
scholar-activists around the Croatian-Austrian philosopher Ivan Illich provided probably the
most brilliant critiques of development. For me, as a layman, the fishing struggle and anti-dam
movements were the first major threats to the current theology of development. The time has
come for an indictment of the secular theologies of corruption which impede reform and deaden
democracy.

Reference
Beetham, David, 1974, Max Weber and the Theory of Modern Politics, Polity.

* This paper began in a rudimentary way as a lecture to the members of Indian Theological Association of
Jesuits at Jalandhar. I want to thank Rudolf Heredia and Francis Gonsalves for harassing me into elaborating it.
 CHAPTER THREE
The Commodification of India’s Healthcare Services
Public Interest, Policy, and Costly Choices
Kaveri Gill

India’s abysmal performance on various health and nutrition indicators, relative to other
developing countries and even some of its poorer neighbours, is well documented (WHO 2015).
Although the country made progress towards achieving health-related Millennium Development
Goals (MDGs), it missed fully attaining them. There is a wide variation between states in
progress made; for example, the goal of less than 100 maternal deaths per 100,000 live births
(MMR) has been achieved only in the more developed states of Kerala, Maharashtra, and Tamil
Nadu (Rao 2015). Access to health services is still highly inequitable, on every axis: between
states, between the urban and rural, and within communities, by class and caste (Baru et al.
2010). As for the famous Omran’s epidemiological transition, it has not occurred: the country
struggles under a ‘dual-disease burden’ of both communicable diseases (24.4 per cent of the total
burden) as well as non-communicable diseases (39.1 per cent) (Mukherjee et al. 2015).

Salient Features of India’s Mixed Healthcare System Today

Just as in the majority of low- and middle-income countries (LMICs), healthcare in India is
delivered by a mixed health system. This is defined as a health system wherein out-of-pocket
payments and the market provision of services predominate as a means of financing and
providing services in a larger environment of publicly financed government health delivery
coexisting with privately financed market delivery (Nishtar 2010). The definition draws attention
to the distinct roles of financing and delivering healthcare, which may involve different degrees
of public and private involvement in each facet depending on health systems of various
countries.
Increasingly, this also involves publicly financed market delivery: for example, private
providers empanelled for public health insurance reimbursement under the Rashtriya Swasthya
Bima Yojana (RSBY) health insurance scheme, wherein BPL beneficiary premiums are paid by
the state. Or private actors contracted into the public delivery system: for instance, medical
specialists under the National Health Mission in various states, as well as those providing
ancillary services, such as cleaning, waste management, ambulatory services, and so on.
In global comparative terms, India’s healthcare system is one of the most heavily privatized in
the world on numerous dimensions. Government spending continues to hover in the range of an
abysmally low 1 per cent of GDP through the decades.1 The government’s share of total health
expenditure annually is less than a third, with most healthcare paid for out of pocket and many
households becoming impoverished for generations due to catastrophic healthcare expenditure.2
India’s total health expenditure (public and private combined), as a percentage of GDP, has
remained between 4–4.5 per cent since the mid-1990s. At more than two-thirds, private spending
accounts for the bulk of it. Historically, this has been out of pocket expenditure but is
increasingly also insurance, private equity, and capital investment made by domestic and
international companies (Burns 2015a). A significant increase in overall healthcare spending is
expected in the next 10–15 years, growing at 15–16 per cent annually from USD 38 billion in
2007–08 to USD 309 billion in 2022–23, with the major share coming from private pockets
(Dasgupta 2012).3
It is also likely to go to the private healthcare sector due to both pull and push factors, that is,
the perceived superior quality of care in the private sector and the difficulty of accessing the
overburdened, underfunded, and underequipped public system (Sengupta and Nundy 2005).
NSSO data reveals that the market share of private facilities in urban care rose from 40 per cent
in 1986 to 62 per cent in 2004, and in rural care, from 40 per cent to 58 per cent in the same
period (Burns 2015a). The private sector accounts for 80 per cent of outpatient services and 60
per cent of inpatient services nationally.
Now, the private healthcare provider in India refers to a very mixed bag with varied
characteristics, ranging from institutions or individuals; qualified and unqualified; registered and
unregistered; operating largely in cities and urban areas, itself a wide spectrum, or with a
footprint in the rural sphere; for profit or not-for-profit; providing allopathic treatment or relying
on traditional systems, and so on. It is also not the case that each can be mapped easily against
received notions: for example, the unqualified being equated only with the unregistered. At one
extreme is the large, corporate, and multi-speciality hospital operating in a metropolitan city, at
the other, the solo quack ‘traditional healer’ plying his services in a slum or a village, and in the
midst, a range of regular qualified specialists and general practitioners, trust and charitable
hospitals (including highly regarded teaching hospitals such as the Christian Medical College
and Hospitals, Vellore as well as Ludhiana), clinics, nursing homes, and diagnostic laboratories.
Other significant private players in the broader healthcare sector in the country are
pharmaceutical and medical equipment companies, and those owning medical education
colleges, as well as the health insurance industry. For the remainder of this chapter, however, the
private healthcare sector refers to the for-profit, formal institutional or individual providers of
healthcare predominantly at the tertiary level. And, in a broader sense, the for-profit drugs and
equipment, and health insurance companies, as well as medical colleges. In other words, the run-
of-the-mill imagery that comes to mind when thinking of the private sector in other contexts.
The public health system providers in India refer to a similarly wide range of actors.4 At the
tertiary end are autonomous teaching and research hospitals of national importance, acting as
institutions of excellence and referral centres for entire regions of the country, such as the All
India Institute of Medical Sciences (AIIMS), Delhi, inaugurated in 1956; the Post-Graduate
Institution of Medical Education and Research (PGIMER), Chandigarh, set up in 1963; as well
as those specializing in certain areas, such as the National Institute of Mental Health and
Neurosciences (NIMHANS), Bangalore; and regular government hospitals in cities. There is also
the vast rural, and increasingly urban, primary healthcare infrastructure. This extends downwards
from district and sub-divisional hospitals: community health centres (CHCs), primary health
centres (PHCs) and sub-centres (SCs), supposedly set for various population sizes including in
slums; and front-line workers, such as accredited/urban social and health activists
(ASHAs/USHAs). A new trend is to lease out the management of some of these to private
actors.5
Administratively, the union Ministry of Health and Family Welfare (MoHFW) and associated
state departments, as well as the directorate and state health societies of the centrally sponsored
scheme in health, the National Health Mission (NHM), are very important in the public system.
Attached to the ministry is the Director General of Health Services (DGHS), advising it on
technical matters, also to do with medical education. There are various autonomous regulatory
authorities at the Centre, inter alia, the Medical Council of India (MCI), Indian Nursing Council
(INC), Dental Council of India (DCI), and their attendant councils at the state level. Other
important actors in the public system more broadly include, inter alia, the research arms, such as
the Indian Council of Medical Research (ICMR) and its institutes; teaching institutions, such as
Lady Hardinge Medical College; and vaccine producers, such as the Pasteur Institute of India,
Coonoor.
Additionally, from a policy and decision-making perspective, the Planning Commission of
India and the NITI Aayog, the body that replaced it in 2015, have been important players, as has
the main representative body of doctors, the Indian Medical Association (IMA). Another set of
transnational actors who are germane to India’s health system trajectory—although as the
country moved towards LMIC status, more in technical assistance rather than financial assistance
and budgetary support terms—are donors and funders of various kinds (bilateral, multilateral,
foundations), as well as research institutions and think tanks supported wholly or partly by them.
Over the decades since Independence there has been a discontinuation of explicitly tied aid
(Ministry of Finance, Department of Economics Affairs 2008) but in the case of technical
assistance, aid may still be implicitly tied in various respects. It may unofficially be conditional,
too. At the subnational level, another recent phenomenon is government-funded technical
assistance bodies, which hire expert consultants and run parallel to the public system. An
example is the Bihar Vikas Mission, notified in 2016 by the Chief Minister of Bihar to ‘fast-
track’ the attainment of development goals.
A final salient feature of the country’s health system is that India’s Constitution deems health
to be a state subject. Individual states are responsible for public health, sanitation, and the
provision of care via hospitals and dispensaries. The Centre has concurrent powers on medical
education, mental health, food adulteration, drugs, population control and family planning, social
security and social insurance, prevention of infectious diseases, and so on. It is responsible for
developing national standards, as well as institutions related to professional training, such as the
MCI. This structure is against a backdrop of vast inequity between and within states, in health
status and outcomes, partly caused by relatively better performing public health systems and
health workforce (largely southern states) or poorly performing ones (predominantly those of
northern or northeastern India), as well as by historical and other factors.
On fiscal federalism, including health and health-related national programmes of the Centre
(for example, the NHM), the Centre has greater financial instruments, resources, and fungibility
vis-à-vis states, who are given responsibility for implementation of ideas they often do not own
with few avenues for increased revenue generation, thus creating a vertical imbalance in funds
and functions (inter alia, Peters et al. 2003, Rao and Choudhury 2012, Rao 2015). In terms of
government spending on health, approximately two-thirds of it still comes from state
governments, with the Centre spending a third of the total (Gupta and Chowdhury 2014). This
exacerbates the horizontal imbalance between richer and poorer states, especially as
compensatory central transfers substitute for, rather than add on to, healthcare spending by states.
In the wake of the structural adjustment of the 1990s, the paucity of funds from the Centre is
found to have pushed poorer states to privatize their public health systems, including primary
and tertiary care, to a great degree, as they sought avenues of compensatory investment (Purohit
2001).

Necessary Conditions for the Commodification of Healthcare

Now, healthcare services are characterized by certain well-known peculiarities and inherent
market failures: asymmetric information (for instance, between patient and provider, so that even
the educated patient does not have the full information needed to assess the nature of illness and
the quality of diagnosis and treatment recommended by the physician); adverse selection (for
example, private insurers will seek to keep out those who might need treatment the most, that is,
chronic patients, the poor, etc.); moral hazard (of various kinds, but one example is of physicians
over-prescribing treatment where there is third-party insurance, say by the government);
uncertainty on numerous dimensions (timing and extent of episodes of illness, etc., which require
insurance to stem the burden on the patient); externalities (for example, neglect of public health
and sanitation, leading to outbreaks of infectious diseases), and so on.
All of the aforesaid features provide strong arguments for governments across the world to
regulate the provision of healthcare, if not play the role of actual payer (via insurance and social
security cover) and provider of healthcare. Historically, the Indian government has been
mandated to play all three roles in healthcare, that is, of provider, financer, and regulator.
However, as seen in the earlier section, India’s health system is today one of the most privatized
in the world, in terms of both finance and provision. More worryingly, it is for all intents and
purposes unregulated. How did the country’s health system arrive at this point?
Following Colin Leys’s (2003) succinct schema as regards the trajectory of the National
Health System (NHS) of the United Kingdom, four precise conditions need to be fulfilled for the
commodification of healthcare services, and the penetration and dominance of the market in a
sector of great public interest: (i) services must be broken into discrete units of output that can be
produced in a somewhat standardized and interchangeable way and priced; (ii) patients must be
convinced to purchase these services as commodities, at the prices at which they are sold, which
could mean spending on branding and advertising but also, discontinuing non-commodified
alternatives, which were previously available for free, etc.; (iii) the existing workforce of service
providers must be converted into producers of commodities, producing a surplus for
shareholders, which could involve changing their professional values and motivation from
socially driven to commercial ones; and (iv) where new entrants confront a risk on their
investment, it must be underwritten by the state by either direct subsidies or access to state funds
and so on (Leys 2003: 84).
This is not a straightforward exercise and Leys cites Gordon White’s (1993) typology on the
politics of markets, arguing that it is particularly relevant to the entry and dominance of non-
market spheres, such as healthcare services. ‘The state’s rules – both the boundary rules and
many others – are placed under pressure, first by business associations and networks – what
White calls the “politics of market organisation” – seeking to influence government policy …’
(Leys 2003: 86). ‘At the level of “market structure” powerful firms can afford highly qualified
strategic planning teams to design ways of enlarging their market share or whole markets, and
teams of lawyers to find ways of avoiding restrictive rules (including tax liabilities), take
advantage of subsidies, and so on. And by permeating public culture generally (especially
through advertising) with individualist and consumption-oriented values, private capital can
gradually erode public support for the collective, non-market provision of services’ (Leys 2003:
86–87).

Critical Junctures in India’s Health Policy: A Chronology

The section traces India’s health policy trajectory in the decades since Independence, and
especially since the liberalization of the country in the 1990s (see Table 3.1).6 It highlights the
chronology of critical junctures, which have cumulatively and systematically resulted in the
steady commodification of the healthcare system, as defined above, overtime.

TABLE 3.1 India’s Health Policy since Independence: Critical Junctures

Year
1946 Bhore Committee Report is submitted
1983 First National Health Policy
1983 Apollo, the first corporate hospital in India, is established
1993 The World Bank gives its first loan for HIV/AIDS control, and subsequently, other
national disease control programmes; Medical Council of India Act amended,
facilitating the expansion of private medical colleges
1995 Drug Prices Control Order (DPCO) slashes the number of drugs under price
controls/percentage of market covered; allows high trade margins for manufacturers
selling drugs under price controls and no limits for others
2000 100 per cent FDI in the hospital sector allowed by the RBI
1999 Insurance Regulatory Development Authority Act establishes a regulatory body for
the insurance sector and opens it to private and foreign insurers
2002 Second National Health Policy
2005 National Rural Health Mission (NRHM) is launched
2008 Rashtriya Swasthya Bima Yojana (RSBY) is launched
2010 Clinical Establishments (Registration and Regulation) Act is passed
2012 51 per cent FDI in multi-brand retail is allowed, including in retail pharmacy stores
2012–17 Health Chapter of the Approach Paper to the XIIth Plan is drafted/High Level Expert
Group (HLEG) on Universal Health Coverage is formulated
2015 Third (Draft) National Health Policy; Fourteenth Finance Commission
Recommendations; NITI Aayog replaces the Planning Commission of India
The first set of policy moments of missed opportunities occur with the non-adoption of the
Bhore Committee Report’s recommendations of 1946 (Health Survey and Development
Committee 1946). At that early stage, the forward-looking report had already set out a universal
healthcare approach, the highlights of which was an extensive public health system architecture
providing for wide coverage in rural areas so as to be as close to the people as possible; which
did not depend on an ability to pay; which stressed preventative approaches as much as curative
care; and which recommended government doctors lose their right to private practice.7 Yet the
country waited nearly 60 years before it seriously took up the challenge of primary healthcare,
with the National Rural Health Mission rolled out only in 2005. For the first few decades after
Independence, the focus in health policy remained firmly on vertical disease control programmes
as well as family planning. Rural health infrastructure, both physical centres and human
resources, were under-resourced, while AIIMS and other hospitals came up in urban India. This
set in place a rural–urban divide in terms of tertiary care that remains to this day.8
Inspired by the Alma-Ata Declaration of 1978, of achieving ‘Health for All by the Year 2000’
by providing universal access to comprehensive primary healthcare, India’s first National Health
Policy of 1983 emphasized preventative aspects, as well as community involvement (MoHFW
1983). The details of the last were not specified. At the same time, it advocated for private sector
involvement to compensate for a lack of public expenditure and investment. The National Health
Policy of 2002 asked for an increase in the financial resources for health in the Centre’s budget,
decentralization of implementation of health programmes to the panchayati raj institution-level,
and inter alia, regulating the role of the private sector in provisioning of healthcare services, as
also recognizing the importance of medical ethics (without any tangible plans proposed), and the
enforcement of standards in food and drugs (MoHFW 2002). As with the draft National Health
Policy of 2015, whose guiding principles span the entire gamut, from equity, universality,
patient-centred and quality care, inclusive partnerships, pluralism, subsidiarity, accountability,
professionalism, integrity and ethics, and affordability, each of these plans and their associated
policy directives remained highly non-specific (Chowdhury 2015). They also remained largely
ignored.
Simultaneously, important developments towards the privatization of the healthcare sector
were taking place. In 1983, the growth of the corporate hospital sector was heralded with the
establishment of the Apollo Hospital in Chennai. It received funding from public financial
institutions, signalling a trend that was to pick up pace with the 1991 reforms, that is, of the
government underwriting risk and providing many incentives and subsidies to the private sector
to enable them to enter into healthcare services and related industries. These included, inter alia,
free or concessionary land to build hospitals, in return for nominal free care to poorer patients;9
public–private partnerships (PPP) of various kinds between state governments and hospital
chains, including the transfer the ownership and/or management of public facilities and ancillary
services to private firms, through outsourcing and contracting in cleaning, laundry, waste
management, and other services; tax breaks; duty exemptions on the imports of medical
equipment; loans at cheap interest rates from public finance bodies and banks; the liberalization
of the insurance industry and the empanelment of private providers for cashless treatment,
mostly for high-end surgeries under public insurance schemes, with premiums paid by the
government;10 allowing 100 per cent FDI in the hospital sector, with additional benefits for
private equity funding, and so on (Burns 2015a).11
Corporate hospital chains, diagnostic and imaging centres and laboratories, medical and
nursing colleges, retail pharmacy, all soon came into the ambit of the private sector. With each of
these steps, Leys’s (2003) fourth precise condition for the commodification of healthcare
services, that is, the risk on new entrants’ investment being underwritten by the state, was being
fulfilled in India.
Giving an insider perspective on the policy trajectory in the health sector in the 1990s, former
health secretary K. Sujatha Rao sets out how a squeeze in government funding led to India
abandoning the vision of Health for All it had agreed to at Alma-Ata in 1978, prompting the
union health ministry to turn to the World Bank in 1993 to start funding its national disease
control programmes (Rao 2017). The ‘wide portfolio of lending helped the World Bank expand
its influence on policy’ (p. 18), and in line with their recommendations to all developing
countries, they pushed for the concept of an essential health service package, as opposed to
comprehensive primary care; limiting the role of the government to the implementation of
disease-control programmes; and the entry of markets in the provision of hospital and medical
care, engaging with the state on a PPP basis (Rao 2017).
The latter opened the door first for local NGOs to help implement government schemes, with
grants from USAID and others, and when contracting processes and capacity became a limiting
factor, to ‘international NGOs and the culture of highly paid consultants’ running a parallel
delivery system (Rao 2017: 19). Today, there is the presence of Foundations with significant
financial heft influencing policy in the health sector, at both the national and state levels, inclined
to offer techno-managerial solutions for a public health system that is lacking along all pillars of
the WHO health systems schema.12 These bodies have the fluidity to move vast funds in various
directions with ease, fewer checks and balances, and relative opacity, than bilateral donors
publicly answerable to parliaments in their own countries. Many have withdrawn financial
assistance as India graduated into LMIC-status, but continue to try to influence policy in a lesser
way through technical assistance.
Another critical juncture in the policy sphere as regards healthcare came with the Twelfth
Five Year Plan (2012–17) and the constitution by the Planning Commission of the High Level
Expert Group (HLEG) to advocate Universal Health Coverage. Rao (2017) gives a fuller and ex-
post health ministry insider’s account, on how the Ministry of resisted the HLEG’s UHC goal,
defined as all care (preventative, promotive, and curative) to all citizens on a cashless basis to be
completely financed through taxes, being pushed by the Planning Commission.13 It feared that
‘government may divert the already scanty resources and attention in favour of expensive
diagnostic-based hospital treatment that had the backing of the corporate sector’ (p. 26), and
insisted that the Planning Commission return its attention to providing universal access to free
reproductive and child health services and treatments for infectious diseases.
It is the process of the finalization of the Health Chapter in the Approach Paper to the Twelfth
Plan, about which a piece in a popular press appeared while the drafting was underway (Gill
2012), that sheds further light on lobbies and policy influence exerted to complete the
commodification of healthcare services in the country. In earlier drafts of the Health Chapter, the
suggestion was made that India follow the ‘managed-care’ model14 of healthcare provision of the
USA.15 Large corporate networks would compete with public health institutions for public funds,
to deliver packages of services (most outpatient care and hospital services) to patients. If public
facilities could not compete, as hitherto poorly resourced public sector institutions would be
unlikely to be able to do, they would not survive. The public sector’s role in delivery of
healthcare would de facto be restricted to a minimal—and less lucrative—Essential Healthcare
Package (EHP), made up of basic child and reproductive care, as well as prevention and
promotion roles. Due to strong resistance to such structural ‘privatization by stealth’, including
how this model works over time to reduce choice in the range of (free) services on offer and
reduces the quality of care (Jan Swasthya Abhiyan 2012; Gaitonde and Shukla 2012), later drafts
of the Health Chapter dropped direct references to the managed-care model. Instead, they spoke
of the ‘continuum of care’ in ‘coordinated care’ models, with ‘integration between primary,
secondary and tertiary services’, and importantly, ‘networks’ of integrated facilities.
By leaving its reference to a network vague, the HLEG Report (Planning Commission of
India 2011) had left itself open to an interpretation by the Planning Commission that it was
advocating a managed-care model. The report proposed that state governments should consider
experimenting with arrangements where the state and district purchase care from an ‘integrated
network’ of combined primary, secondary, and tertiary care providers (without clarifying the mix
of public and private providers), which ought to be regulated by the government and should
receive funds to achieve negotiated predetermined health outcomes (not elaborated upon) for the
population being covered. Critics of the draft Health Chapter of the Approach Paper to the
Twelfth Plan picked up on the word ‘networks’, suggesting that ‘private facility networks’ in the
Indian context would invariably be corporate-led and why did not the Health Chapter argue
instead for individual private providers being in-sourced to fill specific gaps in the public health
system, which was still relatively acceptable as it would not connote corporate private facilities
competing with public facilities for patients.
The Health Chapter abstained from elaborating in detail the set of interventions committed to
be funded and definitely provided by the public health system, giving mere ‘illustrations’
confined to some Reproductive and Child Health services and basic preventive/promotive
interventions.16 It also stated that the extent of the coverage offered in terms of the range of
treatments covered would be constrained by available finances. This was a natural corollary,
since there was to be no stricture that payments to the private sector for services—whether
directly by the government or through insurance—be capped at the same price as that of the
public sector (which the private sector would contest on the basis of offering notionally better
quality). Therefore, if the proportion of corporate or private provided care in the UHC system
were higher, the actual healthcare delivered per rupee would be lower and the more constrained
the ability of a limited government budget to provide the required set of health services.17
The above push for the private sector facilities to directly compete with the public sector
facilities for government funding at a pan India level, staved off by the union health ministry
when proposed by the Planning Commission (Rao 2017), is almost a textbook example
qualifying the first two of Leys (2003) conditions for the commodification of healthcare services:
first, that services must be broken into discrete units of output that can be produced in a
somewhat standardized and interchangeable way and priced; and second, that patients must be
convinced to purchase these services as commodities, at the prices at which they are sold, which
could mean spending on branding and advertising but also, for instance, discontinuing non-
commodified alternatives, which were previously available for free. It also ticks the fourth
condition, whereby the state underwrites the risk of the new entrant to the market. Else why is
not the formal private sector already operating in rural India, to replace the informal private
sector there, rather than waiting to get a share of government funding before doing so?
Services that are provided by the newly emergent corporatized tertiary sector, be they
financed privately or by the state as an insurer, already adhere to the above criteria set out by
Leys (2003): examples include executive check-ups and master health check-ups, wellness
services and so on, none of which have proven to be of scientific benefit. Demand for such
discrete and costly healthcare services has already been created by the industry, so that now even
government providers feel the pressure to offer these new services. Moreover, branding,
advertising, and a luxuriant healthcare experience—modern buildings, with cafes, restaurants,
big screen televisions in private rooms, and so on—have all allowed the private sector to charge
exorbitant prices for the provision of standardized healthcare treatment services, wherein a large
share of the overall bill is for these add-ons to the simple medical procedure.
Under than new government dispensation, the commodification of healthcare is hastened. As
regards public health expenditure, the draft National Health Policy of 2015 declared the intent to
increase public health expenditure to 2.5 per cent of GDP by 2020 (as had been suggested by the
HLEG, albeit by the end of 2017). Looking at the period 2010–11 to 2014–15, when ‘union
government spending virtually declined, spending by states actually grew at close to double-digit
rates (9.86 per cent)’ (Sundararaman et al. 2016). Taken together, however, it falls short and is
worsening with respect to the commitment to reach 2.5 per cent of GDP (Sundararaman et al.
2016).
Under the new government, the NITI Aayog replaced the Planning Commission of India in
2015. The Report of the Sub-Group of Chief Ministers on Rationalisation of Centrally-
Sponsored Schemes (NITI Aayog 2015) made the following recommendations, reflected in the
Budget Estimates of 2016–17: that while the existing funding pattern of schemes defined as ‘core
of the core’ be retained (six schemes, including MGNREGA), the funding pattern of ‘core’
schemes (under which fall the health, nutrition, and convergence programmes, including NHM)
be shared 60:40 between the Centre and the states, where previously, it had been a ratio of 90:10.
This puts the major burden of meeting the minimal public health expenditure on the states, which
is unrealistic (Sundararaman et al. 2016). By doing this, a greater necessity to seek funding via
the PPP modality and corporate social responsibility (CSR) contributions by corporates is
imposed on states by the union government.18
Budget 2016–17 provided for increased health cover to BPL families, of up to INR 1 lakh per
family, claiming to boost health insurance penetration to rural and other areas. It provided for
dialysis services in district hospitals, with PPP modality, and no additional funding, under the
NHM. Finally, it introduced a scheme for the establishment of government-run pharmacy stores
selling generic drugs against private sector prescriptions.
The only context when any pro-poor public expenditure in social sectors seems acceptable in this economic
regime is when they are routed through the private sector – giving further fillip to the runaway growth story of the
private healthcare industry – unmindful of the serious adverse consequences this has had in increasing inequity
and impoverishment. Thus, the only three specific ‘new initiatives’ mentioned in this year’s budget proposals, the
National Dialysis Services Programme, a proposed National Insurance Programme and the expansion of the Jan
Aushadi scheme, would all fit snugly into such an understanding. (Sundararaman et al. 2016)

Turning last to Leys’s (2003) third condition for the commodification of healthcare services,
that is, that the existing workforce of service providers be converted into producers of
commodities and a surplus for shareholders, which might involve changing their professional
values and motivation from a socially driven one to a commercial one. One of the most critical
policy decisions that fuelled this condition has been how medical education has been
increasingly privatized after the 1993 Amendment to the Medical Council of India Act, which
facilitated the expansion of medical colleges in the private sector (Bakshi and Burns 2015).
Charging steep capitation fees and accepting vast donations, it has been argued that graduates
from these institutions are expecting to recoup this outlay from the beginning of their careers and
consequently, more prone to disregard any kind of Hippocratic Oath and engage in corrupt
practices (Gadre and Shukla 2016; Bhyan 2016).
On paper, the Central and state governments in India have promulgated several pieces of
legislation regulating the health sector (Gupta et al. 2010), which can broadly be divided into
three categories, that is, to do with the practice of medicine, facilities, and drugs (Bhat 1996). For
instance, the MCI is charged with several oversight roles: setting standards of good medical
practice and professional conduct for doctors; assuring quality control of undergraduate medical
education in the country and coordinating all stages of medical education; administering systems
for the registration and licensing of doctors to control their entry to, and continuation in, medical
practice in the country; revoking licences of doctors whose fitness to practice is questioned; and
so on (Pandya 2014). However, in the last decade, charges of grave malfeasance have been
levelled at the MCI itself, of its members having accepted bribes from medical colleges seeking
accreditation on a fraudulent basis, with the implicit connivance of the government (Pandya
2014; Bakshi and Burns 2015; Bhyan 2016). The MCI has been accused of deliberately
perpetuating scarcity in the public medical education system, so that unmet demand may be
catered to by the private medical education sector. Despite the most scathing indictment on the
functioning of the MCI by the Department-Related Parliamentary Standing Committee on Health
and Family Welfare (2016), it has surprisingly been allowed to continue as before (Rao 2017).
Setting out the pressures facing doctors working in the corporate commercial healthcare
sector of today, Jain et al. (2014) write:
India has a lack of external accountability and oversight of both public and private health sectors. Most doctors
work in the underfunded and inefficient public sector because it is a secure job with time bound promotions and
little supervision. However, those in much better paid private sector jobs are incentivised to generate business for
their employers by over-investigation and over-treatment of patients who are at their mercy both medically and
financially. Private medicine has flourished in India because of a weak regulatory climate with no standards to
monitor quality or ethics. (Jain et al. 2014: 1).

Numerous pieces in the popular press (Bedi 2016), as well as journal articles and books, speak
of the unethical revenue targets that India’s corporate hospitals set their doctors, who then treat
their patients as revenue generators via unnecessary diagnostic tests and costly surgeries, and
irrational drug prescriptions (Kay 2015; Kanchan 2015; Gadre 2015). On the changing attitudes
of the doctors and other providers in the system to a blatantly commercially oriented one, see
Gadre and Shukla’s (2016) interviews with doctors. In 2010, to allay this dismal situation, the
central government passed the Clinical Establishment Act in order to regulate private medical
services across the country (hitherto supposed to have been self-regulated). It was a move
thoroughly contested by professional associations of doctors themselves (Gadre and Shukla
2016).
***
This article has sought to trace the trajectory of India’s health policy, to show critical junctures at
which the commodification of its healthcare has been extended, meeting Leys’s (2003) four
precise conditions for the takeover of an area of public interest.
Touching upon the politics of markets, following White’s (1993) schema, the state’s boundary
and other rules have been shown to have been put under pressure by powerful private sector
interest groups, cognizant of the absolute scale and growth potential of this sector in monetary
terms. Although India’s has been a mixed health system, it is argued that its privatization, in both
financing and provision respects, speeded up with the neoliberal reforms of the 1990s. What is
remarkable is the extent to which it remains unregulated in practice, which is perhaps also
indicative of the power of entrenched interests, but is going to prove costly for the populace.
Even as the government, and the union government in particular, denied the public health
system minimum funding over decades, the encroachment of the private sector as providers was
justified by the argument that private investment was needed to meet unfulfilled healthcare needs
of the country. The private sector sought profitable areas—tertiary over primary, urban over
rural, and so on—so that market segmentation came to be the policy norm. In the Hirschman
(1970) sense of ‘exit, voice and loyalty’, confronted by a decline in quality in the public
healthcare system (caused not least by the deliberate starvation in funding necessary even for its
minimal upkeep, regardless of the party in power at the Centre and the growth rate of the
country), the middle classes could now choose to exit the public system altogether.19 They no
longer needed to stay and exert their relatively powerful voice, including grievance redressal and
a movement to better the system, because they had no stake in its continued existence and
performance.
‘It is hard to think of anything more important than health for human well-being and the
quality of life. And yet, health is virtually absent from public debates and democratic politics in
India’ (Drèze and Sen 2013: 143). In the general election of 2009, it was noted that ‘health issues
were sidelined’ and politicians paid little heed in their manifestoes and campaigns to India’s
major health challenges (Solberg 2009). The market segmentation explains in part (and only in
part, as it still remains a puzzle) as to why the issue of high quality, affordable and universal
healthcare services has not become deeply politicised in India as it ought to have, being a basic
good, with pressure bought to bear on successive governments at the state level as well as the
national level. As the issue of a lack of regulation of the private sector, as well as ballooning
costs, including of non-communicable lifestyle diseases, hits the middle classes, perhaps we will
see a greater attempt to influence the state to rein in the private sector.20
The argument here is also not that malfeasance and corruption afflicts the private system
alone, as the public system has had and continues to have its share of issues (and as indeed, the
developed country healthcare systems continue to have problems in this regard, too). However,
while corruption in the public system may be addressed if political leadership and will exists (for
example, Tamil Nadu), once the healthcare system is wholly commercialized, redress is much
more difficult, if not impossible, in a society where the spoils to be had are tremendous and rent-
seeking is rife. It is estimated that corruption in the medical industry increases healthcare
spending by 25 per cent (Nundy 2016). While the need for regulation of medical practice is
repeatedly referred to, there is no mention of dedicated and effective regulatory bodies or legal
and operational institutional mechanisms that actually have credibility. Meanwhile, with its
abysmal track record, the MCI and other supposedly autonomous bodies continue to be a part of
the problem, in a textbook case of regulatory capture and failure, rather than a solution.
This chapter has traced India’s healthcare system policy history, with salient inflection points,
and demonstrated its complete commodification overtime. This development is not unknown, but
in this careful selection of critical junctures and policy choices not made—or made and not
implemented—it hopefully becomes apparent that this process was intended and is going to
prove costly for the country in numerous ways.21 It may also prove an irreversible choice, as the
many internal fault lines and contradictions—a failure to see healthcare, along with education, as
a basic right at the time of Independence; a mixed healthcare system with poor primary
healthcare and heavily commercialized secondary and tertiary care; clear market segmentation
along various dimensions, for the poor and better off; and with insurance-funding rather than tax-
funding being sold as a graduated roadmap to a distant UHC—irrevocably constrain the possible
future directions of the healthcare system in the country.

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 CHAPTER FOUR
Globalization and Corruption in the Health Sector
Amit Sengupta

An assessment of the role of globalization in promoting corruption in the healthcare sector in

India would require us, at the outset, to unpack the notions of both ‘globalization’ and
‘corruption’ as we use them in this chapter. By globalization we mean the entire set of neoliberal
economic policies that govern capitalism today and that promote the free movement across
countries of goods and services, and of capital.1 This is not to be confused with other claimed
attributes of globalization such as improved communication technologies, improved connectivity
allowing people to travel to other countries, potential for rapid exchange of knowledge, etc.
Further, in this chapter, we use the broad definition of corruption to mean ‘abuse of entrusted
power for private gain’.2
In the healthcare sector the traditional characterization of corruption is limited to bribery of
regulators and medical professionals, manipulation of information on drug trials, diversion of
medicines and supplies, corruption in procurement, and overbilling of insurance companies. It is
generally recognized that corruption in the healthcare sector is not limited to abuse by public
officials, as private actors are regularly contracted in many countries to provide healthcare
services.3
However, it is necessary to look beyond the traditionally recognized modes of corruption
while tracing the impact of neoliberal polices on corruption in general and corruption in the
healthcare sector in particular. Neoliberal polices in their essence involve a transfer of power
from public institutions to private enterprises and hence it can be argued that if corruption is
‘illegitimate use of public power to benefit a private interest’ (Morris 1991), then neoliberalism
is the epitome of a corrupt social system. This manifests in the case of public services, such as
for healthcare, in the state’s active role as a facilitator of the dominance of private enterprises in
the provision of services.
We identify in this chapter several pathways through which globalization and corruption in
the health sector are lined. The first pathway relates to the ideological sphere, where the role of
the state is sought to be redefined in a manner that benefits private interests working in the
healthcare sector. The second involves the restructuring of global governance for healthcare from
the earlier nation-state driven process to one where private corporations and foundations are
provided space in governance structures. The third pathway is the capture of the regulatory
structures of the state by private actors who are the subject of such regulation. Since all three
paths act by changing public policy, their effects are seldom identified as ‘corruption’ but rather
as a change in policy. However, as all three routes involve public decisions making those acts in
favour of private interests, they need to be correctly identified as the fundamental upstream locus
of corruption that subsequently informs corrupt public policy at the local level. All three of them
enlarge the scale of operations and the power of private enterprises, thus opening up new forms
of corrupt practices.

Ideological Shift in the Role of the State and Healthcare Services

Universal Health Coverage (UHC) is the key reform introduced at the global level by the
neoliberal system, to restructure healthcare systems. In its essence, UHC is the reflection of the
shift in the role of the state as a facilitator of public enterprise and a ‘manager’ and ‘regulator’ of
healthcare services. By the turn of the millennium most low and middle income countries
(LMICs) had inherited crumbling healthcare systems as a consequence of fiscal austerity policies
advocated in the previous two decades by multilateral agencies. To remedy the situation, there
could have been efforts to prioritize the rebuilding and strengthening of the public systems.
Instead, the emphasis shifted from how services should be provided to how services should be
financed. The World Bank played a key role in consensus-building around reforms that were to
become precursors to UHC, much before the World Health Organization (WHO) formally
adopted them as part of its policy plank.4
The role of the state (that is, governments) thus becomes that of a ‘manager’ or a ‘regulator’
of services rather than one of a provider of services. In such a system corruption is no more
limited to individual instances of corrupt government officials engaged in securing illegitimate
gains for private interests. It instead assumes a system-wide dimension where the entire state
machinery and a range of policies are directed at securing increased revenue and profits for
private enterprises. Corruption takes the form of ‘institutional corruption’ as distinct from petty
corruption, such as the payment of bribes for political or other favours. It becomes embodied in
the very purpose of the institution, which leads to regulatory agencies being constrained against
acting in the public interest; they are instead required to act in the market interest.5
Universal Health Coverage was conceived as a system that would progressively move
towards: (i) coverage of the entire population by a package of services, (ii) including an
increasing range of services, and (iii) a rising share of pooled funds as the main source of
funding for healthcare, with a consequent decrease in co-payments by those accessing healthcare
services. Such a system required a clear ‘provider–purchaser’ split, the issues of financing and
management being entirely divorced from provisioning. A provider–purchaser split puts a price
on services, that is, it commodifies them, which is the precondition for their transaction in the
marketplace (Laurell 2007).
Supporters of UHC are happy to emphasize the key role played by governments in
strategically ‘purchasing’ care to improve ‘efficiency’, rather than advocating for them to get
involved in providing services. For example, an issue of the WHO Bulletin argues: ‘Countries
cannot simply spend their way to universal health coverage. To sustain progress, efficiency and
accountability must be ensured. The main health financing instrument for promoting efficiency
in the use of funds is purchasing, and more specifically, strategic purchasing’ (Kutzin 2012).

Global Governance for Health

In recent decades, issues under the purview of global health have moved far beyond the physical
spread of diseases. Since the early 1980s, the global architecture of governance, trade, and
economics has come to be informed by neoliberal globalization, and consequently national
decision-making and national policies are often subject to global influences. This is true in the
health sector as well (Woodward et al. 2001) and the advent of globalization marks a shift in
institutions and structures that govern health at a global level.
Four developments in the last three decades have had an impact on the structures and
processes of global governance for health. The first is the emergence of the World Bank as a
major player in the arena of health governance in the 1980s. Second, the growing importance of
global trade in international relations, and its impact on health in different situations across
countries, has led to a major role for the WTO and for regional and bilateral trade agreements.
Third, private foundations (such as the Bill and Melinda Gates Foundation) entering through
public–private partnerships and other avenues have become big players in global health issues.
Simultaneously, the World Health Organization (WHO)—the only inter-governmental body with
the mandate to oversee global health—has lost its authority largely due to the refusal by the rich
countries to adequately fund it.
A new family of global initiatives that have a major impact on global health governance are
Global Public Private Initiatives (GPPIs). In the past two decades several hundred such
initiatives have been launched, with over 100 in the healthcare sector alone. Global Public
Private Initiatives came to be developed based on an understanding that multilateral co-operation
in the present globalized world could no longer adhere to the older principle of multilateralism
that primarily involved nation states. Global partnerships were, thus, imbued with a new
meaning, that involved not just nation states, but also other entities, including, prominently,
business organizations such as pharmaceutical companies that work through the medium of the
market. These new partnerships were further promoted by philanthropic foundations.
Partnerships with the private sector and civil society are thus held up as the way to achieve what
governments and the United Nations (UN) cannot manage alone (Martens 2007). Global Public
Private Initiatives address what neoliberal economists describe as ‘market failures’, but at the
same time do not question the fundamental faith in the ability of the market to regulate the global
flow of goods and services.
The WHO’s legitimacy has been seriously compromised because of its inability to secure
compliance of its own decisions, which are reflected in the various resolutions passed at the
World Health Assembly. Developed countries which contribute the major share of finances for
the functioning of the WHO have today a cynical disregard for the ability of the WHO to shape
the global governance of health. They see the member state-driven process in the WHO (where
each country has one vote) as a hindrance to their attempts to shape global health governance,
and prefer to rely on institutions such as the World Bank and the WTO, where they can exercise
their clout with greater ease. As with many other UN organizations, the WHO’s core funding has
remained static because of a virtual freeze in the contributions of member states. Its budget
amounts to a tiny fraction of the health spending of high-income member states. In addition, a
large proportion of the WHO’s expenditure (about 80 per cent) comes in the form of conditional,
extra-budgetary funds that are earmarked for specific projects by contributing countries (Global
Health Watch 2006).
An analysis of structures and dynamics of global decision-making reveals the dominance of
entrenched power structures—through the agency of more powerful nations, the Bretton Woods
institutions, private philanthropy, and large transnational corporations—and a democratic deficit
in the structures and dynamics of global health governance. These power structures also operate
directly through bilateral and regional trade agreements; through the operations of bilateral
health-related assistance; and through direct advice and influence. In many respects the
regulatory, financing, and policy outcomes of this system reflect an imbalance between the
interests of a limited number of country governments and global institutions, many of them
private, and the needs and priorities of a majority of the globe’s population.
In the case of medicines the structures of global governance for health currently promote
strong Intellectual Property (IP) protection. Advocacy of strong IP protection (that is, higher
standards of patenting) is designed to secure the monopoly power and thereby financial interests
of multinational corporations (MNCs) in the pharmaceutical sector located in North America and
Europe. The Agreement on Trade related Intellectual Property Rights (TRIPS) under the WTO in
1995 was pushed by countries of the North to benefit their pharmaceutical companies. The
TRIPS agreement harmonized IP laws across the world and prevented countries such as India
from pursuing independent policies that were designed to curb the monopoly power of
pharmaceutical MNCs. In recent years bilateral and plurilateral trade agreements that involve the
powerful economic powers—European Union, US, and Japan—attempt to go beyond the remit
of the TRIPS agreement to further ratchet up standards of IP protection.

Regulatory Capture
As the role of governments is increasingly restricted to that of a ‘regulator’, there is a major
pitfall faced by public regulatory agencies—what has come to be known as ‘regulatory capture’.
It is a phenomenon where regulatory agencies that are designed to regulate industries for the
public interest are ‘captured’ by the industries they are supposed to regulate. As a consequence
regulators end up regulating industries in a way that benefits the regulated industry, rather than
the general public.
Regulatory capture takes place in different ways. The regulatory system gets captured by
those that are supposed to be regulated because they are the designated ‘experts’ who understand
the system. Such ‘experts’ often have dual loyalties, that is, to also represent the interests of
those who are being regulated. Such issues of ‘conflict of interest’ are further augmented by
‘Revolving Door’ practices, where regulatory bodies include people who have had previous and
recent stints in bodies that are the subject of regulation.
One of the most glaring instances of the revolving door phenomenon was seen in the course
of a landmark patent case between Swiss TNC Novartis and the Indian government involving the
anti-cancer drug imatinib mesylate. Gopal Subramaniam, who was the Solicitor General of India
when the case began, took over as the lawyer representing Novartis while the case was
underway. He replaced Rohinton Nariman, who was appointed as Solicitor General of India to
replace Subramaniam (Mathew 2011). In a similar vein, Naresh Dayal, ex-secretary, Ministry of
Health and Family Welfare, retired on 30 September 2009, and soon after joined
GlaxoSmithKline Consumer Health-care as a non-official director (Pant 2014). Rather than
raising red flags over the implications of the revolving door, there are moves towards their
institutionalization. Thus, the 2011 National Health Research Policy (NHRP) seeks to develop
‘mechanisms favouring seamless movement of personnel between teaching, research and
industry’ (GoI 2011).
Capture also occurs through the promotion of ideas and in post-1990 India, the virtues of
neoliberal reforms, including those of deregulation, are promoted by the Indian state. This has
had significant impact on regulatory structures, as regulatory capture is more easily
accomplished when the voice of those who benefit from lax regulation is significantly stronger
than the general public whose interests are supposed to be safeguarded through regulatory
structures and mechanisms (Stiglitz 2009). Neoliberal reforms, undertaken in India since the
1990s, have expanded the scope for private activity and reduced regulation (Ghosh 2010) and the
nexus between the state and big business has strengthened (Chandrasekhar 2014). Regulatory
capture has now morphed into what has been described as ‘... an interlocking dynamic of
policymakers, regulatory officials, corporate players and extremely sophisticated industrial lobby
groups’ (Loeppky 2010).

Institutionalized Corruption: Public Policy as Facilitator of Private

Profit Extraction
The change in trajectory of the state, which we have described earlier, applies as well to the role
of the Indian government in institutionalizing avenues for profit-making by private industry.
Ideological shifts accompanied by changes in public policy combine to create conditions for
profit extraction at a systemic scale in different arms of the health sector. As we examine later,
the power of the government to formulate and implement policy has been systematically used to
create larger and more secured profit-making by private enterprises. We trace below several
instances in the healthcare and medicines sector where public policy has created opportunities for
private enterprises. At the same time these polices have not contributed to advancing public
health goals, thus creating the net effect of a transfer of public resources (or foregoing of public
revenues) to benefit private players without any clear public health gains.

Regulation of Clinical Trials

Changes in the regulatory environment for clinical trials were initiated through the constitution
of a Pharmaceutical Research and Development Committee (PRDC) by the Ministry of
Chemicals & Fertilizers, which submitted its report in 1999. The 15 member committee included
5 members from industry (Anji Reddy of Reddy’s Laboratories, Parvinder Singh of Ranbaxy,
Y.K. Hameed of Cipla, Swati A. Piramal of Piramal Pharmaceuticals, and Amit Mitra of the
Federation of Indian Chambers of Commerce and Industry). The committee, inter alia, citing the
unique opportunity for India to become a leading centre for clinical trials, called for basic
changes in the legislation allowing import of animals, contract research, and a legal status for
institutional ethics committees (Ministry of Health and Family Welfare 2003). In 2005 the Indian
Patents Act was amended to align it to the requirement of TRIPS agreement under the WTO.
This was seen by international pharmaceutical companies as an opportunity to exploit the Indian
market. The PRDC committee’s report echoed the view of pharmaceutical companies that the
changed industrial environment (consequent to the change in India’s Patent Act, which was
anticipated by the committee’s report) could be leveraged to draw in investments into the
pharmaceutical sector.
In 2005 the Indian Government acted on the committee’s recommendations and amended a
key clause in the Drugs and Cosmetics Act (DCA) that had been specifically designed to protect
the interests of trial subjects. Prior to the 2005 amendment to the DCA, foreign sponsors were
permitted to conduct clinical trials with a ‘phase lag’: the trial in India had to be conducted one
phase earlier than elsewhere. This meant that, for example, if the Phase 3 of a trial was
completed outside the country, trials within India had to commence from Phase 2. However,
amendments to ‘Schedule Y’ of the Drugs and Cosmetics Rules, in January 2005, allowed
‘concurrent phase’ trials in the country. Thus, the 2005 amendments made it easier for drug
companies to do research that involved Indian participants (Nundy and Gulhati 2005; Sengupta
2009).
Trial sponsors and contract research organizations (CROs) utilized the liberalized regime to
scale up conduct of clinical trials in India. From 40 to 50 trials in 2003, the country saw around
1,850 trials registered with the government registry in June 2011 (Bhan 2012). Regulatory
structures were unable to cope with the sudden rise in trials and there continued to be a persisting
regulatory lag. Thus, for example, while the new law was notified in January 2005, registration
of clinical trials was made mandatory (with full disclosure of trial data with the Clinical Trials
Registry) only from 15 June 2009 (Pandey et al. 2009).
Deaths of clinical trial subjects also rose exponentially, and an estimated 3,458 research
participants died during clinical trials conducted in the period between 1 January 2005 and 31
December 2012 (The Telegraph 2014). Out of these, 89 deaths were found to be attributable to
the clinical trials. Given the very poor level of regulatory oversight, these numbers are likely to
be underestimated. Belying claims that liberal norms governing drug trials would fast track
approval of necessary drugs, in this period, trials on 475 new drugs were conducted and only 17
drugs were approved for marketing in India (Yadav et al. 2014).
Numerous instances have now been documented of gross ethical violations as a result of the
precipitous change in domestic law on clinical trials and the wide gaps in regulatory
mechanisms. A prominent instance is the trial on a vaccine against the Human Papilloma Virus
(HPV) by the US based NGO called Program for Appropriate Technology in Health (PATH).
The trial conducted by PATH was funded by the Bill and Melinda Gates Foundation and the
vaccines were provided free of cost by Merck and GlaxoSmithKline (GSK). Several thousand
adolescent girls were vaccinated in Andhra Pradesh and Gujarat as part of the trial, which PATH
called a ‘demonstration project’ (Shetty 2011). There were gross ethical violations in the manner
in which trial participants were recruited. In Andhra Pradesh, consent was neither taken from the
girls themselves or from their parents or guardians (Sarojini and Deepa 2013).
Another prominent instance of regulatory failure related to trials conducted between January
2008 and October 2010 by government and private doctors in Indore, Madhya Pradesh. Trials
were conducted on some 233 psychiatric patients who had gone to them seeking psychiatric
treatment. Following media reports the government responded by imposing a mere INR 5,000
rupees fine on 12 doctors for not informing the parent hospital about the conduct of the trials and
for ignoring protocols (Rajalakshmi 2012). There were 18 deaths during the course of these
trials, none of which was investigated by any independent agency (Jain 2013). Matters finally
came to a head when a civil society organization, Swasthya Adhikar Manch (health rights
platform), filed a public interest litigation in the Supreme Court of India.6 The Court, in January
2013, stopped the country’s drug regulatory agency from approving any new drug trials unless
they were personally verified and cleared by the health secretary.
Ten years after the Indian law was amended to facilitate clinical trials by foreign sponsors,
regulatory agencies have only now started putting in place regulations regarding clinical trials
that span issues such as informed consent, ethics committees, compensation norms, reporting of
serious adverse events during trials, and so on. After a rather hasty exercise in 2013, further
amendments to the Drugs and Cosmetics Act have been undertaken in 2014.7
The huge regulatory lapses related to clinical trials need to be seen as part of a trajectory
beginning with liberalized norms based on a committee’s report that had a strong corporate
presence and public policy informed by the ethos of neoliberalism. This was followed by
reluctance to put in place adequate regulatory structures even though evidence of ethical
violations kept mounting. The nexus between policymakers, regulators, and industry, which we
refer to as characteristic of an evolved system of regulatory capture, is clearly in evidence in the
case of the recent developments in the clinical trial sector in India.

Public Policy in India and Intellectual Property Protection

India’s pharmaceutical sector had flourished in the wake of its Patent Act of 1970, which did not
allow product patents in the case of medicines and agro-chemicals. In 1991 the Indian
government embarked on a formal policy to introduce neoliberal reforms and this led to a
significant shift in public policy, which had its impact on the government’s official view on IP
rights. There was now an attempt to argue that strong IP protection would actually further
domestic interests in India. India finally became a founder member of the WTO and signed on to
the TRIPS Agreement.
When a new government came to power in 2004 it was forced to seek support from smaller
parties which stood towards the left of the political spectrum and who had been arguing for
incorporation of pro-health safeguards in the amended Act. The relatively progressive and pro-
public health amendments to the 2004 ordinance, leading to the amended 2005 Patents Act, need
to be seen in the context of the extraordinary circumstances which forced the hand of the
government, as should the use of these safeguards over the past decade. Saddled with a law that
the government at that point (or its successor) did not entirely wish upon itself, the government
has never pushed for a complete realization of the possible benefits of the health safeguards in
the Indian Act.8
Regulatory capture of the formulation of IP policy in India needs to be understood in the
above context. The first link in the chain is the capture of IP legislation at the global level by
multinational corporations acting through the aegis of developed country governments at the
Uruguay Round of negotiations that preceded the formation of the WTO. The second link in the
chain is the capture of public policy in India as a result of its adoption of neoliberal polices in the
1990s. The logical consequence of these trends would have been the formulation of an IP policy
that provided higher standards of IP protection with weak safeguards. This did not happen
because of fortuitous circumstances, which we briefly describe earlier. While the Indian Patent
Act provides the enabling platform for pro-public health measures, it is out of sync with the
overall neoliberal vision of the Indian government, and has been so for quite some time.
This underlying contradiction is now being laid bare as evidenced by significant departures in
public positions by the Indian government. In order to draft this IPR policy, the government
established an ‘IP Think Tank’ that was, inter alia, tasked to unfold India’s new vision on IPR.
As the membership of this think tank became public, questions arose over its composition that
included legal representatives of industry including the pharmaceutical industry (Jishnu 2014).
In January 2015, the think tank released the ‘Draft Intellectual Property Policy’ with a vision
of ‘intellectual property led growth in creativity and innovation’. The draft was criticized widely
as making ‘… a categorical and critical mistake of promoting intellectual property as an end in
itself rather than as a means for achieving social and economic progress through enhanced
production of and access to the fruits of creativity and innovation’ (Flynn 2015). The draft IPR
policy has been warmly welcomed by the US pharmaceutical industry with some representatives
of the industry noting that the changes indicated by the current government could ‘translate into
significant new market opportunities for right holders’ (Economic Times 2015).
Change in public policy in India towards IP protection is fraught with serious implications for
healthcare, not just in India but in a range of LMICs. Most LMICs depend substantially from low
cost Indian generics to meet their healthcare needs and the continued survival of the Indian
generics industry is key to preserving the chain of supply of Indian generics. Today nearly 14
million people in developing countries are on Anti Retrovirals (ARVs) used to treat HIV-AIDS.
A 2010 study estimated that between 2003 and 2008, over 80 per cent of ARVs accessed by
people living with HIV across these countries were supplied by Indian generic companies
(Waning et al. 2010). We now have clear indications that there is reluctance on the part of the
state to utilize the health safeguards that are part of India’s Patent Act. There are disturbing
reports, for example, that the US-India Business Council (USIBC), in its submission to the
United States Trade Representative (USTR), stated that the Indian government had ‘privately
assured’ the industry that it would not use compulsory licences (CLs) for commercial purposes.9
Compulsory licensing is perhaps the most important tool available with governments to curb the
monopoly of MNCs exercise through patents, where the government allows manufacture of
patented medicines by domestic companies.
There are several ways in which attempts are made by multinational pharmaceutical
corporations and their host countries to influence public policy on IP protection in India. Many
of these are in the form of direct pressure on India by rich country governments (especially the
US). The US embassy in India is directly involved in lobbying on IP issues through its IPR
attaché. Dominic Keating, the former IPR attaché in India noted, ‘My key role is to promote high
standard Intellectual Property protection and enforcement in India’.10 In 2014, the US used the
Special 301 processes to escalate pressure on the Indian government by announcing an out-of-
cycle review.11 In 2013 and 2014, the US International Trade Commission announced two sets
of investigations into India’s trade policies that included IP law and policy.12 These actions were
preceded by a sustained campaign by US pharma13 that eventually roped in US law and
policymakers into demanding that the US government initiate strict actions against India over its
IP policies. This included a letter by the US Senate Committee on Finance to the US Secretary of
State asking him to raise concerns over India’s compulsory licence and the Supreme Court of
India’s decision in the Novartis case on his visit to India14 and a letter signed by 170 members of
the US Congress to the US President criticizing India’s IP climate and asking the President to
‘send a strong signal to the Indian government that these actions are inconsistent with India’s
international obligations and set a precedent’.15
There are also several other ways in which influence is exercised. The offer of technical
assistance by developed countries and pharmaceutical MNCs to patent offices and judicial
officers in developing countries like India is a means to influencing the examination of patent
claims. Technical assistance from developed country patent offices can be a powerful tool to
effect change that may be viewed as merely administrative through what has been called
‘technocratic trust’ which ‘influences decision-making processes of trust-giving offices’ (Drahos
2007). Judicial trainings in developing countries are emerging as a method for MNCs to
influence the manner in which courts apply or interpret patent rights. In a landmark move of
sorts, Justice Dalveer Bhandari recused himself from the Supreme Court bench hearing the case
filed by Novartis against the rejection of its patent application of the anti-cancer drug, imatinib.
The recusal of Justice Bhandari came in the background of concerns raised by public health
groups over judicial conferences attended by the hon’ble justice (Mitta 2011). The conferences
attended by Justice Bhandari in 2009 and 2011 were conducted by an organization known as the
Intellectual Property Owners Education Foundation (IPOEF) established by the Intellectual
Property Owners Association (IPOA). The 2011 International Judges Conference of IPOEF was
funded (USD 450,000) by the United States Patents and Trademark Office (USPTO).

Outsourced Care in Public-funded Insurance Schemes

In 2009 the Indian Government launched a nationwide health insurance scheme called the
Rashtriya Swasthya Bima Yojana (RSBY) designed to protect patients from the ‘catastrophic’
impact of out-of-pocket expenses incurred on hospital care, as modelled on Andhra Pradesh’s
Rajiv Arogyasri scheme. The RSBY has been held out as a major achievement by the Indian
government, both current and previous.
In addition to the national insurance scheme there are state-level health insurance schemes
that are in operation. By the end of 2010 an estimated 247 million people—constituting a quarter
of the population—were covered by one or more of these schemes, and coverage has since
expanded (People’s Health Movement, Medact, Health Action International, Medico
International and Third World Network 2011). The public funded insurance schemes are meant
for hospital care only and cover a specific list of procedures. Patients are provided a choice of
accredited institutions where they can receive treatment and be reimbursed for costs not
surpassing a set ceiling. This type of health insurance is publicly funded; in the case of the RSBY
the cost of the premiums is shared by central government (75 per cent) and state governments
(25 per cent). Two fundamental pillars support these kinds of health insurance schemes. First,
they operate on the logic of the ‘split between financing and provisioning’. While financing
comes from public resources (central or state government funds), treatment can be provided by
any accredited facility, public or private. In practice, when it comes to provisioning a large
majority of accredited institutions are in the private sector. For example, in the case of the
Arogyasri scheme in Andhra Pradesh, the total payments to facilities accredited under the
scheme from 2007 to 2013 amounted to Rs 47.23 billion, of which Rs 10.71 billion was paid to
public facilities and Rs 36.52 billion went to private facilities (Yellaiah 2013).
The second pillar of these schemes is that beneficiaries are insured against a set of ailments
that require hospitalization at secondary and tertiary levels of care. They do not provide
comprehensive healthcare, and are limited only to a pre-defined package of procedures.
Excluded are almost all infectious diseases that are treated in out-patient settings, such as
tuberculosis that requires prolonged treatment, most chronic diseases (diabetes, hypertension,
and heart diseases) or cancer treatments that do not call for hospitalization. To take the Arogyasri
example again, the scheme draws 25 per cent of the state’s health budget while covering only 2
per cent of the burden of disease (Prasad and Raghavendra 2012: 125). Such skewed priorities
end up distorting the entire structure of the health system and public money is squandered to
strengthen the already dominant corporate health sector (Shukla et al. 2011).
In theory, good health systems are like pyramids: the largest numbers can be treated at the
primary level where people live and work, some would need to be referred to a secondary level
such as a community health centre, and few would require specialized care in tertiary hospitals.
Better primary and secondary level care ensures that fewer patients end up in more expensive
specialty hospitals to undergo major procedures. The health insurance system in India inverts this
pyramid and starves primary care facilities. In 2009–10, direct government expenditure on
tertiary care was slightly over 20 per cent of total health expenditure, but if one adds spending on
the insurance schemes that focus entirely on hospital-based care, total public expenditure on
tertiary care would be closer to 37 per cent (Reddy et al. 2011: 13). In Andhra Pradesh, following
the implementation of the Arogyasri scheme, the proportion of funds allocated for primary care
fell by 14 per cent (Varshney et al. 2012).
What is even more worrying is that these social health insurance schemes, largely
implemented through partnerships with private providers, have been indicted in several states for
defrauding the system. There have been several reports of unscrupulous private facilities milking
these insurance schemes by conducting unnecessary procedures. Horrific incidents have been
reported, for example, of unnecessary hysterectomies conducted on women as young as twenty-
two (Rao 2017; Jaiswal 2013).
***
While it is relatively easy to identify corruption when, for example, a public official receives a
bribe to favour a private hospital, more fundamental instances of misuse of the power vested in
the state to benefit private enterprises go unrecognized. Thus, for example, a change in policy to
promote outsourcing of healthcare services has a system wide effect and involves a very large
transfer of public assets into private hands. Yet we seldom recognize such an act as an act of
corruption.
In this chapter we have discuss three pathways through which neoliberal globalization
promotes corruption in the health sector. Given that globalization acts, for obvious reasons, at the
global level the links between global trends and policies and their manifestations at the local
level in countries are important to trace.

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Pant, P., 2014, ‘India: A Democracy on the Road to Kleptocracy, hotnhit NEWS features, 9 June
2014, available at
http://hotnhitnews.com/India_A_Democracy_on_the_Road_to_Kleptocracy_by_Piyush_Pant_020311006.htm
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Purnendra Prasad, N. and P. Raghavendra, 2012, ‘Healthcare Models in the Era of Medical Neo-
liberalism: A Study of Aarogyasri in Andhra Pradesh’, Economic and Political Weekly,
XLVII(43): 125.
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at http://www.frontlineonnet.com/fl2902/stories/20120210290203300.html
Rao, M., 2017, ‘Bihar Women who Lost Their Wombs to Needless Surgeries Suffer while
 Doctors Thrive’, Scroll.in, 15 March.
Reddy, K.S., S. Selvaraj, K.D. Rao, et al., 2011, ‘A Critical Assessment of the Existing Health
Insurance Models in India’, New Delhi: Public Health Foundation of India, p. 13, available at
http://planningcommission.nic.in/reports/sereport/ser/ser_heal1305.pdf
Sarojini, N. and V. Deepa, 2013, ‘Trials and Tribulations: An Expose of the HPV Vaccine Trials
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 II

CORRUPTION IN PRACTICE
 CHAPTER FIVE
The Role of the Medical Council of India
Sunil K. Pandya

History
Surgeon-General H.W. Stevenson opened the proceedings of the first meeting of the Bombay
Medical Council at the Secretariat, Bombay, in September 1912, with: ‘… I must congratulate
you all, both nominated and elected members, on being present here today as the first Medical
Council, not only in the Bombay Presidency but in the whole of India’1
Among the Indian (‘native’) members were Sir Bhalchandra Krishna Bhatawadekar, Dr A.G.
Veigas, Khan Bahadur Dr N.H. Choksy, Dr Rajabali Visram Patel, Dr Raghavendra Row, and Dr
Sorab K. Nariman. As the years passed, such luminaries as Sir Temulji B. Nariman, Lt Col. S.S.
Vazifdar, Dr G.V. Deshmukh, Major S.L. Bhatia, and Dr Jivraj Mehta were elected or nominated
to the council.
Dr Stevenson described the act as a charter of the true liberties of all reputable medical
practitioners, which, while protecting and fostering the legitimate liberty of the profession, also
checked professional licentiousness. The inclusion of a doctor’s name on the register guaranteed
his professional integrity.
The council was created under the Bombay Medical Act, which was passed after agitations by
native doctors in Bombay that began in 1881 for the creation of a register of medical
practitioners who had graduated from any of the Indian medical colleges and for the prevention
of quackery. The original proposal was considered by the Government of Bombay and passed on
to Calcutta for implementation all over India. The Government of India concluded that it could
not move on the matter and dropped it. It was in November 1911 that R.A. Lamb, member of the
Governor’s Council in Bombay, moved the first reading of the bill for registration of doctors. He
noted that in the Bombay Presidency medical science was in a more advanced state than in most
of the other provinces of India and that the number of qualified practitioners, which was already
very considerable, was constantly increasing. The Act sought to draw a clear line between
practitioners who were qualified after training for four years in government medical schools so
as to grant them certain privileges. Registration would protect the public at large from irregularly
trained medical practitioners. Governor Sir George Sydenham Clarke, in his remarks supporting
the bill, noted that India was possibly the only civilized country in which the medical profession
was not an organized body. He pointed out the advantages that fully qualified medical doctors
would gain, and regarded its passage as the first step towards the reorganization of the medical
service in India.2
The Medical Act of 1858 that resulted in the creation of the General Medical Council to
regulate doctors in the UK also, as its principal function, differentiated between qualified and
unqualified practitioners. While registration of doctors was voluntary under this Act, an
amendment made the same year made it compulsory.
The publication of the Act in Bombay had evoked some critical comments: ‘… it is rather too
sweeping a law to bring forward just now…. The number of qualified practitioners in India are
(sic) very few, quite inadequate to meet the demands of the countries, specially in regions away
from the town (sic)….’
Arguments were used then that are to be found in discussions even after the passage of a
hundred and more years: ‘The indigenous practitioners in India, the Kavirajes and the Hakims …
no doubt owing to their empirical methods they often do harm than good, and sometimes in a
serious manner, still their efficacy on the whole cannot under the present condition be ignored.’3
By 1918, the council was recognizing practitioners registered in other Indian provinces free of
cost, provided its own registered practitioners were recognized in those provinces.
As the council matured, it was also entrusted with the task of recognizing qualifications
awarded by universities outside the Bombay Presidency. Such recognized qualifications were
published in a schedule of the Act.
In 1937, Dr Mrs Cecilia D’Monte became the first woman member of the Bombay Medical
Council. She was nominated by government along with Major Dr S.L. Bhatia, dean of the Grant
Medical College, and Dr Phiroz Bharucha, lecturer in medicine at Seth GS Medical College.4

A Pioneering Enunciation of the Medical Code of Conduct

In 1926, the Bombay Medical Council issued its guidelines for doctors in the Presidency.5 The
document started with an emphasis on the importance of the golden rule: ‘Whatsoever ye would
that men should do to you, do ye even so to them.’
Here are some of the other injunctions in it: ‘… The duty that a medical man owes to the
profession of which he is a member is one of the highest he is called upon to fulfill as his
obligation to his country can alone be allowed to have greater claims upon him. He should
cherish a proper pride in his calling but endeavor to increase the public esteem in which it is held
by good and worthy deeds. His life should be discreet and sober, avoiding excess or
extravagance of dress and demeanour …
‘In all dealings with patients, the interest and advantage of their health alone should influence
his conduct towards them. As their trust in the profession is great, so the obligation to be true to
their interests is greater and any signal failure in this respect is wholly discreditable and
inexcusable …’
It condemned, among other practices, soliciting private practice, deriving pecuniary profit
from the sale of any secret remedy, entering into any compact with the pharmacist to receive a
share in the profits arising from the sale of medicines and prescribed medical or surgical
appliances, and publishing reports of cases or letters of thanks from patients in non-professional
newspapers or journals. It instructed the consultant to cease attending to the patient when the
consultation was concluded, unless specifically requested to do so by the medical attendant.
Measures were advocated to prevent poaching by a consultant of patients under the care of the
family physician or another consultant. ‘No member should receive commissions from trades-
people …’
A salutary practice pertaining to other physicians was recommended. ‘There is no rule that
medical practitioners should not charge one another for their services but it should be regarded as
a pleasure and privilege to give one’s services freely to a professional brother, his wife and
children or to a medical student.’
It forbade the doctor from ‘the application to patients of new methods of treatment which
have not been thoroughly tested in an experiment’.
It also laid down the text to be included on the ‘not unduly large’ doctor’s signboard.
Confidentiality, autonomy, justice, beneficence and non-maleficence, relationships with
fellow practitioners, maintaining the dignity of a noble profession, and more have all been
addressed in this epochal document without these specific terms being used.
Disciplinary action was swift. In 1928, the council erased the name of Navroji Ardeshir
Cooper, MD, for advertising his private laboratory and the services it offered on the signboard
outside his consulting room. The name of Ratilal Shivlal Shah, MB and BS, was erased for
advertising medicines concocted by him in leaflets and a Gujarati newspaper.6
In 1931, the Government of Bombay sought the opinion of the Bombay Medical Council on a
proposal of the Government of India to add a section to the Indian Medical Degrees Act,
prohibiting the adding to his name unauthorized letters or abbreviations which implied that he
was qualified to practice any system of medicine. The council accepted this proposal but
recommended the addition of penalties against bogus institutions awarding such titles or
diplomas. This addition would complete the measure aimed at eliminating unqualified and illegal
practices that could endanger the health and lives of the people.7

The General Medical Council’s Decision in 1926 and the Formation of the
All-India Medical Council
The General Medical Council in Britain recognized medical degrees awarded by Indian
universities from 1892 onwards (Sen and Das 2011).
After the First World War, the General Medical Council turned its attention to the restoration
of the normal high standards of medical training in the UK. The Government of India, in turn,
considered a similar quest in India. Both authorities came to the conclusion that medical training
in India was deficient. The specific example highlighted was the absence of practical training in
midwifery in northern India, especially in the medical colleges in Lahore and Lucknow, owing to
the purdah system. These drawbacks forced the General Medical Council to reject doctors
trained in India from registering for medical and surgical practice in Great Britain and in foreign
countries with which Britain had reciprocal agreement.8 Sir Donald Macalister, president of the
General Medical Council, informed the council that provincial governments in India refused to
agree to a scheme for an All India Medical Council. The proposal to have a commissioner of the
council inspect medical colleges in India was also rejected by the provincial governments.9
Predictably, a resolution was passed at the All-India Medical Conference in Lahore in
December 1929 to retaliate and restrict the registration of British medical qualifications in India.
Another resolution, though, made better sense. It advised the establishment of an All India
Medical Council.10 A similar demand was also made by the Bombay Medical Council on 7 April
1930.11
At the All-India Official Conference of representatives of provincial governments and
medical faculties, convened by the Government of India at Shimla in 1930, the formation of the
Indian Medical Council to control the standards of medical education was agreed upon. The
director-general of the Indian Medical Services (IMS) was to be the president of the first council.
It was decided that the governor-general would nominate three members, the governments of the
provinces that had a medical college would nominate a member, the medical faculty of each
university in India would nominate a member, and one medical graduate with not less than five
years of experience as a professor, lecturer, or reader in a medical institution was to be elected by
medical graduates from each province whose names were on the provincial medical register.12
Indian medical observers made some suggestions. Dr K. Inamulla (1930) noted that the
General Medical Council had the full power for maintaining adequate standards and
qualifications for the recognition not only of medical degrees but also diplomas and other
postgraduate qualifications. It conducted pre-medical examinations for medical and dental
students. He pointed out that licentiates formed the large majority of properly qualified medical
men in India. There were also diplomas such as the DMRE (diploma in medical radiology and
electrology) and DTM, and practitioners with these also had to be included in the register
maintained by the Indian council. Similar demands were made by Sir Nasarvanji Choksy in
Bombay and the Bombay Medical Council13 and Sir Nilratan Sircar in Calcutta.14 Dr Sircar also
spoke against ‘the very elastic power to be conferred upon the Governor-General to make the
first regulations and also possibly to appoint officers to the medical council. Last of all we can
never agree to the proposals of having a nominated president in the Medical Council. Such
provisions will inflict severe injustice on the profession …’.
Dr Inamulla suggested that the proposed Council must have absolute control over medical
education throughout India and must serve as an advisory body to the central government. Dr
M.R. Guruswamy Mudaliar, third physician, Madras General Hospital, felt that the establishment
of an All-India Medical Council would enable the General Medical Council of Britain to deal
with it on the basis of reciprocity.15
The Indian Medical Council Act (Act No. 27 of 1933) was passed in 1933. Sir Fazl-i-Hussain,
member for revenue and education, Viceroy’s Council, and Mr G.S. Bajpai, education secretary,
had piloted it through the legislative council.
The India Medical Council Act of 1956 superseded it (Act 102 of 1956).

Act No. XXVII of 193316

The Indian Medical Council Act received the governor-general’s assent on 23 September 1933
and extended to the whole of British India. The body was to be known as the Medical Council of
India (MCI).
The council consisted of the following members:

a) one member from each governor’s province nominated by the local government of the
province,
b) one member from each British Indian University elected by the members of the senate of the
university,
c) one member from each province where a provincial medical register is maintained to be
elected from amongst themselves by persons enrolled on the register, and
d) three members to be nominated by the governor-general to the council.

The president and vice-president of the Council were to be elected by the members of the
council from amongst themselves. The term of the president was five years.
Ten members of the council formed a quorum. An executive committee of seven members
was to be constituted from amongst the members. The president and vice-president were ex-
officio members of this committee. The secretary, treasurer, and other officers deemed necessary
to carry out the purposes of the Act were to be nominated by the executive council.
Medical qualifications granted by medical institutions in British India included in the First
Schedule were recognized for the purposes of this Act. The council was required to inspect
medical courses of universities not included in the First Schedule and submit its
recommendations to the governor-general for inclusion in it.
Medical qualifications granted by medical institutions outside British India and included in
the Second Schedule were recognized for the purposes of this Act. (The First and Second
schedules formed parts of the Act.)
Every medical institution in British India which granted a recognized medical qualification
was required to furnish such information as the council may, from time to time, require as to the
courses of study and examinations to be undergone in order to obtain such a qualification.
The executive committee was to appoint medical inspectors to attend any or all the
examinations held by medical institutions for the purpose of granting recognition. The inspectors
were not to interfere with the conduct of any examination, but they were to report to the
executive committee on the sufficiency of every examination attended and on any other matter
required by the executive committee.
Medical institutions found to be substandard were provided the findings of the inspectors
along with a fixed period within which the institution was to provide its explanation. The
inspectors’ findings and conclusions, together with this explanation, were to be forwarded to the
governor-general who would, if necessary, appoint a Commission of Inquiry of three persons
with powers to administer oaths, and enforce the attendance of witnesses and the production of
documents. One member of this commission would be appointed by the governor-general and
one by the council. The third was to be a high-court judge. After checking the veracity of the
matter, the commission was to recommend remedies, if any. The governor-general would, if
needed, require the council to comply with the remedies prescribed by the commission.
This Act was thus intended for the sole purpose of standardizing and recognizing
qualifications granted by universities in British India. It also laid down conditions when medical
colleges could be inspected for the purpose of studying the conditions under which they awarded
their qualifications and arbitration when inspectors of the council alleged deficiencies.
The first meeting of this council was held on 10 March 1934. Sir Fazl-i-Hussain was in the
chair. Colonel Sir Hasan Suhrawady and Dr G.V. Deshmukh (of Bombay) were proposed for the
post of vice-president, with the former being elected to it. The election committee of the council
was then appointed and consisted of Major S.L. Bhatia who was the dean of the Grant Medical
College in Bombay, Dr Vyas, Dr A.S. Erulkar, Dr B.C. Roy, and Dr T. Krishna Menon.

The Indian Medical Council Act, 195617

The Act provided for the reconstitution of the MCI and repealed Act 27 of 1933.
The council was now composed of:

a) One member from each state other than a union territory, nominated by the central
government in consultation with the concerned state government.
b) One member from each university to be elected from amongst the medical faculty of the
university by members of the senate of the university.
c) One member from each state in which a State Medical Register was maintained to be elected
from amongst themselves by persons enrolled in the register with medical qualifications
included in the First and Second schedules and Part II of the Third Schedule.
d) Seven members to be elected from amongst themselves by persons enrolled in any state
medical registers with medical qualifications included in Part I of the Third Schedule.
e) Eight members to be nominated by the central government.

The terms of the president and vice-president of the council was for a period not exceeding
five years.
Among the tasks allocated to the council now were:

a) ‘Permission for establishment of a new medical college, new course of study etc.’ This
included increase in the maximum number of students admitted to such courses or training.
The central government was exempt from this need to obtain permission.
b) Non-recognition of medical qualifications.
c) Withdrawal of recognition of medical college or institution for courses of study and
qualifications granted by them.
d) Prescription of minimum standards of medical education: undergraduate and postgraduate.
e) Prescription of standards of professional conduct and etiquette and a code of ethics for
medical practitioners and specifications of violations that would constitute infamous conduct
or professional misconduct.
f) Maintenance of the Indian Medical Register containing the names and qualifications of all
persons enrolled in any State Medical Register. The Indian Medical Register was to be revised
and published in the Gazette of India and in any other manner prescribed ‘from time to time’.
When names were removed from state medical registers for professional misconduct or on any
other grounds, these were to be removed from the Indian Medical Register as well.
g) The Commission of Inquiry now had two of three members appointed by the central
government.

This Act was last amended in August 2016.18 By this amendment, the ‘uniform entrance
examination to all medical educational institutions at the undergraduate and post-graduate level
… (shall be conducted) in Hindi, English and such other languages … as may be prescribed …’.

The Medical Council of India Compared to the General Medical Council,

UK19
It is relevant to make this comparison as our council is based on that in the UK.
The General Medical Council, UK is an independent organization with two principal goals:
protection of patients and improvement of medical education and practice. In order to attain these
goals, the council sets standards for doctors, oversees their education and training, maintains a
national medical register, investigates and acts on concerns about doctors and helps raise
standards through revalidation.
 The council has a chief executive and registrar. At the helm of the council is the chairperson.
He or she provides leadership, presides over meetings, and ensures efficient and effective
functioning. He also interacts with ministers, leaders of the medical profession, patient groups,
and acts as the ambassador for the council. The senior management team consists of five
members, two of whom are women.
The council has four core values: excellence, fairness, transparency, and collaboration. ‘These
values form the basis on which our organisation operates’.
Standards are developed after consultations with a wide range of people—patients, doctors,
employers, and educators. These standards are then set out in notes entitled Good Medical
Practice.
The General Medical Council, UK provides detailed guidance on ethical principles that
govern medical practice. It also develops case scenarios and tools to help doctors apply the
principles in day-to-day practice.
Periodic monitoring and inspections of medical colleges include discussions with medical
students. Postgraduate medical training, training posts, programmes, and assessments are also
monitored, supervised, and approved by the Council, which develops learning resources as well.
It also offers advice on continuing professional development.
Maintenance of the UK Medical Register involves checking every doctor’s identity and
qualification before they are enrolled in it. The council investigates any concerns by the doctor’s
medical school, employer, or patients. Where needed, evidence is collected and assessed and
may be followed by warnings or restriction of practice or placing the doctor under supervision.
In serious cases the doctor may be removed from the medical register.
A doctor’s registration status is in the public domain and can be checked online on the list of
registered medical practitioners. Doctors’ records are constantly updated to ensure that the
register is accurate.
The Medical Practitioners Tribunal Service investigates complaints and concerns. A full list
of recent decisions can be obtained from its website.20
Every five years, formal confirmation is sought to confirm that each doctor follows standards
laid down in Good Medical Practice.
Here is a partial list of the publications offered by the General Medical Council:

Duties of a doctor
Good medical practice
Good medical practice in action
Good practice in research
Consent: patients and doctors making decisions together
Confidentiality
0–18 years: guidance for all doctors
Protecting children and young people: the responsibilities of all doctors
Maintaining a professional boundary between you and your patient
Leadership and management for all doctors
Raising and acting on concerns about patient safety
Personal beliefs and medical practice
Openness and honesty when things go wrong
Advice to patient seeking guidance about assistance to die

All of them can be downloaded as pdf files from the Council’s website.
Contrast this with what obtains with the Medical Council of India.21
The council consists of 28 members nominated by state governments, several being from the
private sector. The professional address of one starts ‘Shop. No. 125, Third floor, Dawabazar’.
Fifty-three members have been nominated by universities, some being permitted to nominate
three individuals. Seventeen members have been elected by registered medical graduates, six of
these being from the private sector. Eight members are nominated by the central government,
two of them being in the private sector and four having retired from their teaching posts. The
council thus consists of over 110 members!
On the MCI website, under the ‘About MCI’ section, we learn that it is active in maintaining
standards of medical education, starting new medical colleges, determining ‘Indian
Qualifications & Foreign Qualifications’, maintaining the Indian Medical Register, registering
additional qualifications, and developing faculties. Clicking on the individual panels, however,
does not permit us to learn details on any of these activities.
Individuals with plenty of time on their hands would have to go through the minutes of
meetings to glean information on these various topics. Since some of these minutes cover over
100–200 pages and topics discussed are not grouped, the task could be formidable.
Under the section entitled ‘Rules and Regulations’, we are provided details on the following:

Indian Medical Council Rules, 1957

Medical Council of India Standing Orders
Post Graduate Committee Rules, 1961
Students Admitted in Excess Regulations, 1997
Graduate Medical Education Regulations, 1997
The MCI (Conduct of Election) Regulations, 1998
Teachers Eligibility Qualifications, 1998
Establishment of Medical College Regulations, 1999
MCI Regulations, 2000
Opening of a New or Higher Course of Study, 2000
P.G. Medical Education Regulations, 2000
Screening Test Regulations, 2002
Eligibility Certificate Regulations, 2002
Code of Medical Ethics Regulations, 2002
Election of Students Union Regulations, 2009
Prevention of Ragging Regulation, 2009

No rules or regulations appear to have been formulated since 2009.

The Indian Medical Registry section states that it publishes on its website registered doctors
with the various state medical councils across India up to 2015, except for states such as
Haryana, Bihar, Andhra Pradesh, Sikkim, Telangana, Uttar Pradesh, Uttarakhand, Tripura, and
Manipur, where the registry is incomplete. The comments of the parliamentary committee,
referred to below, on the status of the register are revealing.
 We are invited to search the database for a particular registered doctor. I searched for my own
name and failed to find it either on the national registry or that of the Maharashtra Medical
Council as accessed through the MCI website. Since my name does not appear on the list of 112
presently blacklisted doctors by the MCI either, I resemble a stateless citizen. Incidentally,
several names amongst these 112 doctors have, in the ‘Restored Date’ column, the statement,
‘Not disposed of’. There is no further or detailed explanation of this term.
Entries under ‘Media Room / News and Events’ tell us that the last meeting of the executive
committee and of the general body were held on 30 March 2016. The minutes of these meetings
can be accessed under the head ‘Meetings’. The minutes of the executive committee are spread
over 102 pages while those of the general body cover 266 pages. The great majority of topics
concern recognition of qualifications offered by universities against increased intake of students.
It is of interest that on page 10 of the minutes of the meeting of the general body is the
statement: ‘The Council Members condemned the report of Parliamentary Standing Committee
and resolved that an appropriate reply be given at the earliest by the office. It was informed by
the members that IMA is also ready to support the Medical Council of India. It was also
proposed to either hire a PR agency for MCI or create a PR Cell in the Council Office so that
activities/achievements of MCI could be publicized’. I am especially puzzled by the fact that the
Medical Council of India sought refuge in the approval of the Indian Medical Association—an
agency that is under its supervision. The need to ‘hire a PR agency … or create a PR Cell in the
Council Office’ speaks volumes of the efficiency of the Council. Surely, its work should speak
for itself.
I studied the annual report for the year 2014–15 to learn about the functioning of the ethics
committee of the Council.

Ethics Committee:
The present day scenario has changed and as a result of the Consumer Protection Act made
applicable to the practicing physicians, complaints against doctors have increased manifold.

I remain puzzled as to how complaints disposed of could be listed under complaints received.
 The major activity of the council appears to have been inspection of medical colleges, the
revenue from this being Rs 669,608,000.
I cannot find any reference to publications of the kind brought out by the General Medical
Council.

Inefficiency and Corruption in the Medical Council of India

The reputation of the MCI has suffered greatly since Dr Ketan Desai was appointed president in
1996. Dr Desai, incidentally, has had a meteoric rise.
He was born on 29 June 1957. Graduating from BJ Medical College in Ahmedabad in 1983,
he became the head of the department of urology in the same year. He later became a syndicate
and senate member of the Gujarat University, almost always uncontested. He became president
of the Gujarat Medical Council in the 1993 and has also served as president of the Indian
Medical Association and Dental Council of India. He was recently appointed president of World
Medical Association.
In 2009, a review of the functioning of the MCI and the role of Dr Desai was published in the
Indian Journal of Medical Ethics (Pandya 2009). The gist of the essay was summed up in one
line: ‘It (MCI) is plagued by inefficiency, arbitrariness and lack of transparency.’22
The following year, Dr Sanjay Nagral, in an editorial in the same journal, highlighted the
consequences if the MCI continued to tread down the same path—perdition (Nagral 2010). In a
telling sentence, he emphasized why Dr Ketan Desai remained unchecked. ‘Individuals like
Desai can survive and thrive only due to the permissiveness and complicity on the part of their
constituency, subordinates and peers.’ Left unsaid was the role played by the Government of
India and its ministry of health and family welfare in supporting and sustaining Dr Desai.23
The most damning indictment came in 2016 from the parliamentary standing committee of
health and family welfare.24
Numerous deficiencies were highlighted and condemned. Here are some excerpts from the
report:

• ‘the Indian Medical Register is not a live database and contains names of doctors who may
have passed away or retired from active practice, by now, as well as those with a permanent
address outside India and that there is no mechanism in place for filtering out such cases…
the MCI has been unresponsive to health system needs (of the country)…’ (1: p. 85)
• ‘…The Medical Council of India, when tested on the above touchstone, has repeatedly been
found short of fulfilling its mandated responsibilities…the MCI, as presently elected, neither
represents professional excellence nor its ethos. The current composition of the Council
reflects that more than half of the members are either from corporate hospitals or in private
practice. The Committee is surprised to note that even doctors nominated under Sections 3(1)
(a) and 3(1) (e) to represent the State Governments and the Central Government have been
nominated from corporate private hospitals which are not only highly commercialised and
provide care at exorbitant cost but have also been found to be violating value frameworks…
the current composition of the MCI is biased against larger public health goals and public
interest…’ (1: 87–88)
• ‘The Committee observes that the oversight of professional conduct is the most important
function of the MCI. However, the MCI has been completely passive on the ethics dimension
which is evident from the fact that between 1963–2009, just 109 doctors have been blacklisted
 by the Ethics Committee of the MCI…’ (1: p. 102)
• ‘The Committee is shocked to find that compromised individuals have been able to make it to
the MCI, but the Ministry is not empowered to remove or sanction a Member of the Council
even if he has been proved corrupt…. Such state of affairs are also symptomatic of the rot
within and point to a deep systemic malice. Otherwise how could it happen that the MCI,
which has laid down elaborate duties and responsibilities of the ‘Physician’ under the MCI
Code of Ethics Regulations, 2002, could have at its very top a person who was arrested on
charges of corruption in 2010. The former Union Health Minister, who must have an insider’s
view of the functioning of the MCI, making scathing comments about corruption in the MCI,
speaks volumes of the decay in the MCI and is an eye-opener on the need for urgent reforms
in the structure and functioning of MCI…’ (1: p. 76)25

The analysis concluded that optimism may not be justified despite the clear statement of facts
in the parliamentary report and strong recommendations. ‘Recommendations of earlier
committees, when found unpalatable by the government or when conflicting with vested interests
of those in power have been rendered ineffective by the simple measures of either shelving them
or, worse, referring them to yet another committee for study and recommendations. A
government that could transfer Mr. Keshav Desiraju in order to facilitate Dr Ketan Desai’s entry
into the MCI through the backdoor of a recommendation by a pliant university in Ahmedabad
and which could accept the replacement of Dr Ketan Desai by someone else from the same state
does not generate confidence.’26

The Tragedy
The central government is loathe to transform the MCI into a strong, lean, and independent
entity, entirely staffed by persons of unchallenged integrity and with no allegiance to any
political power.
We appear to be incapable of learning from institutions that are performing duties similar to
those entrusted to MCI honestly, openly and efficiently. I have referred to but one such example
above—UK’s General Medical Council.
The medical profession at large appears to show no interest in the functioning of the MCI and
indictments such as that handed out by the parliamentary committee this year. Instead, we have
the president of the IMA hailing Dr Ketan Desai as a mentor to whom even the stalwarts of the
medical profession turn for advice.
The council, as composed at present, has on board individuals who have retired from
academic appointments. Few of the others have any national or international standing. The
names of medical professionals of acknowledged merit in our public sector medical colleges and
institutes such as the Christian Medical College and Hospital, Vellore, and St John’s Institute of
Medicine, Bengaluru are conspicuous by their absence. Merit appears to be a disqualification for
membership of the council.

References
Inamulla, K., 1930, All India Medical Council, ‘Letter to the Editor’, The Times of India.
Nagral, Sanjay, 2010, ‘Ketan Desai and the Medical Council of India: The Road to Perdition’,
Indian Journal of Medical Ethics, 7: 134–35.
Pandya, Sunil K., 2009, ‘Medical Council of India: The Rot Within’, Indian Journal of Medical
Ethics, 6: 1125–31.
———, 2016, ‘The Functioning of the Medical Council of India Analysed by the Parliamentary
Standing Committee of Health and Family Welfare’, Indian Journal of Medical Ethics, 1:68–
71.
Sen, Samita and Anirban Das, 2011, ‘A History of the Calcutta Medical College and Hospital,
1835–1936’, in D.P. Chattopathyaya (ed.), 2011, History of Science, Philosophy and Culture
in Indian Civilisation, Vol. XV, Part 4, Delhi: Pearson Education, pp. 477–522.
 CHAPTER SIX
Malpractice in Medical Education
Avinash Supe and Soumendra Sahoo

The indisputable mission of medical education is a commitment to provide a health service and
engage in high quality scientific research. Earlier, it was believed that the primary role of an
educational institution was only to impart medical knowledge and skills, but the 1910 Flexner
Report led the world to recognize that medical colleges need to impart training to their graduates
in such a way that they not only acquire the required skills but also an ethical approach to the
practice (Flexner 1910). Medical education has since then been carefully designed to inculcate
professional skills and ethical values among those who enter colleges as students and leave as
graduates. It is also important to align the goals of medical education with those of the healthcare
delivery system. Quality medical education is ultimately reflected in a graduate’s performance in
clinical practice. It is therefore, imperative that every medical school regularly assesses the
quality of its education and makes continuous efforts to bring in reforms (Bland et al. 2000).
For much of the last century, medical colleges in India lived up to their expected role.
Medical education and medical practice were both value-based. However, over the years we have
seen a deterioration in ethical values in both areas. Studies done so far have found that during the
past two decades there has been a rapid growth in litigation involving medical education
institutions (Helms and Helms 1991). The main cause of this erosion of values is the subversion
of medical education’s role as one of social responsibility due to corruption. This is manifested
in many ways, including the licensing and re-licensing of medical colleges that are ill-equipped
to impart quality education and the outrageously exorbitant capitation fees collected for the
admission of students to private medical colleges due to the influence of non-academic
considerations on examination results at various stages of a student’s evaluation.
India has seen a sudden increase in medical schools over the last decade. The number has
risen from 256 in 2006 to 479 in 2017. Of these, 259 are privately owned and managed (Medical
Council of India 2017). A hundred and five new colleges have been established since 2010.
Medical education is now seen as a lucrative business linked to large profits. It has drifted away
from its social mission. Powerful political and business interests are running private universities.
Their trusts have established new colleges that have permission to charge huge fees from
aspiring students. Regulatory bodies have turned a blind eye to the deficiencies and subversions
of the minimum standards laid down in several such institutions, passively caving in or actively
succumbing to pecuniary temptations.

Relating Medical Malpractice to the Quality of Healthcare

In the recent past, corruption in the healthcare sector has raised serious concerns and has
received global attention among researchers and policy-makers (Flexner 1910; Bland et al. 2000;
Helms and Helms 1991; Vian 2008). In October 2003, the UN General Assembly adopted the
United Nations Convention Against Corruption, which came into force in 2005. Other UN
agencies have also undertaken anti-corruption measures in health. For example, the Good
Governance for Medicines programme was launched as part of the World Health Organisation
Medicines Strategy, 2004–07. It incorporated corruption as a priority issue. Further, having
recognized the relationship between child mortality and corruption, the United Nations
Children’s Fund linked its promotion of child rights to good governance (Vian 2008; Schönhöfer
2004; Transparency International 2006; Lancet Editorial 2006; UNDP 2011).

Connecting Medical Education to Malpractice

Academic medicine is a synthesis of three interrelated activities, namely medical education,
research, and patient care. Medical schools and their faculties are directly involved in clinical
practice, medical education, and research. To an extent, this synergy is unparalleled in other
professions. The complex interdependence of medical education, research, and patient-care
activities is one of the hallmarks of academic medicine. It is the primary site of vulnerability to
federally mandated reform of healthcare delivery services.

Malpractice at Various Stages of Medical Education

Admission
As a nation, India has the largest number of medical colleges in the world but because it also has
the second-largest population, its doctor-to-population ratio is very low. There are many students
aspiring to become doctors, as shown by the fact that around 118,000 MBBS students appeared
for the postgraduate National Eligibility cum Entrance Test (NEET) in 2016 against the around
34,000 seats available for specialization. This clearly paves the way for malpractice in
postgraduate admission.
The new law, which was drafted in the 1990s, left scope for converting medical education into
a business. There has been a mushrooming of private schools, most of which are funded by
businessmen and politicians with no previous experience of running medical schools. While the
number of government institutions has doubled since the 1980s, the number of private medical
colleges has increased 20 times. This surge has led to the admission of below-average students to
many private medical colleges just by virtue of their parents/sponsors having the capacity to pay
the exorbitant fees charged. The many private medical schools, in addition to the huge fees,
frequently charge ‘under-the-table’ money for admissions. These illegal fees range from Rs 25
lakh to one crore. Although the NEET-PG has increased the official fees instead of continuing
illegal capitation fees, many super-speciality seats have remained vacant.
The cost of a postgraduate seat in radiology in private institutions may easily reach six crore
rupees; this might increase even further at higher-ranking colleges that provide better facilities.
For a middle-class student, it means the family having to mortgage their homes in order to fulfil
their child’s ambition. The outcome is that earning money has become the major priority of a
student graduating from medical college. When such students go into private practice, they are
tempted to over-investigate and over-treat their patients in order to earn back the money they
spent in getting their medical degrees.
 The unmasking of a decade-old admission scam in Madhya Pradesh in 2009 revealed the ugly
face of rampant and systematically organized corruption in examinations conducted for selection
to pre-medical and postgraduate medical courses in the Madhya Pradesh Professional
Examination Board (MPPEB), better known by its Hindi acronym, Vyapam (Vian 2008).
Investigations since 2013 revealed the involvement of several politicians, bureaucrats, MPPEB
officials, racketeers, agents, candidates, and parents and led to the arrest of more than 2,000
persons till 2015.
The NEET had controlled the situation by insisting on admissions only on merit. This exam
has a good structure but there have been reports of question paper leaks through IT frameworks
that have exposed the integrity of the system. Integrating NEET with transparency and honesty
would resolve many issues related to admissions. The National Medical Commission Bill 2017
was introduced in the Lok Sabha in December last year, and is aimed at bringing reforms in the
medical education sector which has been under scrutiny for corruption and unethical practices.

Teaching Methodologies
The current system of evaluating doctors that is followed in India allows anyone who is able to
memorize a large amount of information to become one. The fundamental examination pattern
has remained the same—relying on rote learning techniques, while the humanitarian dimension
is not taken into account. Would-be doctors are evaluated according to the answers they give in
multiple-choice questions (MCQs). These questions test the memorization of facts and steps
rather than actually putting skills into practice. India doesn’t follow the use of objective
structured clinical exams (OSCEs) to assess medical candidates. Due to the MCQ-based entrance
examinations, teaching in colleges is often substandard and there is a major emphasis on rote
learning geared towards passing these tests. Furthermore, there has been no attention paid
towards developing the humanitarian and professional values of students. This is the result of an
assessment system which relies heavily on MCQ-based rote learning and has resulted in the
mushrooming of coaching classes for competitive examinations, some of them being run by
members of the medical college faculty themselves. This compromises teaching in the college,
drawing students away from patients and wards, which are the true heart of medical practice.
Students pay large sums to these teachers who are also their examiners. Improving NEET
questions and including a major clinical context will encourage students to go back to the wards.

Assessment
With such large numbers of students appearing for examinations, there is a parallel requirement
for a greater number of examiners, of whom there is a perpetual shortage. Hence, the integrity of
a person is ignored while appointing him or her as an examiner. In a system where a small set of
external and internal examiners subjectively decides whether a candidate should pass or fail,
without the application of objectively laid out criteria, there is bound to be considerable scope for
arbitrariness. While results may sometimes be unfair due to the idiosyncrasies or biases of
examiners, financial corruption may also influence the outcome. Payments made to secure a
favourable result constitute an overt form of corruption, while non-financial considerations that
introduce bias (such as religion, caste, region, language, gender, political, or social pressure) also
corrupt the objective of the examination system. While no systematic evidence exists on record
to document such cases, anecdotal narrations of examiners’ misconduct are not uncommon in
private conversations scattered across the medical colleges. While the majority of the examiners
are usually honest, some scattered instances of betrayed trust makes us lose faith in a system
which is expected have a fair process of evaluation.
Government-run colleges are not spared from corruption in the conduct of examinations.
Pecuniary benefits and financial transactions can play a role in rendering the examination process
unfair. Vulnerability and yielding to political pressure is especially great in these settings, as
faculty can be transferred from one college to another at the whim of a powerful politician and
promotions can be stalled. Fake degrees and certificates can be easily procured. The Indian
Medical Association (IMA) estimates that 45 per cent of Indian medical practitioners, about
7,00,000 doctors, are unqualified and lacking in formal training (Chakrabarty 2016).

Accreditation
Several concerns have been periodically raised regarding corruption corroding the process of
granting permission to new medical colleges for registration and operation to begin with, and
then, in assessing the continued competence of recognized colleges through regular reviewing.
These doubts are not only raised privately, but also voiced among laypersons and medical
professionals alike. However, they have been fuelled by publicly reported prosecutions by
criminal investigation agencies and caustic judicial observations.
A report published in July 2016 (Chakrabarty 2016) stated the following:

• According to government records and court filings, it was found that one out every six
medical colleges in India has cheating records against them.
• The study found that in order to pass inspections, medical colleges use doctors, provided by
recruiting companies, from other institutes, who stand in as faculty in return for a fee.
• The study also found that healthy people are rounded up to pretend to be sick during
inspections, so that teaching hospitals can show they have enough patients to provide clinical
experience to medical students. Books and patients are available on rent for this temporary
purpose.
• The Medical Council of India (MCI), which is supposed to maintain ‘excellence in medical
education’, is itself surrounded by controversy as its ex-president faces bribery allegations.
There are numerous other lawsuits that the MCI faces and these cases carry on for years.
• The MCI regulations have certain loopholes which ensure that even colleges that lack proper
facilities or infrastructure get accreditation.

It is difficult to prove the important role that money and bribes play in getting permission to
start and renew the licence of a medical college, but this is generally considered to be widely
prevalent the private sector. However, the falsification and manipulation of faculty strength and
patient admission numbers to fool complacent or complicit inspectors who visit medical colleges
has been widely reported. False and manipulated faculty rosters, with non-existent persons listed
to meet the regulatory requirements, are commonly narrated. There are some individuals listed
on a full-time faculty list in several institutions at the same time. The MCI has debarred such
individuals when they are detected (India Medical Times 2015). Part-time faculty members are
shown as full-time teachers whereas their salary slips indicate only limited engagement.
In March 2016, the parliamentary standing committee on health and family welfare submitted
its report evaluating the performance of the MCI and recommended reforms in the regulation of
medical education. The concluding chapter opens thus: ‘The Committee observes that the
Medical Council of India as the regulator of India in the country has repeatedly failed on all its
mandates over the years’. Among the several shortcomings listed are ‘Failure to create a
transparent system of medical college inspections and grant of recognition or de-recognition’,
and ‘Failure to put in place a robust quality assurance mechanism’ (Suvarna 2016). The National
Medical Commission Bill, 2017, seeks to replace the existing MCI with a new body to ensure
transparency (Press Trust of India 2017).

The Way Forward

Though the decline of ethical standards in medical education has caused dismay and despair,
there are few recent developments which offer a ray of hope. There are some new beginnings
that can redress the current ills of medical education in this country. The Supreme Court of India
stepped in when public confidence in the MCI was low, following the charge of corruption
levelled by the Central Bureau of Investigation (CBI) against a serving president. Several of the
council’s powers were transferred to a government appointed ad-hoc committee of experts.
Later, it was handed over to an oversight committee appointed by the court. Beyond these
temporary measures, the Government of India has proposed the creation of a National Medical
Commission (NMC), which will carry out the regulatory functions of the MCI. The transfer of
power to the new statutory body still awaits parliamentary approval. The National Board of
Examinations (NBE) has been a welcome contrast in upholding the standards of integrity in the
governance of medical education (Transparency International 2006). This autonomous body was
initially established to affiliate and regulate postgraduate medical education programmes run by
hospitals not affiliated to medical colleges. The National Board network will take over the
postgraduate board of the proposed NMC. An MAR (Medical Assessment and Rating) board will
grant permission for the establishment of a new medical institution, carry out inspections of
institutions for the purpose of assessments and ratings, and hire and authorize any third-party
agency or persons to do these inspections. The MAR board can also levy monetary penalties
(first time, second time, and third time in ascending order) against a medical institution for
failure to maintain the minimum essential standards specified by the UGME or the PGME
boards. If the NMC becomes well established, this could herald transparency in medical
education in India. However, there are some concerns raised about the NMC bill, such as an
apprehension that bureaucrats may take over medical education. The bill also proposes to frame
guidelines for the determination of fees for 40 per cent of seats in the private medical institutions
and deemed universities. This too may be a concern.
***
India is looking forward to a strong and credible NMC to rescue medical education from the
morass resulting from the failed self-regulation by the MCI. Public confidence in the integrity of
the medical education at each stage—from determining the credentials of medical colleges to the
certification of rightfully selected and well-trained graduates—must be restored. The Indian
medical-education ship must return to the moral moorings of its mission through the collective
effort of all stakeholders as well as the rest of the community.

References
Bland, Carole J., S. Starnaman, L. Wersal, et al., 2000, ‘Curricular Change in Medical Schools:
 How to Succeed’, Academic Medicine, 75: 575–93.
Chakrabarty, Roshni, 2016, ‘Problems Plaguing Medical Education: Why India Suffers a Severe
Lack of Quality Doctors’, India Today, 6 July, https://www.indiatoday.in/education-
today/featurephilia/story/medical-education-problems-327613-2016-07-06
Flexner, A., 1910, Medical Education in the United States and Canada, Washington, DC:
Science and Health Publications, Inc.
Helms, Lelia B. and Charles M. Helms, 1991, ‘Forty Years of Litigation Involving Medical
Students and Their Education’, Part I, General Educational Issues, Academic Medicine, 66(1).
India Medical Times, 2015, http://www.indiamedicaltimes.com/2015/03/26/mci-debars-seven-
ghost-medical-teachers-from-teaching-for-five-years/, accessed on 19 December 2017.
Lancet Editorial, 2006, ‘Corruption in Health Care Costs Lives’, Lancet, 367(9509): 447.
Medical Council of India, 2017, List of Colleges Teaching MBBS,
https://www.mciindia.org/ActivitiWebClient/informationdesk/listofCollegesTeachingMBBS,
accessed on 4 February 2018.
Press Trust of India, 2017, ‘Cabinet Approves National Medical Commission Bill; Common
Entrance, Licentiate Exit Exam Proposed’, 16 December 2017,
https://www.ndtv.com/education/government-approves-national-medical-commission-bill-
2017-1788594
Schönhöfer, P.S., 2004, ‘Controlling Corruption in Order to Improve Global Health’,
International Journal of Risk and Safety in Medicine, 16(3):195–205.
Suvarna, Dipesh, 2016, Standing Committee Report Summary: The Functioning of Medical
Council of India, PRS Legislative Research, http://www.prsindia.org/parliamenttrack/report-
summaries/functioning-of-medical-council-of-india--4234/
Transparency International, 2006, ‘Global Corruption Report. London: Pluto Press.
United Nations Development Programme, 2011, ‘Fighting Corruption in the Health Sector—
Methods, Tools and Good Practices’, New York: United Nations Development Programme;
31 October, http://www.undp.org/content/undp/en/home/librarypage/democratic-
governance/anti-corruption/fighting_corruptioninthehealthsector/, accessed on 19 December
2017.
Vian, T., 2008, ‘Review of Corruption in the Health Sector: Theory, Methods and Interventions’,
Health Policy Plan, 23(2): 83–94.
 CHAPTER SEVEN
Corruption in Everyday Medical Practice
M.K. Mani

It has been my good fortune to have lived through the last eight decades of Indian history, and to
have been in the medical profession for the last six. It has been my misfortune to have lived these
years and been a physician. Good fortune, because I experienced the exhilaration of
independence, and the heady enthusiasm of those days when we set out to build a new India.
Misfortune, because I lived to see that spirit evaporate and descend into sordid opportunism.
Good fortune, because when I first began practising medicine, all I could hope for was to ‘cure
sometimes, to relieve often, and to comfort always’, but as the years went by, I was a part of the
revolution which enabled us to make an accurate diagnosis of most diseases, to cure several
more, and to relieve the great majority. Also, every year has always brought new knowledge and
new hope. Misfortune, because my profession has sunk from the heights where the aim of most
doctors was to fight disease and end suffering, to tremendous lows where most of us want, above
all, to enrich ourselves.
I cannot claim that the medical profession was as white as snow when I was a junior doctor.
Even in those times, there were surgeons in government hospitals who would not operate on
patients in the free wards unless they were ‘consulted’ in their private rooms and paid a fee.
There were physicians and surgeons who engaged touts to patrol railway stations and bus stands
to divert patients to their clinics and nursing homes, and who paid ‘commissions’ to the general
practitioners who sent patients to them. However, they were a small minority, and such activities
were carried out in a clandestine manner and condemned by the majority of doctors. Today, that
deplorable exception has become the rule. We advertise ourselves, we employ touts to bring
patients to us, we pay commissions to the doctors who send patients to us, we perform
unnecessary and expensive tests and accept or even demand cutbacks from the diagnostic
laboratories, we prescribe the most expensive of drugs and are rewarded for this by the
pharmaceutical industry, and we even abet our patients’ efforts to defraud insurance companies.
What will we not stoop to?
In the early years after Independence, medicine was regarded as a good profession. Doctors
were respected and well paid. The work was interesting. Every patient presented an intellectual
challenge, and the practice of medicine was never dull. This was enough inducement for most of
us, as well as for our parents. I have not met anyone whose sole desire was to relieve human
suffering. However, once we enter the profession and become aware of the extent of human
misery caused by disease, we cannot but be touched by compassion. How have we been able to
suppress this elementary response and become machines to exploit suffering humanity? How do
we bring ourselves to add to their agony by performing unnecessary operations or other
procedures? How do we complacently reduce families to penury? There must be some
circumstances that have driven us so low as to forget our essential human nature.

Excuses, But Not Valid Ones

Reservations and quotas for medical admissions have been in place in Chennai (then known as
Madras) since 1921, and were certainly in existence in 1953, when I entered Madras Medical
College. However, the percentage of reserved seats was small, and admission, by and large,
depended on the marks we secured in the science subjects in the Intermediate Examination in
Arts and Sciences out of the maximum possible of 450, with another 50 marks to be gained in
the interview. Good students were assured of getting admission, and were reasonably sure of
entering government service once they qualified. Selection for postgraduate courses was also
largely based on merit, with some weightage given for years of public service. Postgraduate
qualifications added the prestige of teaching for those so inclined. Our college fees were heavily
subsidised by the government. I spent just Rs 280 per year for my medical education. In service,
the salary was poor, but private practice was permitted and we made a comfortable income. In
those days of import restrictions and limited availability of desirable objects to spend our money
on—we had a choice of just three indigenously produced cars—our main aim was to own a
house. Most of our national leaders led exemplary lives. They had sacrificed much in the
freedom struggle, and were not focused on increasing their personal wealth. The example before
us was to work hard for the country, and not work for, or expect, great riches.
Reservation for admission has expanded phenomenally, and now, with 69 per cent of seats
reserved for various communities in Tamil Nadu, and another 15 per cent for an all-India quota,
only 16 per cent of seats are available for Tamilians in open competition. In one recent year for
which the Directorate of Medical Education released the statistics, there were 18 applicants for
each of the 1,635 seats available in government medical colleges, of which just 262 unreserved
seats were available via open competition to the students of the state. Many people therefore seek
admission at capitation fee-charging medical colleges, and the proliferation of such institutes has
made medical education expensive. The courts have banned capitation fees and have limited the
amount that can be charged, but if you win the confidence of any student who has obtained
admission to one of these courses, he will tell you that he spent lakhs or even crores of rupees. In
a case now being heard by the Madras High Court, a complainant said he had paid Rs 53 lakh for
an MBBS seat. A further 120 complaints were lodged with the police totalling Rs 84.59 crore, an
average of Rs 7 lakh a seat. This will almost certainly be black money, illegally concealed from
the tax authorities, so entry to the college itself starts with corruption. These people will
obviously regard this as an investment and expect a return, so the pressure on the young doctor is
to make money and he enters professional life with that aim.
If one can pay for a medical seat, one can also pay to obtain a medical degree. While we have
many stories about examiners who will pass students for a consideration, not many instances
come out in the open and can be cited as proven. However, one case came before the Lokayukta
of Karnataka in 2003 and an examiner was proved to have taken money from candidates to give
them high marks in an examination. The Lokayukta made the examiner return the money to the
students and reverse the marks awarded, and on his instructions, the university debarred the
examiner. However, the Lokayukta failed in his duty, because he did not penalize the students
who had paid the bribe.
Along with rising expenses in the quest for a medical degree, we have seen a decline in
ethical standards and rising corruption in Indian society. In 1951, an Indian Civil Services (ICS)
officer, Mr S.A. Venkataraman, was imprisoned for two years for accepting financial
consideration in the form of very expensive presents at his daughter’s wedding. This form of
corruption would hardly be noticed in today’s India. Our leaders enrich themselves
indiscriminately. Our politicians declare their assets every time they stand for elections and these
declarations seem to become larger and larger with each successive election. The income tax
department seems to show no interest in finding the source of their funds and in recovering the
taxes due (Sainath 2009). We have also metamorphosed into a consumer society. The best of
luxuries available anywhere in the world can be had in our markets, and the temptation is to earn
enough to afford all of them. These status symbols also bring social prestige. The doctor who is
driven in a Mercedes counts for more than he who drives a Santro. When all of society is steeped
in corruption, how can the medical profession alone rise above it?

Advertising in Medicine
Now that money has become the major aim of the average doctor, the next consideration is the
means of making it. Advertising has become commonplace, with commercial advertisements
frequently being seen (Mani 1995). In addition, any doctor who has done something out of the
ordinary rushes to the lay press to publicize it. One would laud him for bringing his feats out in a
peer-reviewed publication, but it is easier and quicker to impress a news reporter and through
him, the general public, who may not be sagacious enough to question what percentage of these
procedures were successful, and what percentage left the patient worse off than he had been.
It is legitimate to educate medical professionals by giving lectures to medical associations,
and I have often found an increase in referrals from an area after I have spoken to the local
branch of a medical association. It is also regarded as our duty to educate the public, especially
when we teach them how to prevent disease or detect it early, and when we inform them of the
options available. Obviously, this process should not include an invitation to come to the
speaker’s clinic, or give the impression that only he can provide the remedy or can do a better
job than his fellow doctors. This line is often crossed with impunity.
Theoretically, we are prohibited from advertising in the press. It has generally been accepted
that in a newspaper, a doctor can publish a notice about his availability at a certain location in
case a consultation is needed. He can keep his patients informed if he will be away for any length
of time, and he can certainly make an announcement when he returns. However, this permission
has often been stretched to give details of training received or conferences attended. The
legitimacy of this is dubious, but it does not depart too much from what is permitted.
However, it has also become common to make absolutely commercial advertisements. To cite
one of many examples, The Indian Express of 23 August 1994, had a ‘marketing feature’ entitled
‘Nutrition, Medical & Health Care.’ This 32-page booklet carried advertisements from hospitals
mentioning the wonderful work being done by their consultants, often naming them. I quote a
few examples from this document:
Under his own name, Dr G, Director, H Hospital, says, ‘By the expert diagnosise (sic) Dr G
gained the confidence of people of Madras, this is being proved by the crowd we have seen, and
such mammoth building in very short space of time and his 24 hours attention to the patients’.
(Reproduced verbatim, spelling, punctuation, and all except the names.)
Hospital I states that ‘the gastroenterology department under the care of Dr J has become so
popular that patients from North get admitted to I for his personal care’.
 Hospital K states that ‘Newer diseases are also growing at a rapid speed. To face the
challenge a great urge for technical expertise is growing in the annals of the medical profession.
Dr K through his several orientations at various levels around the world has proved on more than
one occasion that many such challenges can be faced/overcome through advanced and improved
technology’.
Surely this pamphlet should have drawn immediate action from the Medical Council of India,
but nothing happened, and such advertising remains common.

Corruption in Government Hospitals

The daughter of a domestic servant delivered her first baby in 1997 in one of the government
hospitals in the city. I was displeased when she went to a mission hospital for her second baby,
and paid a package fee of Rs 1,000. It was only then that she explained that the free delivery in
the government hospital cost her far more than that amount, as she had to pay one or other of the
staff for every little service: to stay on a bed instead of a mat on the floor, for the use of a
bedpan, for help with nursing her baby, and so on. It is also true that some doctors have to be
paid at home for major procedures to be performed in hospital, though I am sure this is a very
small proportion of the entire staff. It is also common knowledge that doctors who place orders
for expensive equipment are often rewarded by the manufacturers and dealers. This raises the
cost, and eats into the Government’s health budget. In a private hospital, the extra costs would be
recovered from patients.

Inducements Given and Received

Many consultants now offer inducements to practitioners who send them patients, cutbacks, or
commissions. Hospitals have institutionalized this practice by giving back to the referring doctor
a proportion of the money spent in the hospital by the patients he has sent to them. Diagnostic
laboratories also reward doctors who send patients to them for tests. In 1995, I made a complaint
to the Medical Council of India (MCI) about a lithotripsy centre that sent me cutbacks for
sending them patients. Though I sent copies of all the correspondence and of the cheques to the
MCI, and though I wrote personally to the president of the council, no action was taken (Mani
1996).
The availability of extremely expensive diagnostic tests like CT scans and MRIs, and
therapeutic options like lithotripsy, has led to a proliferation of high-cost equipment, not just in
hospitals but also in many free-standing diagnostic or therapeutic facilities. With too much
money invested in these big-ticket items, the investors are often desperate to draw patients who
will pay them enough to recoup their expenses and rake in a large profit. They try to legitimize
these cutbacks by giving them the label of interpretation charges, or sometimes call it ‘fees for
assistance with a procedure’. Practicing doctors are only too happy to channel their patients to
these centres, often for unnecessary investigations or procedures. Hospitals also often exert
pressure on their employees to use expensive equipment for investigation or therapy. If a doctor
does not generate a certain amount of income, he may be asked to leave the hospital, which is
what is occurring in many corporate hospitals.
A group of patients made an effort to stop this practice themselves. They printed and
distributed a public notice which stated that 90 per cent of Chennai’s doctors cheat their patients
by accepting commissions from CT, MRI, and ultrasound scan centres. ‘Whose money is this?’
asked the pamphlet, and went on to give the answer: ‘The patient’s. Further, these centres often
entertain the doctors at star hotels with money which rightfully belongs to the public.’ The
pamphlet named six centres and suggested that the public avoid them, and preferably go to
public hospitals for scans if their doctor asked for one. Another pamphlet was addressed to all
the doctors of the city. Both these tracts were in Tamil, and I have translated the extracts here:
‘Medicine is a noble profession. Before entering the profession you took an oath. Remember
the terms of that oath. Far from upholding it, you are committing the heinous crime of hitting
your patients below the belt, when they have placed their trust in you. It would be better to work
as pimps. We warn all private medical practitioners that we have built up dossiers on your
nefarious activities. We know how much you have received from different scan centres for
sending patients to them. We have given copies of the documentation to the patients themselves,
and when you stand in the court of law they will give evidence against you. We give you till the
end of May to mend your ways. If you continue to take cutbacks we will publish your names in
newspapers and magazines’. The document then goes on to give a list of the magazines and
newspapers.
These pamphlets created some anxiety among practising doctors in Chennai, who met and
passed resolutions that the acceptance of cutbacks was reprehensible, and should be condemned,
and certainly no doctors should indulge in this practice. However, the patients’ organization did
not publicize the lists, and the profession has now returned to its happy practices.
The pharmaceutical industry has been a willing partner in our quest for wealth. Drug
companies are more interested in selling expensive drugs than cheap ones. You will often find
doctors prescribing expensive new antibiotics when much cheaper and older alternatives would
do just as well. This is usually because the industry offers inducements—in the form of
entertainment, funding overseas trips, or expensive gifts—to doctors who prescribe high-cost
remedies. Companies often keep track of the prescriptions of practitioners and keep account of
the money brought in by them. The Citizen, Consumer and Civic Action Group (CAG) is a
Chennai-based NGO formed several years ago to protect citizens’ rights in a number of areas. In
2011, they organized a national seminar on the ‘Regulation of Promotional Practices by
Pharmaceutical Companies’. At this meeting, they presented the findings of a survey they had
conducted of medical practitioners, pharmaceutical representatives, pharmacies, hospitals, and
members of the public. From the findings, it was clear that many doctors are influenced to
prescribe certain drugs by the inducements offered by the pharmaceutical industry.
Pharmaceutical concerns kept track of the prescriptions made by doctors, and the rewards offered
to the doctors were proportional to the sales of their drugs (Mani 2011). I am not aware of this
important study having been published.
It has become routine for the industry to provide funds for medical conferences. Much of the
support goes to providing fellowship. The dictionary defines this word as ‘the state of being a
fellow or partner; friendship; communion; an association; an endowment in a college for the
support of postgraduate fellows; the position and income of a university fellow; the reckoning of
proportional division of profit and loss among partners’. The lexicographer does not know that to
the Indian medical fraternity, it means imbibing intoxicating liquor in the company of one’s
peers at someone else’s expense. I do not know whether alcohol is a catalyst in the acquisition of
knowledge, but it certainly improves the attendance at medical meetings. We are informed of the
monthly meetings of the Chennai chapter of the Association of Physicians of India by an
invitation card that boldly states that so and so company and the Chennai Chapter of the API
invite us for the monthly meeting. The MCI expressly forbids us from being entertained by the
pharmaceutical industry, but has taken no action against the API for this blatant disregard of its
injunctions.
Doctors often claim that their acceptance of this hospitality will not influence their prescribing
habits. I can attest that this statement is not true based on my own experience. I was invited as a
guest lecturer to speak to an association of doctors in another city. The general body meeting was
held just after my lecture, and I was invited to stay on and attend the proceedings. One of the
office bearers said a number of pharmaceutical firms had been supporting the educational
activities of the association, but there were a number of others who had refused to do so in spite
of having been asked. He named the recalcitrant firms. Should we not, he asked, reward those
who have been encouraging our academic aspirations, and demonstrate our disapproval of the
others, with our prescriptions?

Abetting the Patient in Crime

Doctors will often oblige patients by giving them false certificates to avail of leave, or to avoid
attendance in a court of law. When the rich and influential are arrested and sent to jail, it is
almost inevitable that a day or two later, the detained will experience pain in the chest. A doctor
will certify that he has a dangerous heart disease and he will then be shifted to a hospital. He will
not gain his liberty, but being confined in a comfortable hospital ward with visiting privileges is
so much better than spending time in prison. A high-profile under-trial prisoner was moved to a
premier government hospital of Tamil Nadu and kept under observation for ‘critical cardiac
disease’ for several weeks. According to the doctors, he continued to have unstable angina for
two months and therefore could not appear in court. However, no effort was made to study his
coronary vessels or to relieve any obstructive pathology. The court actually insisted on a team
from a government hospital in another state being called to verify that the local doctors were
being honest, a poor reflection on the doctors of our state.
Insurance fraud is a much more pernicious practice. Very often a patient will receive a
diagnosis of a disease that calls for expensive treatment. He will then apply for insurance, and
expect his doctor to declare that the disease began two months after the day he registered for an
insurance policy, so that he will be eligible for reimbursement. The majority of doctors are happy
to please their clients by giving them the necessary certificates. The specious argument is that it
is the doctor’s duty to help the patient to pay for his treatment. A patient gave me a history of an
illness that had been in existence for three years, but instructed me to record in the case sheet that
it commenced two months before his consultation with me. When I told him I would only record
and certify to the truth, he said, ‘If you are going to be unreasonable I will go to another
nephrologist,’ and walked out of the room. Insurance companies end up paying large amounts in
hospital dues for these patients. The insurance company is not a charitable organization, and has
to ensure its own profits by raising the premium. This hits the honest subject who has taken
insurance legitimately, for he has to pay more to purchase the same amount of cover.

Transplantation
As a nephrologist, I am ashamed to say that there is no field of medicine that is as corrupt as
renal transplantation. When transplantation was established as a regular procedure in India in the
1970s, there was no official regulation of what we did. Analogous with blood transfusion, the
practice of purchasing kidneys from the poor was soon established. We conveniently forgot that
while blood is a renewable commodity that can be harvested with negligible risks to the donor,
there are definite risks and disabilities associated with the loss of a kidney. Immediate mortality
was very rare, and a slogan was raised by some unscrupulous transplanters that it was better to
‘buy than to let die’. There was much debate, not only in India but all over the world, about the
ethics of buying kidneys. The executive of the Transplantation Society at first condemned
commercial transplantation, but as dialysis became more widespread and the supply of deceased
donor kidneys failed to keep up with the number of patients entering end-stage renal disease,
they reconsidered the matter and decided that while they had rightly condemned ‘rampant
commercialism’, there should be no objection to ‘rewarded gifting’. The difference between
these two was not defined. What was conveniently forgotten was that this was a buyer’s market.
The poor ignorant seller of the kidney had no concept of the true value of the kidney to the
recipient, and no idea of the risks she would run. The use of the feminine pronoun is appropriate,
since most unrelated donors are women. To a person in abject poverty, a sum of Rs 30,000 or
40,000 seemed great riches. This enabled the practitioners of the unrelated donor transplant to
claim that since the vendor and the buyer of the kidney both benefitted from the deal and were
happy to go through with it, no one had a right to object to such a universally beneficial
transaction. This lie was nailed by a group of expatriate Indians from the US, who studied 305
renal donors from Chennai slums six years after donor nephrectomy, and found that 96 per cent
did so to pay debts but 74 per cent were still in debt six years after surgery. More tellingly, 79
per cent regretted having sold their organ, and 87 per cent felt their health had deteriorated after
the donation. Family income actually fell by one-third (Goyal et. al. 2002).
There were numerous scandals with donors claiming they had been promised large sums of
money but were dismissed with a pittance once surgery was done. Complaints were made that
people were operated for abdominal symptoms and their kidneys were stolen during surgery. At
last our sluggish legislators bestirred themselves to pass The Transplantation of Human Organs
Act of 1994. The preamble to the Act states: ‘Whereas it is expedient to provide for the
regulation of removal, storage and transplantation of human organs for therapeutic purposes and
for the prevention of commercial dealings in human organs…’ [emphasis mine]. Unfortunately,
though some of us who had been promoting the Bill and lobbying for its passage had drafted a
legislation completely banning unrelated donors and even those related only by marriage, the
legislators introduced a clause permitting transplantation from spouses and from unrelated
donors ‘by reason of affection or attachment towards the recipient’. This opened the gates for the
use of unrelated donors. The Government of Tamil Nadu adopted the Act in 1995. An
Authorisation Committee was appointed to study all unrelated donor transplants and to ensure
that the Act was followed scrupulously. The fact of the matter was that most of the applications
were accepted, even when the recipient was a multi-millionaire from the north, and the donor a
slum-dweller from Chennai who had met the recipient barely a week earlier. It is clear that the
only reason a person would donate a vital organ to a passing acquaintance is financial, but the
Authorisation Committee appointed to ensure that the Act is obeyed seems unable to see that the
law is being flouted. As recently as 2015, the committee sanctioned 151 unrelated live donor
transplants. A newspaper exposed the fact that an entire village on the Bengaluru–Mysuru
Highway in Karnataka was populated by people with only one kidney. The agents who brokered
these deals were arrested and convicted, but managed to get themselves released before
completion of their sentence and resumed their activities.
Transplant teams are getting ever more ingenious. With the deceased donor transplant
programme reasonably successful in Tamil Nadu, we have an option for the patient without a
related donor and unwilling to break the law in letter or spirit and buy an unrelated donor organ.
Some marginal kidneys1 are harvested and refused by one transplant team after another. A
couple of teams willingly accept all such kidneys, which have been refused by everyone else.
This is to perform a live unrelated donor transplant under the guise of a deceased donor
transplant, to deceive any inspecting committee. One of my patients who moved to one such unit
told me he was promised an unrelated live donor organ when the next unsuitable kidney turned
up. It would be recorded as having been transplanted into his body, but in fact, it would be
discarded and he would receive a live donor organ harvested at another hospital, to which the
donor would be admitted with a diagnosis of a disease calling for nephrectomy. Unfortunately,
he is unwilling to admit in public to having received a transplant under these circumstances,
since he is equally guilty under the law and fears prosecution.

Is There a Remedy?
The malady is deep-rooted. The consumer group report cited earlier says that 60 of 92
practitioners questioned favoured accepting gifts from pharmaceutical companies, and 78 wanted
companies to pay for their ‘academic activities’ (Mani 2011). This has to be an underestimate. It
is more likely that a corrupt doctor would have concealed his failings rather than the reverse.
When such a large proportion of practitioners are happy to make money however questionable
the means, the likelihood of their voluntarily accepting a code of conduct is small.
I believe we will only be able to eliminate corruption in Indian medicine if we can eliminate
the parallel economy, and I hope the efforts of our current government to do so will bear fruit.
The proliferation of capitation fee medical colleges is fuelled by the huge sums of money earned
by the promoters of these institutions. We need well-equipped colleges, and for that to happen,
they should be permitted to charge reasonable fees from their students, but not to the extent
where they make the astronomical profits now extant.
Ethical and honest behaviour should be taught to medical students as a part of medical
education. Students are more likely to imbibe habits from example rather than precept, and
teachers must be selected on that basis in addition to professional expertise and the quality of
their teaching.
Since the Indian medical profession has demonstrated its tendency to stray from the right
path, there has to be an incorruptible organization to keep us honest. The MCI has to be revived,
strengthened, and filled with members who set an example for the rest of us. It should be
proactive, and should not wait for a complaint to be filed.
In today’s India, this is a pipe dream. I hope 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. In the words of Tagore, ‘Where the mind is without fear and
the head is held high’…‘Into that heaven of freedom, my Father, let my country awake’.

References
Goyal, M., R.L. Mehta, L.J. Schneiderman, and A.R. Sehgal, 2002, ‘Economic and Health
Consequences of Selling a Kidney in India’, JAMA, 288: 1589–93.
Mani, M. K., 1995, ‘Advertising in Medicine’, Natl. Med. J India, (8): 82–83.
———, 1996, ‘Our Watchdog Sleeps, and will not be Awakened’, Issues in Medical Ethics, 4:
105–07.
———, 2011, ‘Angelic Doctors’, Natl. Med. J India, 24: 113–14.
Sainath, P., 2009, ‘The Age of the Aamcrorepati’, The Hindu, 20 June.
 CHAPTER EIGHT
Hospital Practices and Healthcare Corruption
Sumit Ray

Healthcare corruption in private hospitals is rampant and multidimensional and its consequences
are not limited to the individual patient. It has larger population and societal ramifications. To
understand this corruption appropriately, we must view it in the context of healthcare delivery in
India. It has to be analysed in the context of medical neo-liberalism characterized by the absolute
commoditization of health. It must be evaluated on the basis of its effect on the goal of Universal
Health Coverage (UHC), part of the United Nations Millennium Development Goals (MDG) and
of the Sustainable Development Goals (SDG).
Since the 1990s, with the ‘liberalization’ of the economy in India, there has been a push to
privatize healthcare while reducing investments in public health delivery. One major
consequential shift is the transformation of the patient into a ‘consumer’. Unlike patients, the
term ‘consumer’ makes them bear the responsibility for the choices they make or fail to make
regarding their health (Fisher 2007). The responsibility shifts from the collective and the
government to an individual’s capacity to pay to access healthcare, which becomes an industry
attracting private investment to profit from people’s illness and distress.
India has more than 74,300 hospitals and 1,654,000 hospital beds; 72 per cent of hospitals and
60 per cent of beds are in the private sector (NSSO 2013; Government of India 2015). Of a total
of one million private healthcare enterprises, about 25 per cent are medium to large medical
establishments. The remaining are microenterprises (Mackintosh et al. 2016). Foreign Direct
Investment (FDI) in healthcare has been increasing since 2000. The total investment in hospitals
and diagnostic centres crossed USD 4,235 million in December 2016 (Dept. of Industrial Policy
and Promotion 2016).
These shifts are not incidental. They have dramatically changed the way the medical
profession sees itself. In a privatized healthcare system, the responsibility of the physician is not
to the patient and her/his health, but to the shareholder, proprietor, or partners who own the
hospital. The doctor–patient relationship has become one of extracting the most profit on the part
of the hospitals (and doctors) and negotiating the best prices on the part of the patient. As the
‘business’ deal becomes the primary mode of interaction, the relationship tends to become
adversarial when costs climb or there are complications and the expected results are not
delivered. This leads to a significant lack of trust in the relationship, which has now begun to
manifest itself in the increasing frequency with which violence against health professionals
occurs across the country. This violence will not stop until people feel that the healthcare system
and doctors are working in their best interests and not in the interests of profit.
Of the 4 per cent of GDP spent on health in India, just over a quarter comes from public
spending, the remaining three-quarters from private. Out of this private spending, almost 87 per
cent is ‘out-of-pocket’ (OOP), that is, without any insurance cover1 Thus, health is a major cause
of impoverishment—anywhere between 55 million and 68 million people are being pushed
below the poverty line every year because of healthcare costs (Ministry of Health and Family
Welfare 2015).
Corruption in hospital practices refers to the functioning of the medium to large
establishments, mostly located in urban and peri-urban areas, that constitute 25 per cent of all
private healthcare enterprises. Their influence over healthcare policy is disproportionate to their
relatively small share in healthcare delivery. Hence, their corrupt practices ought to be a matter
of greater interest and subjected to closer scrutiny. Corrupt practices can be broadly divided into
those meant to help increase patient load and those put in place to milk patients once they are
drawn in.

Cut Practice and Facilitation Fees

The commission paid for referrals, euphemistically called ‘facilitation fees’, is the most common
method to draw in patients. An article in the British Medical Journal in 2014 by David Berger, a
district medical officer from Australia who had volunteered in a hospital in India, exposed the
entrenched culture of kickbacks and bribes. A scathing editorial in the same journal a month later
highlighted the level of rot that had set into India’s health system (Jain et al. 2014). Multiple
stings by television channels and the print media showed that a doctor could make hundreds and
thousands of rupees by referring patients to larger hospitals. Many of these hospitals give 10–15
per cent of the patient’s final bill as a kickback. This pushes the hospital to require the patient to
undergo unnecessary procedures and diagnostic investigations, to inflate the bills of the already
hard-pressed patient (who, nearly 90 per cent of the time, spends it ‘out of pocket’) to
accommodate the commission. An unfortunate consequence is that many medical practitioners
are now only referring patients to larger hospitals for the easy money, working as middlemen
rather than making any attempt to diagnose and treat patients. This can and is leading to an
erosion of their clinical abilities and serious de-skilling.
Diagnostic setups within a hospital and outside the ambit of hospital management give 30 to
50 per cent of the cost of an MRI or a CT scan to the referring doctor. For laboratory tests, the
range is 20–50 per cent. This level of kickbacks makes it impossible for many laboratories to
maintain their integrity while carrying out all prescribed tests. Many of the tests prescribed by a
doctor are only meant to push up the bill and thus, his own commission. Hence, a lot of the
samples collected from apparently healthy-looking people are thrown into the sink, and are
referred to as the ‘sink tests’. This can be dangerous for patients, as diseases and problems could
be missed due to tests not being done. Unfortunately, it also makes it difficult for hospitals and
laboratories that function ethically and honestly to survive, as few doctors refer them patients.
Some hospitals, which have established a reputation for excellence and ethical clinical care and
are at the cutting edge of knowledge and technological advances, may still continue to do well,
but for most, it is difficult to survive without giving cuts. Unfortunately, the networks of the
dishonest and unethical have become dominant over the networks of the honest. What is even
more disheartening is a sense of inevitability and acceptance among a large section of doctors.
Section 6.4.1 of the Medical Council of India’s (MCI) Code of Professional Conduct Etiquette
and Ethics Regulation 2002 states that a physician shall not give or receive commission for
referring a patient. Section 1.7 of the same code states: ‘A physician should expose without fear
or favour, incompetent or corrupt, dishonest or unethical conduct on the part of members of the
profession’. It is rare, though, to have any physician complain against colleagues or expose the
practices of a hospital. In any case, the MCI has no authority over hospitals or doctors
associations, but only individual doctors (Medical Council of India 2002). Moreover, laws to
protect whistle-blowers in India being weak, there is a very real fear of reprisal. And whatever
law exists to regulate hospitals is yet to be implemented.

Revenue-target Medicine
For large segments of the private healthcare sector in India the target is not necessarily better
healthcare delivery, but higher revenue generation. Thus, the nature of growth and structure of
hospital administration in the private sector is driven by revenue generation. Organized private
sector hospitals used to be located mostly in larger cities and towns but are increasingly
expanding into smaller (Tier II & III) towns and cities expecting higher return on investments in
these places. At present, 48 per cent of all private hospitals and nearly 67 per cent of corporate
hospitals are in smaller cities and towns (Mukhopadhyay et al. 2015).
The model works on employing ‘star’ physicians and surgeons—on very high
salaries/professional fees—who attract the clientele, the patients. Typically, the rest of the
personnel, including junior doctors, nurses, technicians, and other staff are poorly paid. Huge
revenue targets are set for the ‘star’ doctors, whose increments, incentives, or even jobs could be
dependent on meeting these.
There was a time when hospitals depended on word of mouth and the reputation of their
doctors in order to establish themselves. With increasing competition, especially among the large
corporate players, organized marketing and branding have taken over (Bapna 2016). With this
has come highly paid MBAs and finance executives, experts at managing balance sheets and
brands but not patients. The focus on revenue generation is as much to offset the high salaries of
some doctors and top executives, as it is to generate returns for investors. This often leads to
dehumanizing of the doctor-patient relationship, with both patients and doctors losing control
over these interactions.
It is not doctors’ services or room rent that bring in the maximum revenue. Roughly half the
revenue in a private hospital is generated from medical and surgical disposables and drugs (30
per cent) and diagnostics (20 per cent). Procedures and theatre charges bring in 15 per cent and
bed charges/room rent another 15 per cent. This break-up also explains unethical, inflated
prescriptions, unnecessary procedures and diagnostic investigations.

Markups on Drugs, Implants, and Disposables

Hospitals, especially large ones, leverage the advantage of the low prices they get on bulk
purchases of everything—from bandage and gauze to medicines and implants. While some
markup is understandable to account for the cost of inventory, management of the procurement
process, and some dividend to the hospital, a hospital’s profit margin on every item is huge.
What is procured at rock-bottom prices is sold to the patient at the maximum retail price (MRP),
which could be several times the procurement price.
Take meropenem, an important and life-saving latest-generation antibiotic used for serious
bacterial infections. Hospitals are supplied the drug at Rs 300–700 per gram, but it is mostly sold
to patients at an MRP of approximately Rs 2,900. The required dose is 1–2 grams three times a
day, for a week to a fortnight (on an average, about 10 days). The mean cost price is about Rs
18,000 to Rs 30,000 and the selling price Rs 87,000 to Rs 1,75,000—at nearly a 500 per cent
profit!
Hospitals insist that patients staying in the hospital for treatment should buy everything from
the hospital pharmacy. To the patient, this is unfair and predatory when the items they are billed
for are available for a lower price outside. This situation is a result of most hospitals not passing
on any benefits of the reduced prices they get from bulk buying. In an extreme case of greed, the
Competition Commission of India found that a major corporate hospital in Delhi and Becton
Dickson India Pvt Ltd, a manufacturer of disposable syringes, were prima facie guilty of
colluding to sell disposable syringes from the hospital’s in-house pharmacy at almost double the
market price. It found that the company was printing a higher MRP of Rs 19.50 on syringes
supplied to the hospital, while MRP on syringes sold in the open market was Rs 11.50. So not
only was the hospital getting the syringe cheaper through bulk buying, it was also selling it well
above the MRP. The profit the hospital would be making each day from just one item, disposable
syringes, is massive (Nagarajan 2016).
While these are examples of predatory pricing, there are even more egregious instances of
possible harm to patients when medical decisions are motivated by profit. An example of
overuse of certain treatment modalities, when pressured by revenue targets, is the use of
intravenous nutrition, called Parenteral Nutrition (PN), in critically ill patients in intensive care
units (ICU). Multiple studies in critical-care medicine in the last decade have shown that it is best
to feed the patient enterally, that is, into their stomachs and intestines, rather than intravenously,
even for the most critically ill. Enteral feeding (EN) requires significant planning and effort on
the part of critical-care specialists and ICU nurses. It costs the patient Rs 200–400 per day.
Parenteral nutrition (PN) is only to be started if one is unable to feed the patient enterally for
more than a week despite best efforts. As evidence built up for this, our usage of parenteral
nutrition in a 48-bed ICU with 200–210 admissions a month dropped to just 10–20 bags a month.
Certain similar-sized hospitals with the same type of ICUs, but with huge pressure on revenue
generation, are still using 150–250 bags per month (Personal communication). The relevant point
is that we are a not-for-profit hospital, with no pressure for revenue generation. The bag of PN
procured by the hospital for Rs 1,000–1,500 is charged Rs 2,500–4,000 to a patient. That brings
in a profit of Rs 200,000–600,000 per month, on just this modality. If that wasn’t bad enough,
the chances of secondary infections is much higher with PN. There can be significant electrolyte
and metabolic imbalances with PN as compared to EN and the outcome is surely not better; in
fact, it may be worse! Not only is this treatment more expensive, but more dangerous for the
patient. And it still continues to be misused.
Another example is the extent of use of coronary stents in general, and of bioabsorbable
coronary stents in particular. Stents are used to open up clogged arteries supplying the heart.
Drug-eluting stents are the most widely used, accounting for over 95 per cent of stents used in
India. The latest stents in the market are bioresorbable vascular scaffold (BVS) or stents that get
absorbed by the body. The import price of most stents, barring the BVS, was Rs 8,000–25,000,
while the cost to patients ranged from Rs 24,000–170,000. The BVS with an import price of Rs
42,000 was sold to patients for Rs 180,000–200,000. According to the National Pharmaceutical
Pricing Authority (NPPA), hospitals took the biggest cut on stent prices—up to 650 per cent and
stenting as the preferred mode of treatment soared. Questions have been raised about how much
of it was necessary or appropriate. Some senior cardiologists claim that nearly a third of all
stenting procedures in India are inappropriate and have called for medical auditing (Nagarajan
2017a). Studies in the United States, which also has a highly privatized healthcare system,
showed that nearly 27 per cent of stenting was inappropriate in 2009, dropping to about 13 per
cent in 2014 after stricter checks and guidelines. In many hospitals, the cardiac service generated
30–40 per cent of the total revenue, so there was incredible pressure to do more and expensive
procedures (Desai et al. 2015; Stergiopoulos et al. 2012). In the case of BVS, the most expensive
of stents, several hospitals and interventional cardiologists pushed it for the high margins to
hospitals and kickbacks for themselves, though cheaper proven DES stents are still considered
the ‘gold standard for treatment’ (Nagarajan 2017). If that was not bad enough, there is a large
and growing body of evidence that the more expensive BVS stents have more than double the
risk of re-blockage and other complications (Ellis et al. 2015; Wykrzykowska et al. 2017;
Cassesse et al. 2016)!
Profit maximization by private hospitals makes private healthcare extremely expensive and
results in a steadily rising cost of healthcare delivery. There is need for pressure from civil
society groups, the media, and people’s movements to limit the maximum price of all essential
medicines, disposables, and implants under the Drug Price Control Order. Though some essential
drugs, and now stents, have come under price control, this has been achieved by continuous
public pressure.

Misappropriation of Public Funds for Private Gain

Public-funded health-insurance schemes are a recent modality for transferring public funds to
strengthen private facilities. Since over a decade, various health-insurance schemes have been
started by different states—Andhra Pradesh, Tamil Nadu, Delhi, Karnataka, Kerala, Maharashtra
—along with the central Rashtriya Swasthya Bima Yojana (RSBY). But coverage and benefits
are weak. In 2014, only 13 per cent of rural and 12 per cent of urban households were covered
(Seluang et al. 2014). A piece in Economic and Political Weekly (EPW) on the Aarogyasri in
Andhra Pradesh (2012) showed that 25 per cent of the state’s health budget dedicated to the
scheme addressed only 2 per cent of the disease burden (Prasad and Raghavendra 2012). Thus,
these programmes drain scarce public funds to pay for treating a small subset of diseases and for
limited procedures in private hospitals, which push for expanding insurance schemes so that
people access their way-more-expensive treatments in the name of helping improve healthcare
access. The majority of the population, too poor to seek private healthcare, get converted
overnight into potential consumers thanks to government-funded health insurance. This is
unsustainable for a good healthcare system and the goal of achieving Universal Health Coverage
(UHC).
If that wasn’t bad enough, there are multiple media reports of unnecessary procedures like
hysterectomies (uterus removal) in young women in Andhra Pradesh, Bihar, and Chhattisgarh
paid for by these schemes (Rao 2017; Jaiswal 2013). With this, corruption among doctors and in
private healthcare reached a new low!
Unethical practices and profiteering become the dominant narrative in over-privatized, ‘for-
profit’ healthcare systems. Giving more scope for the involvement of the private sector in public-
funded insurance schemes is fraught with the risk of such dehumanizing medical treatment and
profiteering in the absence of a strong and effective regulatory mechanism for private facilities.
In 2010, Parliament adopted the Clinical Establishment Act2 designed to regulate standards of
care in all healthcare facilities.3 Apart from the fact that its implementation been stalled in many
parts of the country due to lobbying by private physicians, hospitals, and doctors’ bodies (led by
the Indian Medical Association), the Act itself leaves a lot to be desired.
Like the MCI, the regulatory body envisaged under this Act does not have enough
representation from civil society, patient rights advocacy groups, and elected people’s
representatives. It is dominated by doctors and their associations. As the MCI experience has
shown, this is a recipe for disaster, as it becomes a club of doctors, who will never effectively
punish their own. Further, all the information to be provided about hospitals for their registration
is voluntary and there is no inspection of the facilities. Checking is only done on complaints and
the penalties for violations seem woefully inadequate. For effective deterrence, we need stronger
regulations and punishments for unethical and corrupt practices. Criminal proceedings should be
initiated against the institutions and doctors who have committed unnecessary surgeries and also
defrauded the government. Unfortunately, the political will seems to be missing—or is it that the
poor do not count in our scheme of things?

The Uncharitable Charitable Hospitals

Non-governmental organizations (NGOs) and faith-based groups deliver a large proportion of
healthcare in certain parts of the country. In 1920, nearly half the hospitals in India were run by
Christian missionary institutions. Though their numbers have dwindled, they still play an
important role in delivering healthcare, particularly in underserved areas, managing nearly 3,731
healthcare facilities (including 200 large hospitals) and around 80,895 beds (Gokavi n.d; Cherian
et al. 2013).
The Public Charitable Trust Act enacted in 1950 enabled private entities to set up charities.
This Act also includes clauses on income tax waiver. Historically, many philanthropists set up
charitable hospitals (also called trust hospitals) after this Act became law (Chaudhari 1986).
Unfortunately it is now being misused rampantly by commercial hospitals.
An article by Ravi Duggal of the International Budget Partnership in the EPW in 2012
brought to light how many of the largest and most expensive hospitals in Mumbai established
under this Act, have not only been given an income tax waiver, but also got land at concessional
rates or on cheap lease rent, got extra Floor Space Index (FSI), concessional utility rates, waiver
or concessions for octroi, customs duty etc. However, they no longer engage in any charity. He
calculated that these hospitals accounted for nearly 10,000 beds in Mumbai and that with no
charitable work, they were adding to their surplus (being charities they cannot be said to make
‘profits’) significantly. These hospitals are supposed to provide 10 per cent of their beds for free,
while an additional 10 per cent are to be significantly subsidized. In 2012, they had a gross
surplus of nearly Rs 1,000 crore, for which they did not pay Rs 300 crore as income tax, nor did
they do any charity, which would have been valued at a minimum of Rs 225 crore. This has been
going on for years, and they ought to be penalized and their benefits stopped. Despite civil
society groups and health activists demanding this, the government hasn’t taken any action in the
last two decades, and this is just Mumbai (Duggal 2012). If we look at the country as a whole,
the amount of fraud many of these so-called charitable or trust hospitals are doing with public
money or public resources like land would amount to thousands of crores of rupees. Of course,
there are still a few who have stuck to their original ethos and mandates.

The Private Health Sector Efficiency Myth

The dominant narrative in India and globally is that the private sector is more efficient than the
public sector in healthcare delivery. This notion has gained ground in the era of liberalization.
The important question is—efficient at what? As Rosemary Morgan et al. (2016) state, ‘The
crucial policy question about the private sector is not its performance in isolation, or relative to
the public sector, but the extent to which it supports or detracts from progress towards universal
health coverage’.
Efficiency is the extent to which resources are used effectively or are wasted (Hsu 2010).
Examples of inefficiencies are overprescribing, wastage, and use of expensive branded medicines
over generic ones. Average prescription drug costs were higher in the private sector than in the
public sector in India and Bangladesh, where public services are poorly resourced (Basu et al.
2011; World Bank 2005). Multiple studies focusing on the treatment of specific conditions
suggest that private treatment resulted in high service costs and potential for inefficiency. An
example is unnecessary Caesarean sections, which increase costs and are not good for patients.
The number of caesarean section surgeries performed are unacceptably high in the private sector
(Kaul 2017; Brugha and Pritz-Aliassime 2003).
A study published in Health Affairs in 2014 compared hospital administrative costs in eight
countries (US, Canada, Scotland, England, Wales, France, Germany, and Netherlands). The US,
with its privatized healthcare system, had the highest administrative costs at 25 per cent of
hospital spending, compared to 12 per cent for Canada and Scotland and 16 per cent for England,
all public health systems. Interestingly, even within the US, administrative costs were higher in
‘for-profit’ hospitals (27 per cent) than in public hospitals (23 per cent) (Himmelstein et al.
2014).
Several studies suggest that service quality, which includes responsiveness of staff and is
often measured by patient satisfaction, is better in the private sector. A systematic review of 102
studies by Basu et al. (2011) on the quality of services found that diagnostic accuracy, adherence
to medical management guidelines, knowledge of correct diagnosis and treatment, and the
incidence of unnecessary procedures were worse in the private sector than in the public sector.
Overprescribing and non-adherence to guidelines are an important cause of drug resistance in
bacterial, tubercular, and malarial infections in low- and middle-income countries (LMIC).
Equity, defined as the ‘fair availability of and access to quality healthcare commensurate with
need and without regressive financial implications’, is also an important parameter to measure
efficiency of a health system (Morgan et al. 2016).
In India, private healthcare predominantly financed by out-of-pocket (OOP) payments is
highly inequitable. This extreme inequality in healthcare delivery is the reason for India’s
miserable ranking in the Millennium Development Goals (MDG) and the Sustainable
Development Goals (SDG) on healthcare; we were ranked 143rd (of 188 countries) and were
below Botswana, Namibia, Gabon, Ghana, Myanmar, Laos, and Cambodia (Lim et al. 2015).
The clear differentiating feature for countries in the same socioeconomic group as India that have
done much better (Vietnam, Nicaragua, Tazikistan, Uzbekistan) is their public spending on
health (Ray 2016). They allocate 3–5 per cent of GDP as public health expenditure, compared to
India’s measly 1.2 per cent. This is about 50–75 per cent of their total health spending as
compared to India’s 30 per cent. The message is clear. To improve healthcare, we need to
increase public spending to at least 3 per cent of GDP in the next few years and possibly to 5 per
cent by the next decade.
Public spending on healthcare and developing and strengthening the public health system and
its accountability is essential. It will make our healthcare more equitable and accessible and shift
poor- and middle-income patients away from impoverishing and indebting private healthcare.
The quality of public healthcare has to improve to the point where all classes would be ready to
access it. If the upper classes want better hospitality, they may access private healthcare, but it
shouldn’t be because of the quality of healthcare delivery. An important step in this would be to
disallow public servants to access private healthcare (with public funds), except in exceptional
circumstances. This would push senior public servants—bureaucrats and politicians—to invest
more effort in improving the public health system. What is also missed while discussing
corruption in private hospitals is that it breeds and worsens corruption in the public health
system, by bribing public health service providers to refer patients and investigations to private
providers. That makes a bad situation even worse!
Hospitals are a part of curative medicine. And as the saying goes, give a boy a hammer, and
he will find that everything he encounters needs pounding. To treat all ailments in a hospital
would be unnecessary and expensive. But when hospitals become a business, they tend to lure all
ailments to them—the hammer has to convert every problem into a nail it can pound. Thus more
appropriate and less expensive modes of healthcare like public health and preventive health have
taken a back seat as the hospital-based model takes precedence. With the huge money it
generates, hospital managements have also exerted influence over government policy, attempting
to push it away from investing in healthcare, and instead persuading it to purchase healthcare
from the ‘more efficient’ private sector.
The private sector remains poorly regulated and buying healthcare from it, with public money,
is a recipe for disaster. To begin with, hospitals need to be brought under strict regulation on
both costs and protocols, and standard guidelines for treatment. If the public needs to be
protected from the predatory and exploitative practices of mobile phone companies through a
telecom regulator, it is quite surprising that the government has shown no urgency in establishing
a regulatory framework for healthcare delivery in general and for the private, for-profit
healthcare sector in particular. Accreditation of hospitals with government-instituted quality-
improvement organizations, with a focus on intense internal and external clinical audits, will help
improve the quality of healthcare delivery. Exemplary punishment should be instituted and
enforced for abuse of patient rights and misuse of social-health insurance schemes for increasing
profits of private players.

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 CHAPTER NINE
Ethical Issues in Organ Transplantation
Vinay Kumaran

There is no doubt that the need for organ transplantation is huge in a country like India with a
population of 1.2 billion and a debilitated public health system. For instance, it has been
estimated that about 100 individuals per million suffer from end stage renal disease (Kher 2002).
Of these, 90 per cent never see a nephrologist. Of those who do, some form of renal replacement
therapy is started in 90 per cent and the remaining 10 per cent are unable to afford any treatment.
Of those who begin dialysis, about 60 per cent are lost to follow up within three months. In 2002,
when Kher’s paper was written, about 3,000 kidney transplants were being performed in India
each year, of which 75 per cent were being done in the private sector and only about 100 were
from deceased donors. The situation is dire for patients with failure of organs which do not have
‘replacement therapy’. Thus, it has been estimated that about 200,000 Indians die of liver failure
every year (Kumaran 2016), for which no replacement therapy is available, and that about
30,000 of these would be candidates for a liver transplant (Kumaran 2016). The number of liver
transplants performed in India is estimated to be approximately 1,500 a year, the majority being
living donor liver transplants performed in private hospitals. The development of large volume
liver transplant centres with excellent outcomes has undoubtedly saved many lives and returned
moribund patients to a near-normal life, but many problems remain to be addressed.
Doctors in India are representative of the society they are from and it would be unreasonable
to expect them to perform with extraordinarily higher standards of integrity than the rest of the
country. Those of us who work in the system are aware of the extent to which corruption has
become endemic, but it took an outsider to point this out in a manner that has made everyone sit
up and take notice (Berger 2014). Unlike other countries in which corruption is an aberration and
is noticed, documented, and punished, in India, the modus operandi seems to be to pretend that it
does not exist.
I have identified some areas of concern and discuss them in some detail, one at a time. I give
examples from other countries in which such practices have been identified, investigated, and
punished and make a statement that the same practices also exist in India. The areas of concern
include:

1. The buying and selling organs.

2. The manipulation of waiting lists to allocate organs to patients out of turn because of their
status or for pecuniary or other considerations.
3. Performing transplants on patients who do not need it, for financial or other reasons.
4. Denying transplants to patients who need them because of concerns for statistics and for
 profit.
5. Lying about the outcomes of transplants.
6. Failing to maintain minimal standards of care.
7. The strange case of Dhani Ram Baruah.

Buying and Selling Organs

In the 1980s and early 1990s, India was a favoured country for kidney transplant tourism and
transplant between an unrelated patient and donor was first performed in this country in the mid-
1970s (Mani et al. 1978). It was estimated then that more than 2,000 kidneys were taken from
living unrelated donors and sold in the metropolitan cities of India in 1991 (Kandela 1991).
Patients with kidney failure from other countries and rich patients from India could buy a kidney
from a poor person who was identified and procured by a tout. Often the counselling and medical
evaluation was hurried and inadequate. Post-operative follow-up was almost non-existent. The
recipient outcomes were poor and the donor was often worse off after selling the organ than
before operation—even in financial terms. These ‘scams’ typically came to the notice of the
authorities whenever a donor complained about not being given the promised sum of money,
which was often a fraction of that extorted from the recipient.
One of the objectives of the Transplantation of Human Organs Act of 1994 was to stop organ
trafficking. While the rules did make it difficult for an unrelated donor to donate an organ to a
patient, instances of trading did not cease completely.

What is Wrong with Buying and Selling Organs?

This question is not an unreasonable one. It seems like a win–win equation. A person who is
dying of organ failure receives a life-saving transplant and someone who is in desperate need of
money receives a much-needed financial boost. It is not an easy question to answer. R.R.
Kishore discussed the morality of sale of human organs from a pragmatic viewpoint in an article
published in 2005 (Kishore 2005). He pointed out that once transplant from a live, related donor
is accepted, the following components of organ removal are already vindicated:

a) A person’s expectation to enjoy life with the help of organs belonging to others is valid.
b) The breach of a donor’s bodily integrity and the consequent harms are permissible.

He stated that ‘a person’s act of severing his/her organ in order to liberate a fellow being from a
terminal illness or to save his/her life cannot be dubbed as immoral simply because the act is
accompanied by a reasonable material consideration otherwise selling water to the thirsty would
be an equally big sin’. He went on to add that ‘any act done to save the life of a human being, or
to liberate him from suffering cannot be construed as contrary to human dignity’. He pointed out
that the ‘concept of human dignity is being selectively applied in the case of certain tissues
alone. Blood, bone marrow, sperm and eggs are being openly sold’.
One may argue that donation of blood, bone marrow, sperm, and eggs does not pose a risk to
the donor, but this is not strictly true. Donations of ova involve the administration of hormones to
stimulate the ovaries to produce multiple eggs. Sometimes hyper-stimulation occurs and deaths
have been reported. Yuma Sherpa, a 23-year-old woman, died after an egg donation at an IVF
clinic in Delhi in 2014. An autopsy report showed internal bleeding in the pelvis and
hypertrophied ovaries.1 Another similar case occurred in Mumbai in 2010 in which a young egg
donor went missing and then later died after donating her eggs at a fertility clinic. There were
allegations that she had donated eggs even before becoming a major.2
One of the problems with making anything illegal is that a black market in the scarce
commodity immediately appears. After the process of approving living donor transplants became
more rigorous, practically ruling out donation from unrelated donors, some patients went abroad
for their transplants. Singapore has proved to be a popular destination with some prominent
celebrities having undergone transplants there. Living donor transplants between unrelated donor
and recipients is permitted there and so Singapore became a destination for those in need of a
transplant and with the means to afford it.3
However, a flourishing black market also developed within India, after ways were found to
bypass the conventional system. An Ayurvedic doctor ran a prolific kidney transplant racket in
Gurgaon.4 In a business that ran over more than a decade, and in which he is estimated to have
garnered over Rs 100 crore, over 600 kidney transplants were performed in his premises
completely undetected. His ‘customers’ included foreigners and non-resident Indians from
Greece, Canada, Saudi Arabia, the United Arab Emirates, and the United States of America.
Donors, predominantly poor people from rural areas, were confined in secret locations, evaluated
(probably in a cursory fashion), and taken to the operation theatre. The doctor’s agents travelled
in a vehicle with a built-in laboratory, looking for donors, and performing blood grouping and
cross-matching in the vehicle before negotiating a rate. Typically donors were paid between Rs
50,000 and Rs 100,000. The recipients were charged anywhere between Rs 18 lakh to Rs 25
lakh. The doctor placed advertisements in international medical journals offering a ‘full service’
medical tourism package which included travel arrangements and hotel accommodation for the
patient and family. When the operation was finally revealed, many recipients waiting for kidney
transplants elsewhere said that ‘had we known that this was going on, we would have gone to
him instead of to a conventional transplant center’.
This is, by no means, the only such misdeamenour. A massive transplant ring was uncovered
in Punjab in 2003 and according to police, as many as 30 donor deaths may have occurred.
Although such a large number seems unlikely, there is no doubt that donor well-being is not a
priority in such operations.5 More recently, five kidney transplant recipients at the Apollo
Hospital, Delhi were alleged to have received donations from unrelated donors in an interstate
kidney racket.6 Among those arrested were the personal assistants of senior doctors at the
hospital. The CEO, Medical Director and three other doctors from LH Hiranandani Hospital,
Mumbai were taken into custody after a report of a kidney transplant being scheduled in which
the donor was shown to be the recipient’s wife using forged documents.7 This led to extensive
debate regarding whether doctors were expected to be able to verify the genuineness of
documents submitted as proof of a relationship.
These incidents are by no means restricted to India and have been reported from all over the
world. A report describes patients from a psychiatric facility in Argentina being used as an
‘organ farm’ (Anon 1992a). In another instance, a Harley Street physician is alleged to have
arranged transplant operations in which four Turkish donors were paid between GBP 2,500 to
GBP 3,360 each for their kidneys (Anon 1992b). One of the pioneers of living donor liver
transplantation, Christoph Broelsch was sentenced to three years in prison for corruption, fraud,
and coercion by the district court in Dusseldorf. Relatives of some of his patients reported feeling
coerced to donate (Tuffs 2010). On 1 March 2003, Der Spiegel published an article entitled
‘Kidneys against Cash’, accusing Broelsch of being involved in organ trading. Allegedly,
Broelsch had performed a living donor kidney transplant in December 2001 on an Israeli
recipient from a Moldovan donor. According to the article, the family of the Israeli recipient paid
hundreds of thousands of dollars in cash to the donor. Broelsch’s own hospital was in Essen, but
the hospital ethics committee there had turned down the operation because of doubts about the
relationship. He then moved the transplant to the Jena University Hospital which did not have a
committee.8
It is quite likely that the cases which come to attention may be just the tip of the iceberg.
There is little doubt that organ trading is taking place all over the world, including in India, in a
systematic manner despite legislation against it.
It has been suggested that if it were not illegal and if the process were to be supervised by the
government, many of the harmful effects of the process could be avoided. Thiagarajan et al., at a
time when it was not illegal in India, referred to the practice as ‘unconventional renal
transplantation’ (Thiagarajan et al. 1990). They argued that if donors were carefully selected,
without middlemen involved, and the operation performed in a good hospital, both patient and
donor would benefit.
Barry (1999) suggested provisions for ethical sale of kidneys from living donors, The
suggestions included:

1. The donor and recipients should be citizens of the same country.

2. No brokers.
3. The donor and recipient are not known to each other.
4. A non-profit agency or voluntary organization oversees the transaction.
5. An algorithm to ensure the physical and mental health of the donor and to prevent disease
transmission is followed.
6. The donor and recipient have independent teams of physicians.
7. Long-term care for health problems arising from donor nephrectomy is provided to the donor.

Unfortunately, even when these ‘unconventional’ kidney transplants were legal (for instance,
in India before 1994; in Iran the policy still exists), the evidence suggests that the outcomes, both
for the recipient and for the donor, are far poorer than when unrelated altruistic donations are
considered. Salahuddeen et al. reported the outcomes in a group of patients from Oman and UAE
who came to India and bought kidneys from local donors (Salahudeen et al. 1990). There was a
one-year mortality rate of 18.5 per cent, most of the deaths occurring within three months of the
transplant. There was also a more than 5 per cent incidence of de-novo infection with hepatitis B
or human immunodeficiency virus (HIV). It is not clear whether the patients were infected by the
donors (inadequately screened) or by the machines on which they may have received dialysis
before the transplant. Similarly, a report on patients from Singapore who had travelled to India or
China for living unrelated kidney transplants reported quite poor recipient outcomes and many
de-novo infections with viral hepatitis and HIV (Sever et al. 1994).
The Iran experience was similar. Broumand reported that 95 per cent of the donors who sold
their kidneys under the state-managed organ donation system received no follow-up visits
(Broumand 1997). Zargoshi reported that 82 per cent of the paid unrelated donors were happy
with their donation, 75 per cent did not achieve the goal for which they donated, and 99 per cent
would have preferred to beg or take a loan to meet their financial problems, if given a chance to
reconsider their decision to sell their kidneys (Zargooshi 2001).
 The idea that permitting sale of organs would make transplantation available to more patients
also turned out to be unfounded. Data from Iran showed that as the number of transplants from
paid unrelated donors went up, the number of transplants from living related donors went down,
and the total number of transplants remained essentially unchanged (Zargooshi 2001).
The consensus of opinion across the world seems to have crystallized around the concept that
buying and selling organs is ethically unacceptable. In the USA, the Transplantation Society
published guidelines regarding living donation in transplantation (Transplantation Society 1985).
The guidelines specifically prohibit soliciting of unrelated donors for profit. A special resolution
adopted by the society recommended that ‘no transplant surgeon or team should be involved,
directly or indirectly in the buying or selling of organs or tissues or in any transplant activity
aimed at commercial gain to himself or herself or an association’ (Transplantation Society 1985).
The World Health Organization (WHO) endorsed these guidelines and added ‘in light of
principles of distributive justice and equity, donated organs should be made available to patients
on the basis of medical need and not on the basis of financial or other considerations’.
Unfortunately, in countries without universal healthcare coverage, the patient’s capacity to afford
a transplant and life-long immunosuppression does become an unavoidable financial
consideration. The WHO stated that the sale of organs violates the Universal Declaration of
Human Rights as well as its own constitution. It states that ‘[t]he human body and its parts
cannot be the subject of commercial transactions’. Accordingly, giving or receiving payment for
organs should be prohibited. The Declaration of Istanbul on Organ Trafficking and Transplant
tourism defined ‘Transplant Commercialism’ as ‘a policy or practice in which an organ is treated
as a commodity, including by being bought or sold or used for material gain’ (Transplantation
Society 1985).
The opinion of the transplant community does not necessarily reflect the opinion of the
general public or even the medical community at large. Guttmann and Guttmann (1993)
administered two different questionnaires to 100 medical students, 150 members of the public,
and 137 physicians and 94 nurses, of whom 24 and 34 respectively were involved in looking
after transplant patients. The questionnaires had a case scenario of a 32-year-old man with renal
failure, one from Montreal, Canada and the other from Chennai, India. Neither had relatives who
could donate. The Canadian man was on dialysis and was listed for a deceased donor kidney
transplant. The Indian did not have either option. In both scenarios, the possibility of paying a
donor for a kidney was presented and respondents were asked if they found it acceptable.
There was more sympathy for the Indian patient with 49 per cent of total respondents—74 per
cent of the public, 57 per cent of the medical students, 27 per cent of the medical professionals,
and 43 per cent of the transplant community—saying it would be acceptable for him to buy an
organ. However, even in the situation of having dialysis available and with the prospect of a
kidney from a deceased donor eventually becoming available, in the case of the Canadian
patient, the option of buying an organ was supported by 40 per cent of all respondents—69 per
cent of the public, 51 per cent of medical students, 23 per cent of medical professionals, and 21
per cent of the transplant community.
Clearly the last word has not been spoken about the practice of trafficking in human organs
and it continues in covert fashion throughout the world. However, there is a broad consensus that
the practice is undesirable and should be stopped.

Manipulation of the Waiting List for Organ Allocation

In theory, all men are born equal and every life has an equal value. In practice, Jews were gassed
and incinerated, the Rohingyas seem to be facing ethnic cleansing in Myanmar, we allow
children to starve to death in Sub-Saharan Africa, and members of the Secret Service and other
state security agencies guarding heads of state are trained to guard their charges by interposing
their own bodies between the person and any assault. The principle of equity is tested every time
a ‘Very Important Person’ (VIP) needs an organ to save his life. We have not yet seen a scenario
in which an American President requires an urgent transplant. Would he be given the next
available organ?
In practice, it is clear that VIPs have received preferential treatment in many instances with
thinly disguised attempts to conceal the unfairness. Sometimes wealth alone rather than office
renders a person ‘special’. We consider a few instances.
Perhaps the most widely publicized case of manipulation of the waiting list was (somewhat
surprisingly) reported from Germany. Cases were described over a period of 10 years at 4 liver
transplant centres: the University of Gottingen, University of Regensberg, Munich Klinikum
Rechts der Issar Hospital, and the University Hospital Leipzig (Pondrom 2013). At all four
centres, doctors allegedly falsified medical records to indicate that patients were undergoing
dialysis. It may be recalled that, in the years preceding the application of the MELD (Model for
End-stage Liver Disease) score for organ allocation, transplant physicians in the US would admit
patients to the hospital or transfer them to the intensive care units (ICU) even when not
medically indicated in order to acquire priority on the waiting list. In the setting of a scarcity of
donor organs, one organ can save one life. It is normal for a transplant surgeon to empathize with
his own patient and to attempt to give his patient an unfair advantage. This becomes more
sinister when there is a financial motive to do so. In the German scandal, Dr Aiman O was at
Gottingen and at Regensberg. Records of 23 patients were found to be falsified. Dr O was
arrested and charged with nine counts of attempted manslaughter, one case of serious injury, and
one count of aggravated assault resulting in death. At the Munich Klinikum Rechts der Issar
Hospital, four patients waiting for liver transplantation had urine added to their blood samples to
raise their serum creatinine reports and make them seem to be in a worse medical condition. The
adverse publicity when this corruption scandal came to light led to a decrease in organ donations
in Germany by 13 per cent and indirectly led to more deaths among patients waiting for an
organ. It later emerged that Dr O’s contract included bonus payments for every liver he was able
to transplant.9
In a case in the US, doctors at the St Vincent Medical Center skipped nine of their own
patients on a regional liver transplant list, giving preferential treatment instead to a Saudi
national ranked 52nd.10 The Saudi national received a liver which should have gone to a patient
at UCLA. While the article does not disclose the motivation for this act, hospitals in the US
invariably bill patients who pay out of pocket, particularly foreign nationals, far more than the
price determined by collective bargaining agreements with insurers and with Medicare and
Medicaid. The Royal Embassy of Saudi Arabia paid St Vincent USD 339,000 in addition to an
undisclosed fee to the doctors. Another article in the Los Angeles Times sheds more light on this
incident.11 The hospital had listed a Saudi Arabian national for a liver transplant. It was notified
by the organ procurement agency that a liver was available for another patient who was out of
town. The hospital should have notified the agency that the patient was not able to reach the
transplant centre in time. The liver would have been allocated to the next patient on the waiting
list at UCLA. Instead, they accepted the liver and used it for the Saudi patient’s transplant.
Hospital staff members allegedly falsified documents several times in order to hide this. First,
they accidentally (and accurately) informed the United Network of Organ Sharing (UNOS) that
the patient should be removed from the list because he had just received a liver. Realizing their
error, they then retracted this correspondence and requested that the patient be put back on the
list. Later, they notified UNOS that the patient wanted to be removed from the waiting list
because he was transferring to a centre in Europe. Meanwhile, they continued to send forged
follow-up communications identifying the second patient as the first (who meanwhile had died).
They also digitally altered the pathology report of the removed liver to indicate that it was from
the other patient.
Another controversy about organ allocation arose in the UK.12 The King’s College Hospital
transplant team was the subject of an investigation after using part of a liver for a child from the
Gulf who was listed as a private patient. Other transplant surgeons protested as national
guidelines state that livers must be offered to all other NHS centres before they can be given to a
patient from outside the European Union. In this case, the liver from a 40-year-old donor was
first received at St James University Hospital in Leeds. After instructions from UK Transplant,
the surgeons at St James University Hospital sent the liver to King’s College Hospital for a
super-urgent adult NHS patient. Later they learnt that the liver had been split and the left lobe
had been transplanted into a 7-year-old boy from the Gulf. The article reported that King’s
College Hospital had given livers from UK donors to 22 private patients from Kuwait and the
UAE in the past 4 years, making more than 4 million pounds from these private patients. One
would suppose that the state-sponsored NHS system would be relatively immune to the perverse
incentives which prevail in other parts of the world, but unfortunately the lucrative private
practice option also results in similar problems there.
There are other ways in which VIP patients get what they want (which is sometimes different
from what they need). This may not be of great concern to us until it results in disadvantaging
other patients.
At a time when liver transplantation for liver cancer had fallen into disrepute because of high
recurrence rates, the famous baseball player Mickey Mantle underwent a deceased donor liver
transplant at the Baylor Institute of Transplantation (Randall 1996). He received a liver within 48
hours of listing. He developed lung metastases within three months of the transplant and died,
probably earlier than he would have without a transplant. Of course, another patient who would
potentially have had a long-term survival with that liver, missed out. In this paper, Richard
Kaplan of the National Cancer Institute was quoted as saying that the transplant community faces
a temptation to tip the balance in favour of a celebrity because of the media attention such
patients attract. I would go one step further and admit that we often succumb to the temptation.
Another such case is that of Steve Jobs. From information in the public domain and from his
official biography, (Issacson 2011) we can reconstruct the sequence of events as follows. Steve
Jobs was initially diagnosed with a tumour in the pancreas. At the time of diagnosis there was no
evidence of it having spread anywhere else. Jobs was advised surgery to resect the tumour.
However, Jobs had a well-known ‘reality distortion field’ and was given to ‘magical thinking’
and he decided to treat the tumour with various quackeries including a vegan diet, acupuncture,
herbal remedies, and the services of a psychic. The tumour proved resistant to such measures and
nine months later Jobs underwent surgery. It is possible that in those nine months, the tumour
spread to the liver. It was a relatively indolent maligancy called a neuroendocrine tumour. He
later underwent a liver transplant at the Methodist University Hospital Transplant Institute in
Memphis, Tennessee. This centre had a short waiting time to transplant and Steve Jobs, with a
private jet at his disposal, was able to reach the hospital quickly when a liver became available.
We also know that when he had the transplant, he had tumour deposits in the peritoneum. This
would normally be a contraindication to proceeding with the liver transplant.
One of the things which keeps tumours under control is the immune system of the patient. It is
known that tumours progress quicker in immunosuppressed patients and this is true of
neuroendocrine tumours as well. Jobs died about 2.5 years after the transplant. He got what he
wanted rather than what he needed.
The situation was muddied further when it emerged that the surgeon who had performed the
transplant had moved into the (2 storey, 13 room) house where Steve Jobs had convalesced after
the transplant. Although he bought the house (at a bargain price from a shell company held by
Apple), the Apple counsel was paying the taxes and utility bills for the house for nearly two
years.13
Another interesting case of a VIP getting preferential treatment was that of the Ottawa
Senators (a Canadian ice hockey team) owner and billionaire Eugene Melnyk. When he was told
that he needed a liver transplant, his organization held a news conference and made a public call
for help.14 Nearly 2,000 prospective liver donors stepped forward.15 The transplant took place
within five days of the appeal. The team tweeted that the donor was partly motivated by the
thought that a healthy Melnyk would be able to ‘bring the Stanley Cup home’.16
I do not think we can expect higher ethical standards from the Indian medical profession when
similar situations come up. I can describe a personal experience. In 2010–11, organ donations
were few and far between in north India and most patients listed for deceased donor liver
transplants would die while still on the waiting list. We were understandably excited when the
family of a brain-dead patient in our own ICU at Sir Ganga Ram Hospital agreed to donate his
organs. We called in a patient on our waiting list and prepared for the rare deceased donor liver
transplant. At the last moment I received a call from the Chairman of the Board of Management.
He said ‘we’ve received instructions from the Health Ministry that the liver will be given to a
patient in Hyderabad. We cannot afford to antagonise the ministry’. A roving transplant surgeon,
offering his services on a visiting basis, came to the hospital, procured the liver, and flew with it
to Hyderabad where he performed the transplant. It later emerged that the recipient was a
‘business associate’ of a politician. He is rumoured to have died soon after the transplant.

Performing Transplants on Patients Who Do Not Need Them

It is clear that doctors can be as avaricious as anyone else and hospitals that offer an incentive or
fee based on the number of cases handled are providing a perverse incentive to perform more and
more transplants. A few years ago, the CEO of a major hospital chain told me that there is only
one metric important for him. That statistic is the billing per day per bed. In case of a medical
patient admitted for a febrile illness, it is unlikely for the billing to exceed, say, Rs 10,000 a day.
On the other hand, for an uneventful liver transplant, the figure could be well over Rs 100,000 a
day. It is not surprising that more and more hospitals are trying to start liver transplant
programmes, often with little understanding of the investment required. Once again, I turn first to
an example from abroad to illustrate the nature of the problem, although in this case I have some
personal experience of the events described.
The Thomas E. Starzl Transplantation Institute of the University of Pittsburgh Medical Center
(UPMC) was once recognized as the Mecca of transplantation. Set up by the pioneer of liver
transplantation after whom it has been named, the institute, at its height was doing nearly 500
liver transplants a year. However, as other liver transplant centres came up and the number of
donors plateaued, the transplant volumes at UPMC began to decline. It still had a reputation for
taking on the most difficult cases and many of the innovations in the field in surgical technique
as well as immunosuppression had emerged from this institute. Surgeons at the centre criticized
other centres for what they called ‘boutique cases’. It referred to patients who had liver disease
but were not very sick. They were living nearly normal lives and because they were in
reasonably good shape, the transplantation process was often smoother with low complication
rates. However, these patients were also probably better off without a transplant. As they pointed
out ‘patients called in for the operation from the 19th hole of the golf course have a higher
survival without transplant’.17
An article in the Wall Street Journal and a series of articles in the Pittsburgh Tribune Review
did a great job of investigative journalism to reconstruct the sequence of events. As John
Carreyou for the Wall Street Journal pointed out, UPMC was a non-profit hospital system whose
income was largely exempt from income tax.18 However, the company was being run in a
manner indistinguishable from a for-profit company. The CEO and senior executives were being
paid enormous salaries. The article reported that the CEO, Jeffrey Romoff, was paid USD 4
million in 2007 and 13 other employees earned in the range of USD 1–2 million. Wanting to
increase the revenue generated from liver transplants, the hospital invited a flamboyant young
surgeon named Amadeo Marcos to ‘ramp up’ the liver transplant programme. Marcos,
undoubtedly one of the pioneers of living donor liver transplantation in adults, had a reputation
for increasing the liver transplant numbers. He was prevailed upon to move from the Strong
Memorial Hospital in Rochester, New York to the Starzl Institute. In an email to the
management, Marcos claimed that he could double the number of liver transplants being done at
UPMC. Marcos would be paid at least USD 500,000 a year with additional incentives based on
achievement of ‘clinical and academic goals’. Over the next few years, he did manage to keep
his promise. Incidentally, those were also the years when I was a fellow at the institute.
Marcos managed to increase the number of transplants using two distinct strategies, both
targeted at the patients who were relatively well. The sicker patients would get transplants
anyway since the MELD system was designed to allocate organs to the sickest patients first. One
strategy was to accept livers which other centres did not want because they had problems
(elderly donors, fatty livers, and so on) and transplant them into patients who were not very sick.
These patients, according to him, would be more likely to survive the transplant even with a
borderline liver. However, others countered that these patients may have been better off without
a transplant altogether. Some of them would go on to require another transplant if the first liver
did not work and deprive a sick patient elsewhere of a liver.
Fabregas identified four liver transplant centres which were systematically following a policy
of accepting ‘marginal’ livers rejected by other centres and transplanting them into patients who
were not very sick.19 Starzl was quoted in the article saying, ‘It is undoubtedly true that there are
transplants being done that shouldn’t be done’. These four centres had done 846 such transplants
since 2005. Marcos was quoted in the article saying he did not favour using marginal livers for
the sickest patients. He agreed that it would benefit the patient but felt it would hurt the centre’s
overall survival statistics.
Joseph Tector who was the head of the Indianapolis transplant program which also was doing
a large number of such transplants was interviewed by Fabregas and had some rather bizarre
observations.20 ‘It’s like shopping for cars, OK, and it’s your 16-year-old kid who needs a car’,
Tector said. ‘They don’t need a Maserati. They need to get to school. They need to be able to
drive to practices and stuff like that, and that’s it. So that car doesn’t have to be the greatest car
in the world for them to have a very good quality of life. These organs are no different.’ Tector
said he tells patients what they need to know—or ask—about the donor organ. ‘Basically what
we tell people is that “Cinderella’s dead. Snow White is dead. You are not getting their liver”.’
There was also a financial incentive for the hospital to operate on less sick patients. The
federal government and private insurers pay a flat rate up to certain limits for a liver transplant.21
Transplant centres make money on patients whose care costs less than the rate and lose money
on those whose care costs more. The article pointed out that a study from Northwestern
Memorial Hospital’s transplant centre in 2005 showed that the hospital lost money when it
treated patients with MELD scores higher than 15. Each one point increase in MELD score
added USD 4,309 to the cost of caring for the patient.
While Marcos and Tector were probably prioritizing the number of transplants they were
doing rather than what was best for their patients, scientific evidence was emerging which would
change organ allocation behaviour in the US. An article by Merion et al. in the American Journal
of Transplantation in 2005 looked at patient’s risk of dying while they were waiting for a
transplant or after transplant (Merion 2005). They looked at a cohort of 12,996 patients placed on
the waiting list for liver transplant between 2001 and 2003. They found that as the patients
became sicker, the benefit of transplantation increased. They reported that, at the time of listing,
more than half the patients had a MELD score of less than 15. At the time of transplant, 24 per
cent of the patients still had a MELD score less than 15. For patients with a MELD score of less
than 15, the mortality after transplant was greater than the mortality on the waiting list for a
follow-up period of one year. This essentially meant that for them the transplant was more
hazardous than continuing to wait. One may think that these patients would eventually become
sicker and need a transplant, but that also turned out not to be the case. In this study, looking at
follow-up of at least a year, only 5 per cent of patients with a MELD of under 15 progressed into
a MELD score category that required a transplant for a better survival rate. They also showed
that as the MELD score rises (patients get sicker), the benefit of transplant goes up enormously
and there is no MELD score at which transplant is clearly futile.
Unfortunately, nobody has attempted such an analysis of patients undergoing liver
transplantation in India. There is undoubtedly competition between liver transplant centres for
number of transplants performed. There is also pressure from the hospital managements to do
more and more transplants. Finally, most liver transplant centres in India follow a fee-for-service
model where the money paid to the transplant unit depends on the number of transplants done.
This creates a perverse incentive to perform a greater number of transplants, even in patients who
would be better off without transplant. I will recapitulate Starzl in the Indian context and assert
that ‘It is undoubtedly true that there are transplants being done that shouldn’t be done’.
An additional consideration in India is that is not uncommon for transplant surgeons to take
an additional cash fee from patients apart from the bill generated by the hospital.
A curious problem specific to the city of Mumbai would be pertinent to mention at this
juncture. The Zonal Transplantation Coordination Committee in Mumbai looks after allocation
of organs from deceased donors. Until recently, the number of organ donations in the city was
very small and the focus of the organization was to make sure the organs were allocated in a fair
manner. All patients in the city waiting for deceased donor transplants were listed with them. If
there was a donor in a transplant centre they would use the liver and one of the kidneys and the
other kidney would be allocated to a patient from the city list. The longest waiting patient at that
centre would be allocated the liver. For the kidney a scoring system which also included waiting
time was used. In case of the liver, patients with acute liver failure meeting King’s College
Hospital’s criteria would get first priority.
This did not matter as long as organ donation rates were low. Waiting for a deceased donor
liver was a lottery. However, with increasing organ donation rates (there were more than 50
organ donations in Mumbai in 2016), problems showed up with this system. Since allocation was
by date of listing rather than by severity of liver disease, sick patients would generally have more
stable patients ahead of them in the waiting list. They would die waiting for an organ. When an
organ actually became available, the longest waiting patient would get the organ. These would be
the most stable patients. I suspect, although this information is not available, that many of them
would be in the category of low MELD (<15) and would actually be harmed rather than helped
by the transplant. The well-meaning system is probably harming all categories of patients, those
who get a transplant as well as those who do not. We know from Merion’s paper (Merion RM
2005) that these patients with low MELD scores have a very low rate of progression to a MELD
score at which transplant is actually beneficial. Unfortunately, the ‘date of listing’ policy results
in centres saturating the waiting list with patients who may not actually need a transplant and
patients who actually need a transplant are unlikely to get it on time.

Denying Transplants to Patients Who Need Them

I will not go into the financial aspect of offering a liver transplant to everyone who needs one.
The operation is a major one performed on a sick patient. The need for blood products,
medicines, consumables, and investigations is greater than for any regularly performed
operation. Organs are scarce. The expertise is not available in most parts of the country. In the
final analysis, a country with a GDP of USD 1,805 per capita22 and an expenditure on healthcare
of 4.7 per cent of the GDP23 cannot afford to provide transplants to all who need them. Here we
will consider those patients who need a transplant, can afford them, but were never offered the
option.
We begin with data from the US. As the Fabregas series of investigative articles showed, the
policy of fixed remuneration for liver transplants in the US by insurers and the government
incentivizes transplant centres to perform transplants only on less sick patients24 even though
these patients might actually be harmed rather than helped by the transplant. On the other hand,
sicker patients who have a much greater benefit from the transplant take longer to recover and
consume more resources. They are, in other terms, less profitable for the institution. This is
further exacerbated by the fact that centre outcomes are available for all to see on the Scientific
Registry of Transplant Recipients website. Centres which take on sicker patients will have poorer
outcomes than those that do not although the overall outcome of all patients with liver disease
will be better (less patients would be abandoned to die as too sick to transplant). If the outcomes
are below a certain threshold, insurance companies or the government may refuse to reimburse
the hospital for transplants, effectively shutting down the programme.
In 2007, the Center for Medicare and Medicaid Services (CMS) began a new policy called
‘Conditions of Participation’. Transplant centre outcomes were used to label them as good or bad
performers. Centres that performed below the new CMS-defined benchmarks for volume of
transplant procedures and one-year survival rates for patient and grafts could lose funding by
CMS as well as by private insurers. Immediately after implementation of the policy, there was a
spike in the number of liver transplant candidates de-listed because of patients becoming ‘too
sick to transplant’ (Dolgin et al. 2016). These patients would, of course, eventually die but they
would not show up on the waitlist mortality figure. The policy was not associated with a
significant improvement in the one-year survival even though centres were now transplanting
less sick patients who would benefit less from the transplant. The rate of delisting increased from
1 in 9 transplants to 1 in 5 transplants. It was clearly easier to label a sicker patient as ‘too sick to
transplant’ than to take on the commitment of resources and the financial disincentive and the
threat of poorer outcomes.
A very different form of bias exists in India which prevents patients from getting transplants
at the optimal time. Liver transplantation in India is predominantly living donor liver
transplantation. It would seem to be trivial for physicians looking after patients with liver disease
to refer them for transplant at the right time. With no wait for an organ from a deceased donor,
the transplant could be done at the right time and one would expect excellent outcomes.
Unfortunately, the truth is far from this. Most gastroenterologists, many of whom refer to
themselves as hepatologists despite not having any sub-speciality fellowship, have trained at
centres where liver transplantation was not available. Patients with decompensated liver cirrhosis
were managed medically from crisis to crisis until they died. These are very lucrative patients for
a ‘hepatologist’. They visit the clinic regularly, they have many procedures like endoscopies and
large volume paracenteses which can be billed for. They have frequent inpatient admissions.
They are basically geese which lay many golden eggs before they die. If they are referred for a
transplant on time, the supply of golden eggs dries up. Another potentially confounding factor
was that transplant outcomes in India in the late 1990s and early 2000s were actually poor and
the learning curve phase of liver transplantation led to patients being referred for transplant only
when death was inevitable.
In 2013, at Sir Ganga Ram Hospital in Delhi, we reviewed the outcomes of our liver
transplants according to the referral pattern (Kumaran et al. 2013). We found that the 21 patients
referred for transplant by the gastroenterology department of our own hospital had a very high
in-hospital mortality (33 per cent) while the 76 patients who had come directly to the liver
transplant unit had a much lower in-hospital mortality of 6.5 per cent. The patients referred by
the gastroenterologists were much sicker. They were far more likely to have been in-patients (85
per cent vs 22 per cent) and if inpatients, far more likely to be in the ICU (42 per cent vs 15 per
cent). They had much higher MELD scores (30 vs 21). Obviously, they were not being referred
at the right time for transplant. Later interactions with other transplant teams in the country have
revealed that the problem is systemic. There is a handful of trained transplant hepatologists in the
country who are able to assess when a patient needs a liver transplant. The others follow the
‘goose laying golden eggs’ protocol.

Lying about the Outcomes of Transplantation

There is no doubt that the early years of liver transplantation in India saw very poor outcomes.
The first four liver transplants attempted at the All India Institute of Medical Sciences (AIIMS)
all ended in mortality within 28 days. Even after the first few successful transplants in 1998,
outcomes remained dismal for many years. The initial poor outcomes had a self-perpetuating
effect. Patients were referred late because, while they were relatively stable, neither they nor the
referring physician wanted them to take on the perceived high risk and cost of transplantation.
It was only after about 2006 that liver transplants began to be done regularly and with good
outcomes, predominantly at two centres in Delhi, Sir Ganga Ram Hospital and Apollo Hospital.
As liver transplant numbers increased and the outcomes began to approach those at good centres
elsewhere in the world and as the number of liver transplant centres increased, it was
accompanied by competition and the pressure to overstate the outcomes and minimize the
complications. Nowhere is this more obvious than when we talk (or rather avoid talking) about
donor deaths and complications.
The death of a healthy donor is a tragedy and all measures must be taken to avoid it, but we
must not delude ourselves into thinking that we can continue to perform major liver resections in
large numbers of people with zero mortality and minimal morbidity. Ideally every donor
mortality should be reported and used as a learning opportunity to avoid similar problems in
future. Unfortunately, the community of transplant surgeons all over the world have neglected
this crucial aspect of liver transplantation and our figures for the risk of the operation are
basically guesswork.
Russell Strong, who performed the first successful living donor liver transplant, was
concerned about the proliferation of living donor liver transplant programmes (Strong 1999). He
pointed out that he was aware of at least six donor deaths but only one had been reported in the
medical literature at the time.
An early attempt to quantify the risk of donor mortality was made by Bramstedt in 2006
(Bramstedt 2006). Medical journals as well as print media were searched for living liver donor
deaths. United Network of Organ Sharing and European Liver Transplant Registry (ELTR) were
queried for information about donor deaths. Websites of US transplant centres offering living
donor liver transplants were reviewed to identify whether death was stated as a donor risk. A
total of 14 living donor deaths were identified. Interestingly, only one of the five donor deaths in
the US had been reported to UNOS.
A more determined attempt to identify donor deaths was made by Trotter et al. (2006). They
were able to identify 19 donor deaths and 1 donor in a chronic vegetative state. The lack of
information about the circumstances of the donor deaths is highlighted by some of the items in
their paper. For instance, ‘a donor of unknown age and unknown relationship to the recipient
donated an unknown lobe and died 10 days after surgery of unknown causes’.
A more recent survey of living donor liver transplant centres across the world was published
in 2013 (Cheah et al. 2013). This was based on a survey sent to 148 centres performing living
donor liver transplants. They identified 23 donor mortalities in 11,553 hepatectomies (0.2 per
cent) and a morbidity of 24 per cent. Unfortunately, a survey like this has no mechanism to
verify the data and centres could choose to simply lie about their donor outcomes. Centres with
recent donor mortalities or with high morbidities may have chosen to not respond to the survey if
they had inhibitions about shameless lying; so, this is likely to be an underestimate. Eleven of the
donor deaths in this survey had not been previously reported in the literature.
We have very little published data on donor mortality from India despite the large number of
living donor liver transplants done here. Reddy et al. (2013) reported a donor death at the Global
Hospital, Chennai, apparently due to systemic inflammatory response syndrome due to acute
pancreatitis. They conducted an internal as well as external audit of the case and reported the
events culminating in the demise of the donor. Ideally, all donor deaths would receive the same
amount of auditing and transparency, but unfortunately the general trend has been to hide donor
deaths rather than report them.
The death of a donor and recipient at KEM hospital in Mumbai was reported as a setback to
the establishment of liver transplant services in the region but none of the reports mentioned that
a team of surgeons from a high-volume centre in Delhi had been invited to come to KEM to help
with the transplant.25
The community of liver transplant surgeons in India is still relatively small and an event like
the death of a liver donor cannot be kept hidden. Despite all efforts, resident doctors, nurses,
intensivists, anaesthetists, and so on have their own grapevines which rapidly disseminate news
of such events. Sometimes family members of deteriorating patients seek second opinions.
Occasionally the transplant teams consult each other in confidence when faced with problematic
situations. Information obtained in this manner does not constitute data which can be published,
but we get an overall picture.
Our best estimate (Nagral et al. 2015) is that at least 20 donor deaths have occurred in India in
approximately 6,000 living donor liver transplants (0.3 per cent). This is a figure close to
international norms, but it is disturbing that although most of the donor deaths have occurred at
high volume centres (or when surgeons from high volume centres have operated at other
centres), the tendency is to not acknowledge them. No attempt has been made to learn from these
tragedies or to invite collaboration between centres to learn from these cases other than the single
case report.
There is considerable discrepancy between the transplant community’s acceptance of donor
risk and that of the community at large. Colter et al. (2001) conducted a survey regarding
acceptance of risk in the community. Half the 150 respondents were family members of patients
at a medical care group serving an indigent population and half were from a private clinic. Sixty
per cent of the respondents said they would prefer to donate to their family member and die and
have the recipient live rather than forego donation and have the recipient die. Their threshold for
donor survival was 79 per cent and their threshold for recipient survival for which they would
accept that 21 per cent mortality was only 55 per cent. Eighty-one per cent of the respondents
stated that the potential donor rather than the physician should have the final say. Respondents
also preferred the option of donating and having the recipient die than refusing to donate and
having the recipient die of liver failure. Forty-four per cent of respondents stated that they would
rather donate and die and have the recipient live than donate and live and have the recipient die.
Another more recent survey was conducted at the Queen Elizabeth II Medical Center, Halifax,
Canada (Molinari et al. 2014). This centre does not perform living donor liver transplants. The
survey was conducted among the caregivers and family members of 96 patients with end stage
liver disease listed for liver transplant at the centre. Even when the aetiology of disease was self-
inflicted as in alcoholic liver disease, 81 per cent of the respondents were keen to donate. Twenty
per cent of these were willing to donate even if the patient continued to drink. Half the
participants declined surgery when the risk of complications was greater than 75 per cent or risk
of death was 30 per cent or more.
Of course, what respondents state in such surveys may not match what they decide to do in
the real world, but clearly the population at large would accept a certain risk in order to save the
life of a loved one.
Donor outcomes are not the only subject for lying (or creative mathematics). The veracity of
claims regarding number of transplants and outcomes is also sometimes dubious in the absence
of a systematic and reliable mechanism for collecting such data. In the US, for instance, a
mortality cannot really be hidden because each patient is identified by the social security number
(another reason why the patient substitution shenanigans could only be performed with foreign
nationals).26 Potentially the Aadhaar number could eventually serve the same purpose in India.
Creative mathematics have been used, not only to inflate the number of transplants done (a
well-known transplant centre advertised a ‘cumulative experience of 10,000 transplants’) but
also to minimize complications and mortalities by ‘strategic censoring’. Indian transplant
surgeons are by no means unique in creative use of statistics and examples from abroad are better
documented. I will cite one well-known instance as an example.
Amadeo Marcos is undoubtedly one of the pioneers of adult-to-adult living donor liver
transplants using right lobes. He began doing living donor liver transplants in adults using right
lobes at the Virginia Commonwealth University in Richmond. Outcomes of the first 40 cases
were published in 2000 (Marcos et al. 2000). After the first 22 cases, they realized that sicker
patients (UNOS status IIA) had a high mortality after this procedure and restricted the procedure
to patients who were not very sick. He referred to this strategy as ‘attack the waiting list from
behind’ (Marcos et al. 2000). We know now that the patient in the back of the waiting list were
probably not sick enough to benefit from liver transplantation. In fact the data from Merion et al.
(2005) would show that transplantation would harm these patients more than continuing to
remain on the waiting list. In any case, comparing the first half of the series with the second half,
he reported that the incidence of recipient biliary complications decreased from 35 per cent to
nil. Biliary complications remain a still unsolved problem in living donor liver transplantation,
but this paper gave the impression that the problem was easy to solve by stenting the biliary
anastomoses.
A later paper by Maluf et al. (2005) was published from the same centre which included this
cohort of 40 patients and an additional 29 patients who underwent living donor liver transplants
subsequently. The authors were other members of the team after Marcos had moved on to the
Strong Memorial Hospital in Rochester, New York. The mean MELD score of the recipients was
13. They compared the first 23 cases to the next 46. As mentioned in that paper, they stopped
offering living donor liver transplants to the sicker patients after the first 23 cases. Maluf et al.
reported a biliary complication rate of 34.7 per cent in the first 23 cases and 24 per cent in the
subsequent 46 patients.
The discrepancy between nil biliary complication rate in cases 21 to 40 in the first paper and
the 24 per cent rate in cases 24 to 69 (of the same series) is baffling. It probably cannot be
explained by development of late biliary complications which were diagnosed after the first
paper was published.
A similar discrepancy was noticed when Marcos joined the University of Pittsburgh Medical
Center. In fact, Thomas Starzl himself noticed the high incidence of biliary complications in
patients undergoing living donor liver transplants at the Starzl Institute. He is quoted as having
stated in an interview to Luis Fabregas about Marcos that ‘his personal behaviour included lying
about complications’.27 Starzl reviewed the outcomes of 121 living donor transplants performed
by Marcos and found that the incidence of life-threatening complications among the recipients
was nearly double that reported by Marcos.28 Starzl sent his findings as a paper to a journal only
to have Timothy Billiar, the head of the department of surgery, write to the journal not to publish
the data.
Eventually a compromise was arrived at and, after an outside audit, the complications were
published (Marsh et al. 2009). The majority of the patients who underwent living donor liver
transplants had a MELD score less than 15 calling into question the benefit of the procedure.
Within one year, 80 of the 121 recipients (66 per cent) had grade III or IV (Clavien System)
complications. The incidence of biliary complications was 42 per cent and the incidence of
vascular complications was 15 per cent. The biliary complications often required major
interventions (20 surgical reconstructions, 25 endoscopic or interventional procedures). Seven of
the recipients required re-transplantation with deceased donor livers.
I do not believe Marcos’ is an isolated case. The statement ‘his personal behaviour included
lying about complications’ undoubtedly applies to some, if not many, transplant surgeons in
India as well. Liver transplant surgeons tend to be larger than life characters with forceful
personalities and perhaps they would not be so successful without these. In many cases they live
in a ‘reality distortion field’ where they convince themselves that reality is what they would like
it to be. They are not even aware of lying. They merely consider it a waste of time to put in place
robust systems to measure outcomes in an objective manner.
I was a fellow at the University of Pittsburgh during Marcos’ most prolific years there. As a
first year fellow, one of my jobs was to take a round of the patients before the Consultant’s round
and to write the progress notes in the patient’s case sheet. One morning I wrote in my notes
‘drain has 300 ml of bile’. The consultant on rounds changed the note before signing to ‘300 ml
of straw colored fluid’. I was somewhat befuddled and wondered if straw in America was a
different colour from what it is in India. To settle the question, I drew some of the fluid and sent
it off to the lab for a bilirubin level. The level came back very high, demonstrating unequivocally
that the fluid was almost pure bile indicating a bile leak from the anastomosis. I was summoned
to Marcos’ office and told off in no uncertain terms to do what I was told and not attempt to use
my brain.

Failing to Maintain Standards of Care

As liver transplantation has become standard of care for the management of patients with end
stage liver disease, more and more hospitals in India have begun to realize that they can no
longer continue to pretend to treat patients with acute or chronic liver disease without offering
liver transplantation. It is also perceived as a ‘lucrative’ operation (the billing per bed per day
metric). Unfortunately, relatively few centres have embarked upon the undertaking with a clear
idea of the investment required.
One of the problems has been the lack of clarity regarding what constitutes a trained and
competent transplant surgeon or hepatologist. Many hospitals have embarked upon liver
transplant programmes with surgeons who have spent short periods of time at transplant centres
abroad in the capacity of observers with no clinical responsibilities and no structured training
programmes. The results were disastrous and many programmes began performing liver
transplants only to give up after initial poor outcomes.
Another particularly appalling trend has been the ‘hired knife’. The practice of engaging a
surgeon or surgeons to come to a hospital, operate on a patient, collect the fees (sometimes in
cash directly from the patient), and leave resulted in expectedly deplorable outcomes, including
some of the unreported donor mortalities.
The consequences of embarking upon a poorly planned liver transplant programme have not
been adequately investigated in India. The attempt to start living donor liver transplantation at
KEM Hospital was one such. As the head of the department there pointed out, ‘We will lie low
for some time as our team is demoralized’.29
Better documented was an instance in Japan. Professor Koichi Tanaka is one of the pioneers
of living donor liver transplants, particularly in children. After his retirement, he was prevailed
upon to set up a new liver transplant programme in Kobe, targeted predominantly at foreign
patients. Seven of the first 10 recipients of living donor liver transplants at the centre died.30 The
initial investigation by the Kobe Municipal Government comprised interviews with Professor
Tanaka and other staff and concluded that there were no problems.31 However, an audit
conducted by the Japanese Liver Transplantation Society concluded that three of the initial four
deaths could have been avoided. Among the problems cited was the lack of full-time
professionals in other departments of the hospital.32 The problems identified at the Kobe
International Frontier Medical Center exist at many liver transplant centres in India.

The Strange Case of Dhani Ram Baruah

In 1997, Dr Dhani Ram Baruah, a well-known cardiac surgeon practicing in Assam, announced
that he had successfully transplanted the heart of a pig into a human patient. Such a claim from a
centre with no prior experience in transplantation and outside the context of a peer-reviewed
Institutional Review Board-approved clinical trial was disconcerting enough. The subsequent
uproar eventually led to his being arrested. He remained in custody for 40 days and eventually
signed a statement saying that the surgery never took place.33 He later claimed to have found a
cure for AIDS using ‘Baruah Biological Combat Genes’ as ‘biological missiles’. Unsurprisingly,
this potentially Nobel Prize winning work has not been published in any peer-reviewed journal
of repute, but Dr Baruah continues to attract patients willing to pay large sums of money for
these therapies.
Unfortunately, Dr Baruah is not alone in such dubious practices. ‘Stem cells’ have become the
new buzzword in the medical community and the country is dotted with centres which offer
‘stem cell therapy’ for everything from gall bladder cancer to liver cirrhosis, often charging large
sums of money for these fundamentally fraudulent practices.

Recommendations
In this section I will attempt to suggest potential solutions for the problems that we have
identified in so far in this chapter.
The Transplantation of Human Organs Act, 1994 has generally done a good job of making
organ trading very difficult in India. While not impossible, it is still difficult enough that people
find it easier to go abroad with their unrelated donors and have their transplants in Singapore or
even in the US rather than trying to ‘buck the system’ here.
The manipulation of waiting lists for donors is not restricted. Examples from Germany, the
UK, and the US have shown that there are ways of corrupting even mature allocation systems. In
comparison, allocation systems in India are very primitive. Many Indian states do not have
systems for brain death declaration, let alone allocation of organs. Different states use different
systems for allocation. It is crucial to develop a simple, transparent, and robust system for
allocation of organs to the patients in need of them. It is important to build in mechanisms for
sharing information across states, when required.
While discussing how transplants are often performed for patients who do not need them, we
cited examples that illustrated how ‘perverse incentives’, usually financial in nature, overtake the
objectivity required in assessing the need to perform a transplant. In such situations, decision-
makers even ignore the potential harm that an unrequired transplant may cause. A full-time fixed
salary system of employment for the transplant team would alleviate some of the immediate
pressure to transplant more and more patients and focus instead on providing each patient with
the care that is best for them.
We also saw how patients in desperate need are often denied an organ transplant due to the
perceived impact these cases may have on the statistics of the hospital. However, at the root of
this very real problem is scrutiny of wrong parameters. If the outcomes of all patients presenting
to a centre with decompensated liver disease were to be audited instead of simply the outcomes
of the patients transplanted, the centre would have a real incentive to take on high-risk cases as
well. This would also be a better way of measuring how good the systems are at looking after
such patients.
The best way to combat the problem of lying about the outcomes of transplants, which we
discussed earlier in the chapter, would be to have robust systems in place to monitor outcomes
independently and to audit the systems in place whenever adverse outcomes occur. For instance,
at our centre at Kokilaben Dhirubhai Ambani Hospital, a ‘liver transplant tracker’ is updated on a
continuous basis and sent to the Managing Director of the hospital every month. Every mortality
is audited with members of the hospital management present at the audit. Problems identified in
audits are discussed and solutions implemented in real time. Every month transplant outcomes
are reported to the Department of Medical Education and Research (DMER). The outcome data
could potentially be used by the DMER to trigger an external audit if they seem unacceptable.
It is unfortunate but true that the existing standards of care followed by transplant centres are
not stringent enough. Many transplant centres have received permission from state health
departments to perform liver transplants without having a full-time transplant surgeon on staff.
The standards for qualification as a transplant surgeon (at least for liver transplant) need to be
objective and stringent as should be standards for other staff such as anaesthetists and
intensivists.
While we briefly discussed the strange case of Dr Dhani Ram Baruah, the case is only
representative of the many such cases that may or may not get noticed. Our government has
made a policy decision to promote medical systems known to be ineffective or even harmful
under the collective umbrella of AYUSH. Compared to the scale on which Ayurveda and
Homoeopathy are practiced in our country, the occasional bizarre quackery like this seems to
fade into obscurity.

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 CHAPTER TEN
The Public Sector and Corruption in Health Services
S.V. Nadkarni

Corruption is not just illegitimate earning. Lack of integrity, dishonest behaviour, or neglect of
duty are also corrupt practices. There is no doubt that the whole healthcare system has become
corrupt. Opportunities have increased, the public sector is overburdened, and the private sector
has monopolized the care of the affording class. Modern technology is inscrutable and that helps
the corrupt. There are financial restraints; the public sector spends only 1.1 per cent of the GDP
on the healthcare of a billion people. Despite the paucity of funds, there is a uniform demand for
free treatment from the public sector, as 76 per cent of people’s total expenditure is from their
own pockets at present. Bureaucracy is rigid, almost antagonistic, and professionals in the public
sector are not treated well. Medical education offered in institutes is inappropriate, with colleges
not focusing on creating primary physicians at all. As the sector is managed through taxation and
treatment is free, there is absolutely no cost consciousness.
But the public sector must be improved. Primary care accounts for 70 per cent of total
healthcare. It is therefore imperative that medical colleges create competent primary care
physicians. For this, colleges must start primary health centers (PHCs) and offer training for at
least two years to all those who do not get postgraduate seats. Only patients referred from PHCs
should get free treatment at a college hospital. Another important step should be to establish a
department of cost and data analysis with adequate powers and an adequate budget. This will
have a profound effect on the overall performance of all doctors and medical centres. The budget
from taxation can be used for infrastructure, but the actual health services must be purchased
from social insurance; everyone will have to contribute as per his/her income. The entire public
sector practice must be taken away from the bureaucracy and handed over to an autonomous
trust, so that medical professionals will be well treated and receive a performance-based income.
The Consumer Protection Act does not help at all. In fact, it abolishes the faith that patients
have in doctors. It should be scrapped and an alternative method evolved to protect the interests
of the patients. The public sector must advertise itself properly and forcefully.
To put it briefly, it can be safely stated that the public sector, as it is functioning today, is the
root cause of corruption in the entire healthcare system in India. According to Webster’s
dictionary, the word ‘corruption’ means the ‘impairment of integrity, virtue or moral principles
or inducement to wrong doing by improper or unlawful means (such as bribery) or dishonest or
illegal behavior especially by powerful people (such as government/police officers)’. Medical
professionals offering healthcare services can easily be included among ‘powerful people’. As
per this definition, the whole healthcare services sector is completely corrupt, both the public as
well as private sectors. There is very little integrity. Moral principles are trampled upon and the
behaviour of medical professionals in both sectors is far from honest. The basic philosophy of
the profession ought to be to offer relief to the suffering patients: ‘to cure sometimes, to relieve
often, to console always’.
Although it is legitimate to expect due remuneration for the services given, the efforts ought
to be genuinely in the interests of the patient, the family, and the community. Members of the
medical profession appear to have failed miserably in this task. Individually, many practising
doctors might mean well while performing their duties. It is the system that is forcing most to act
as they do. Are they not more selfish than ever before? Possibly yes; but as George Bernard
Shaw said, ‘As for the humour and conscience of doctors, they have as much as any other class
of men – no more and no less.’ Besides, opportunities have increased because of the advances in
the management of various illnesses due to modern technology. As the gap in the knowledge of
the experts and the common man increases, it becomes easier to cheat him. Another effect of the
advances in medical technology is that the health services have slipped from the hands of
medical professionals into the commercial hands of those who see only profit as their primary
goal, the main objective of service to the needy becoming a lower priority. International banking
is not far behind in making hay while the sun shines. It is reported that the International
Monetary Fund IMF has given Rs 2,000 crore (Rs 20 billion) in loans to just five modern
tertiary-care hospitals in Delhi. But then, this is the private sector.
Can we blame the public sector for the abuse of technology by the private sector? Indirectly,
yes. A well-organized, expanding public sector with an eye on healthcare services as its prime
objective could have curbed, if not prevented, such a gross corruption of healthcare services in
India. It should be noted that, as per data available freely on internet, 80 per cent of primary care
in India is in the hands of private sector, 80 per cent of allopathic practitioners and specialists,
and 60 per cent of hospital beds are in the private sector and it is forcing 39 million patients to
fall below the poverty line due to the out-of-pocket expenses on healthcare every year. Thus, the
important role of the public sector is strongly underlined. It must be better organized and must
rapidly expand to offer fair and impartial healthcare services at a reasonable cost. I am strictly
avoiding the term ‘free’ services. The idea that the public sector is expected to give healthcare
services free of charge must be done away with. This presumption has led to another
presumption—that the public sector is meant only for the healthcare needs of the poor or the
destitute and that is the root cause of the miserable state of affairs in this public sector.
There is a saying in Hindi that when translated means ‘I am there for the food, but for the
struggle, my brother is free’. In India, the healthcare needs have conveniently been divided into
those which are easily profitable and those which are difficult, risky, and for those which do not
pay. The former are taken over by the private sector and the latter are thrust upon the public
sector. This is the most convenient division of labour. The private sector, being a monopoly, is
free to squeeze the wealthier classes and the public sector serving the less well-off section of
society can safely neglect the poor and the destitute. There are very few genuine activists to fight
for them. The supporters of the free market, with the help of the press and the media, now
severely criticize the government and the public sector health services and propose the total
abolition of the public sector. That is precisely what the present government wants to do on the
advice of Mr Panagariya, the economic adviser to Mr Modi, our prime minister.

Problems
There is no doubt that public sector healthcare is in shambles. At the same time, there need be no
doubt that only the public sector can and will offer the needed minimum healthcare to the
maximum number of people. The problems of ensuring optimum healthcare to the maximum
number are very complex. The most important problem is poverty. Nearly 37 per cent of the
population is unable to get the recommended level of calorie/protein intake daily; and over the
last few years, calorie intake has reduced further. 47 per cent of children below the age of five
have stunted growth. The financial burden of providing healthcare lies entirely with the
government. Both the state and the central governments enthusiastically accept this burden and
claim to provide free medical services to all. But the best advantage of free treatment is taken by
government employees who, incidentally, can easily afford such treatments and they form nearly
12 per cent of the total population. Yet, government spending on healthcare services is just 1.1%
of the country’s GDP or just 4.4 per cent of the total expenditure of the government. It is 10th
lowest expenditure by any of the 191 countries in the world. The central government’s
contribution to healthcare for different states has been further reduced in the last budget of 2016–
17. At present, nearly 76 per cent of the total expenditure on health services is borne by the
patients. Yet, each successive government insists that the financial needs of the healthcare budget
will be met with from general taxation.
The previous central government had appointed a High Level Expert Group (HLEG) in 2010
under the chairmanship of Dr K. Srinath Reddy. The HLEG submitted its report in 2012 and
made many important and useful suggestions for developing Universal Health Coverage (UHC)
for all citizens of India. The committee did suggest that the government should increase its
contribution to healthcare to 1.7 per cent by 2017 and 2.5 per cent by 2022. Unfortunately, the
committee also suggested general taxation as the main source of income—‘with mandatory
contribution from the salaried class’. The HLEG committee also insisted that the entire scheme
should be free of charge. There will be no collection of the fees at healthcare centers. In my
opinion, this insistence of free treatment by governments, politicians, and the people in general,
is the root cause of the malfunctioning of the public sector. It has also led to a high level of
monetary corruption.
District hospitals and other major hospitals in the public sector are always overcrowded, and
middle-class patients are reluctant to seek treatment there, but private-sector hospitals are so
prohibitively expensive that they have no choice but to resort to the former. Most often, they use
personal influence or their social status to push their way ahead of the poor; soon bribes are
offered as often and the whole system is corrupted. The poor remain neglected. Service providers
act as if they are obliging and the patients feel obliged too. Such arrogance is a rule rather than
an exception. Secondly, there is no correlation between the actual expenses incurred and the
payment for the treatment, which is zero or near zero. This leads to arbitrary and often costly but
glamorous demands from the local politicians, activists, and/or NGOs, like CT scans or
ventilators, etc. The scarce money is misused. And more important items in general use are in
short supply. Most patients suffer and a few get the benefit of ‘modern treatment’, usually with
poor results. Most importantly, it is impossible to create any cost-consciousness among doctors,
activists, or the community due to this concept of free treatment. The whole issue of providing
health services is looked at emotionally without the necessary hard financial logic. If we wish to
improve public sector healthcare, we must create an immense level of cost-consciousness, as the
resources are so few and the needs are so many. What treatment at what cost with what actual
benefit or outcome ought to be a question asked by everyone. The exact opposite is what is
happening and politicians of all hues clamour for modern amenities, AIIMS-like tertiary-care
hospitals and for super-specialists even in small towns. The real need is to improve primary
healthcare services.

Government Bureaucracy
The attitude of the government bureaucracy is yet another major cause of the great deterioration
of public sector healthcare. It would be foolish to expect any bureaucracy to be motivated. It is
an inert body. But in good governance, it can be expected to show cold efficiency and some
sympathy. Obviously, we do not have good governance. The government machinery treats
doctors as any other clerical staff, forgetting that they are professionals. Besides, the clerical-
minded officers have a subtle, deep-seated jealousy about doctors who are generally so respected
in society. Such callous treatment given to the respectable profession takes its own toll; doctors
become indifferent and unwilling to continue in public service. Those who are good in their
profession rapidly move into the private sector to earn better money as well as better respect.
Unfortunately, some of the present generation doctors are also to be blamed. They are devoid of
the professional dignity expected of them, adding fuel to the fire. Their outlook and approach has
rapidly deteriorated into a bureaucratic mindset, relegating their primary job of providing good
healthcare, whatever the circumstances, to the background.
The process of selection and appointment is long and tedious. It takes months—even after
being selected—to be able to join the service. But what is even worse is that doctors are
transferred out of their hospitals, just like most clerical staff, so they find it hard to settle down
into their jobs. It is difficult to impress upon the authorities concerned that a doctor settled in a
place can serve the local community far better. It is important that the medical professional
develops a rapport with the families and the community and also gets involved in the
organizational aspects of the service. Secondly, a fixed salary structure with ensured increments
and promotions based on seniority alone without any consideration of quantitative or effective
output leaves no incentive to work better. There are no records worth the name to assess the
quality of work, no records to assess the final outcome, and no records to know how much was
spent on which service and with what result. In fact, apart from personal zeal to perform and
improve, there is no plausible reason why one should work at all. Most employees show no
interest in their own duties and those who work out of personal interest leave for greener pastures
of private practice when they mature. The doctors working in the public sector are discouraged
by another crooked method adopted by the officers in government—to fill the vacancies on a
temporary basis showing that the posts of medical professionals are filled. These doctors
continue in temporary posts on a permanent basis; in fact, there are doctors on temporary
appointment for even up to eight to 10 years, or more. The crooked advantage is that they are
‘terminated’ for awhile before completing one year and reappointed within a week or so. There
are no increments, no long-term benefits like provident fund, gratuity, etc., nor any earned leave.
The accounts department may get a pat on the back for saving money, and crooked minds
immense happiness by being nasty to professionals, but the casualty in all this is the deteriorating
services with each passing year. Public sector doctors and administrators are criticized as being
callous, disinterested, and working only for money with the inevitable call for shutting down
public-sector medical centres. Nowadays, we can see many public sector units being handed over
to the private sector under the so-called public–private partnership (PPP) arrangement. Barring a
few genuine efforts by dedicated NGO-run units, in most instances, the private sector earns at
public cost without any financial risk. The politicians are happy too, as they can claim that they
have taken action to improve the services. The expenses mount, but most surveys have shown
that there is not much improvement in the actual services at these centres. The present
government does not appear to be very keen to support the public sector, though it has to make
right noises about universal health coverage. In addition, the advent of modern technology has
helped the idle, as also the timid, to shirk their responsibility. Both these classes claim lack of
modern facilities and lack of trained assistants to avoid treating even the moderately serious
cases. Most of the patients are referred to a higher medical centre at the drop of a hat. The beds
in the medium-range taluka hospitals are mostly unutilized.

Medical Education
Medical education, as it is imparted today, hardly helps. The educationists, the vocal educated
middle class, and the press are unanimous in condemning the present education system. But the
reasons given are diametrically opposite. Most critics feel that the colleges are primitive and the
students are not exposed to the great advances in clinical practice. There are none of the modern
equipments in most of the colleges like CT scans, MRIs, endoscopes, latest investigative tests,
and so on. On the other hand, people like me feel that the present education is totally out of tune
with the realities of life in India. Formerly, there was a lot of emphasis on ward clinics and the
teachers were reputed clinical specialists in active private practice. So, they laid a lot of stress on
clinical observations and had a practical approach befitting the local socio-economic conditions.
Now, the teaching has become bookish and examination oriented. There is more of classroom
education and the ward clinics, which formed nearly 80 per cent of the teaching in clinical
subjects, are almost ignored. As teachers also look at reports and hardly examine or
communicate with the patients, the students also avoid attending wards to concentrate on
reading. The books are written by Western authors or are imitations of these foreign books. But
the ground situation in the wards filled with poor patients being totally different, what the
students learn is most impractical, bizarre mixture of the two; it does not help them at all and
they are unable to treat the poor and the lower middle classes in public sectors or even in private
practice, where their method of treatment turns out to be very costly and illogical. The new
medical graduates can manage to treat only the upper middle classes and the rich, who together
form, at the most, 40 per cent of the Indian population. Neither the public nor the private sectors
cater to the needs of the lower middle class and, to some extent, the middle middle class. It is
difficult to find doctors fit enough to serve in the public sector.
Even the very government seems to have no confidence in its own machinery. The central
government started a scheme, Rashtriya Swasthya BimaYojana (RSBY), for the people below
the poverty line to help them, whenever they need major surgery. But, instead of relying on its
own public sector, it was opened to the private sector also. The scheme offers a maximum of
Rs30,000 per operation to the needy poor but the indications for surgery are not defined.
Schemes on similar lines are also being implemented by Andhra Pradesh and Maharashtra.
Though it did benefit some needy poor people, it certainly led to massive corruption, women
becoming the victims again. Hysterectomies were performed by the hundreds in every state and
the vast majority of them in the private sector. It was paradoxical that the women below the
poverty line spent an additional Rs900 to Rs29,000 out-of-pocket expenses for these operations
as per a survey done by an activist NGO. That is the present scenario. The central government
has many more national programmes, like one for tuberculosis, one for leprosy, one for child and
maternity care, one integrated child development scheme, and so on. Each is supported by a
certain quantum of funds which is distributed to various states. But they are creating a lot of
wastage. The local authority has no right to change the use except for what it was given. So, a lot
of multivitamin tablets lie unused, while medicines for tuberculosis may be in short supply.
Luckily, the local authorities are being empowered to use the funds as per their local needs by
reallocating those given. It is not clear whether this has actually happened.

The Need to Improve Medical Education

So how can we change the situation and make the public sector more competent, more viable,
and achieve the goal of universal health coverage? We must start with the medical education
offered in colleges. In the present system, it is presumed that the college hospital is like a tertiary
healthcare centre having all the latest modern facilities. It is forgotten that it has a dual role, of
producing primary physicians as well as general specialists. Therefore, it ought to be more like a
‘one-stop-shop’ where every type of service is available; so a student can choose the type of
service he or she would like to continue in his/her life, including primary healthcare. We are not
training anyone for that at all. So, the first important step should be to start primary health
centres (PHCs) —at least three or four—under the department of preventive and social medicine
(PSM), which would be better termed the department of primary care and social medicine
(PCSM). Only listed, simple and affordable medicines, injectables etc., should be made available
at these primary centres, as is the case in such centres elsewhere; the list could be appropriately
updated. Similarly, only standard simple listed investigations should be allowed, costly modern
investigations being strictly prohibited. Personally, I would include ultrasonography with a
2.5MgH probe as a simple investigation along with a plain X-ray. All patients will have to attend
the PHC first and will be entitled to free treatment at the college hospital only if and when
referred from the PHC. Thus, parameters of when to refer cases to secondary care will also get
defined. Graduates who do not get postgraduate seats can be posted here for two years as
resident students in primary care. If they work in the different speciality wards in the morning
hours and work in PHCs in the evening hours in the first year and in various intensive care units
in the second year, they would develop immense confidence to work as primary physicians
anywhere. They would know how to treat patients with limited available facilities and limited
affordable medicines. They would know when to refer the patient and when the patient is critical
and may need ICU management. They will also be able to develop enough skill to start
intravenous infusions, pass a Ryle’s tube or to aspirate fluid, and take a biopsy with a gun needle.
Every one of them would then become a very competent primary physician. Primary healthcare
is nearly 70 per cent of total healthcare and that need of the country will be fulfilled. Similarly, if
all the patients were to mandatorily attend general specialists in the hospital and were allowed to
attend the super-specialists only if referred to, the general specialities will recapture their field
and super-specialities will be needed only for difficult, previously unmanageable cases.
Reference guidelines will also develop. The middle class also needs to be looked after. Those
who prefer to attend the college hospital without going through these PHCs, with references
from the private sector could also be accommodated at a different timing in OPD and 20 per cent
beds in the hospital could be reserved for them in the wards but—with charges and only about 50
per cent subsidy. This will attract the middle class who will willingly pay for a separate identity
and a few extra hospitality facilities. The same pattern can then be implemented in all public-
sector hospitals. The public sector can thus become competitive, get some additional revenue,
and absorb far more professionals including a large number of primary physicians. In turn, it will
help to curb—to some extent—the exorbitant charges of the private sector. Medical education
will be compatible with the local socio-economic and developmental circumstances of the
region, the teaching will return to hands-on ward clinics, the middle class will get better
treatment, and the modern science will get its ‘appropriate’ status. The whole service will
become affordable.

Department of Cost Analysis and Data Analysis

None of this is going to be easy. Far from it. Lots of controls will have to be put in place so that
patients are not continued to be referred to higher levels, as they are now. No controls can be
established without good clinical and administrative records. Additionally, it is necessary to find
the costs involved, of each and every service offered to each and every patient, as also record the
final result (outcome) after treatment is over. I have repeatedly stressed on the need to establish a
department of cost analysis and data analysis (CADA) with an adequate budget; at least 1 per
cent of the total budget (inclusive of establishment costs) of each hospital or medical centre. For
example, each medical college falling under the purview of the Mumbai Municipal Corporation
has a total budget of around Rs 900 crore (Rs 90 million); so the budget for a CADA will be
around Rs 6 to 8 crore (Rs 60 to 80 million). As records are so important, this department,
though stationed in the medical centre, must work directly under the highest authority, for
example, the municipal commissioner in Mumbai. Like the accounts department, it must be
independent of the local administrative authority, such as the dean. Devoid of local pressures, it
would then be possible to collect relevant data, compulsorily if need be. It is important that we
do not aim at perfection but are satisfied with a rather crude but sufficiently analyzable data.
Otherwise the junior members of the staff find it difficult to record the required data, the whole
system takes a long time before it is implemented, and the costs become formidable, leading to
the scheme being abandoned, in all likelihood. Costing and disease classification should also be
relatively simple, though in line with international records. It should be perfectly imperfect.
Successfully implemented, it will enable the authorities to know who is working how much,
what are the results, and what costs are incurred in obtaining the results. Comparisons will
pinpoint which protocols are more effective and which team is performing well or badly. More
importantly, it will help in creating cost-consciousness, if every hospitalized patient gets a bill—
let us call it a cost estimate—of expenses at the time of discharge. Plenty of corrective actions
will then be possible and the services can be improved by leaps and bounds. Henceforth, the
salary structure of doctors and other professionals will be based on performance and not just
attendance—a minimum fixed salary supplemented by incentive payment as per performance.
All can be made to realize that demanding more equipment or added personnel means extra cost
and they are accountable to show a measurably better outcome—qualitatively or quantitatively.
The public sector will be privatized, in a manner of speaking, at least in terms of performance.

Budget
How do we find the resources for maintaining and expanding the public sector? The HLEG
appointed by the previous government submitted its report in 2012 wherein it did suggest that the
government should increase its expenditure on health services to 1.7 per cent of the GDP by
2017 and 2.5 per cent of the GDP by 2022 but insisted that general taxation should be the main
source of the budget and that the treatment should be entirely free. I beg to differ. I feel that it is
the main reason why health services don’t pick up in the public sector. There has to be some
connection between the way money comes in and money goes out. There is no way to create cost
consciousness in this method of providing health service. Social insurance is the only method
which correlates what one pays and what one receives, though collectively. Every person must
contribute for health services as per his/her financial status and everybody must get health
service according to his/her essential needs without having to pay at the medical centre. That
must be the main source of the budget for purchasing health services. The general taxation must
continue to provide funds and its contribution must be raised from 1 per cent to 1.7 per cent by
2017 and to 2.5 per cent by 2022, though it is doubtful whether this will happen. Though the
central government contributes substantially, the states should contribute about 50 per cent, of
which 15–20 per cent should come from local bodies like the municipalities, jilla parishads, or
municipal corporations. Additional selective contribution from the central government must also
help to reduce the regional imbalance between states. The money from general taxation should
be spent on developing and maintaining the infrastructure and for standard staffing of all the
medical centres. It may also supplement the state efforts for specific tertiary care or for expenses
for specific diseases like tuberculosis, HIV, etc., which are aided by the central government at
present. However, such separate schemes, including ones like RSBY, should be totally abolished
and merged into the comprehensive universal health coverage. Some amount from general
taxation will also be required as subsidy for those below the poverty line who cannot contribute
for and purchase health services. But the actual services must be purchased through the social
insurance (as mentioned above) wherein every salaried person, every business/industry, and
every self-employed person, will have to contribute a percentage of his/her income as decided by
the government. As costing will already be done, the charges will be defined for each service; be
it consultation, investigation, or surgical procedure. So, billing and collecting the amount from
the insurance authorities will pose no problem. This collection of revenue by each hospital,
therefore, will depend on the actual performance and will determine the efficiency of the whole
team and define the scope for expansion of the centre. It must be emphasized that doctor’s fees
must be separately decided and mentioned, apart from the other hospital charges. That will be
helpful in calculating the remuneration of the doctor on the principle of ‘fixed minimum +
incentive as per performance + bonus for effective outcome minus deduction for excessive
expenditure’. A detailed methodology is beyond the scope of this article, but suffice it to say that
this method will take into consideration the quantitative performance plus the actual effective
benefit to the patient and the community and, negatively, the wasteful expenditure incurred by
the doctor in his/her management protocols.

Dealing with Bureaucracy

It is imperative in this scheme of working that medical professionals be taken care of and given
their due respect. They should be allowed to settle in one place, as far as possible. They should
not be transferred every few years as is the current practice. Women who form a majority in the
profession nowadays like to settle in one place and like to have a relatively fixed schedule of
working. Many of them will willingly join and continue in the public sector if these things are
taken care of. Performance-related payments and incentives will ensure that the doctors do not
leave the services and, in fact, strive to improve their performance. The two-tier system will add
to the moral satisfaction of the professionals and bring additional revenue to the medical centre.
It may also help in expanding the services. But all this is impossible if the public sector is
governed by bureaucracy. After all, it is an industry and quite a huge one at that. So it must be
taken over by an autonomous trust created by the government, managed by management experts,
and assisted by mature medical professionals. Difficult? Maybe, but it is absolutely essential.
National Health Service of UK is a leading example.
Essential Services
The services that should be included in the UHC must be decided by how fundamental the
services are and the financial capacity of the region. Healthcare is a state subject and socio-
economic conditions differ very widely among different states. Though there is no dispute that
all healthcare needs are not essential, and that some are desirable while other are mere luxuries,
what is to be considered as essential services depends on the economic status of the community,
as also on what the community is already enjoying as essential services. Hence, such services in
metropolitan cities may differ widely from the essential services for villages; similarly, they may
differ from state to state. This is a difficult point to grasp or accept for most intellectuals.
However, the contribution of the people for social insurance will make the difference clear.
Healthcare services, therefore, should be decentralized and each locality should be allowed to
define what it wants to include in UHC as essential services, what level of medicines and
investigations should be allowed at primary centres, and so on. Of course, the minimum services
that must be included will be determined by the central board of governance and there can be no
compromise in that. It is absolutely necessary to decentralize the primary and secondary
healthcare services, even though it may appear that they are very unevenly distributed. My
considered observation is that it does not make much of a difference in the ultimate outcome.
The life expectancy at birth and the incidence of diseases between the ages of 15 to 60 are worse
in cities like Mumbai, though it has the highest number of doctors and hospitals, the highest
number of beds, and the maximum medical facilities per 10,000 population. On the other hand,
the tiny neighbouring country of Bhutan has much better health and happiness indices, though it
has only two doctors per 10,000 people. The state and the central body should take care of the
tertiary-care and medical colleges with added attention to specific diseases that significantly
affect the region.

Consumer Protection Act: A Major Problem

The biggest obstacle to any efforts to reduce the costs of secondary and tertiary healthcare is the
Consumer Protection Act (CPA). Medical professionals can do their best only when the patients
have full faith in them. Clinical practice is an art and a good doctor uses his artistic skills to
judge how much importance is to be given to what is ailing the patient. Previously, if a doctor
judged the illness is not serious and the patient cannot afford the treatment, he would use his
discretion to avoid unnecessary investigations and try simple measures. Mostly he was
successful; in a few cases where the illness progressed despite simple measures, he did proceed
to more investigations and the best possible modern treatment. The situation has changed,
however. Patients are no longer willing to accept failures. They call them mistakes. The
Consumer Protection Act has given them a means to punish the doctor. In reality though, apart
from causing him stress, it isn’t the doctor who is punished Even if he is convicted by the
consumer court, all he has to do is pay some compensation amount. To protect themselves,
doctors take a professional indemnity insurance. Presuming a specialist doctor sees just four
patients a day and works for 250 days, his insurance premium works out to be just Rs 30 per
patient, equal to Rs 30,000 per annum for an insurance of Rs 50 lakh (Rs 5 million). But he has
raised his fees by Rs 50 or Rs 100, so that he is already making more profit. The big loser here is
society at large. Faith is lost and Faith is a Healer. A contract means that the doctor is not
allowed to fail. He must carry out a complete investigation, offer the best of the treatment
without any compromise for the sake of socio-economic considerations, even for the sake of the
patient. And, yet, he must warn the patient of all possible ill consequences that could happen. In
short, he must create fear or panic in the patient’s mind, just to save his own skin. The patient
may be organically treated well, but mentally, he is left in perpetual doubt about the future
course of action. His dependence on the doctor and the modern investigative facilities grows
more and more. He is never happy. All this fate falls on the poor and lower-middle-class people
also, though, tragically, they are not the ones who demand such perfections. Over-investigation,
unnecessary procedures, and over-drugging are as much due to greed of the professionals as due
to impact of the fear of CPA. We have to find some better alternative. The act must be abolished.
Clinical establishment act takes care that the hospitals are maintained up to the prescribed
standards. The specialist doctors must be qualified or adequately experienced, so his medical
decisions cannot be questioned but his behavior can be. Did he attend in time, did he start the
treatment at the right time, did he respond to emergency calls, are all acts which can be
scrutinized to prove his innocence or his guilt. Secondly, statistics will speak for or against him.
If, with similar protocol in similar illness, he has given adequate, comparable results, he has
proved his method of treatment as being aboveboard. Records ought to be compulsorily
maintained and data analysed. Besides, a scheme of ‘no fault compensation’ can be introduced
wherein an unexpected death or disability will be monetarily compensated— only for persons on
whom the family was solely or mainly dependent. If the CPA is made non-applicable to the
medical profession and such alternative steps introduced to protect the interests of the patient, it
will go a long way in reducing the costs of health services. It will also help to restore the faith of
the patients on their doctors, at least to some extent.
The public sector will have to advertise its importance as well as its performance. May be, a
TV station can constantly televise in simple language the procedures to be followed at various
medical centres, the way the public sector treats its patients for less costs, the futility of many of
the modern investigations and modern methods of management, the figures of the actual
performance, and so on. It may alleviate much of the panic created by the medical ‘market’. The
people must be told emphatically about the real virtues of the public sector loudly and clearly
enough to make them willing to pay more and more for its expansion. Let the private sector serve
the rich. Only a well-organized public sector with adequate financial resources can do justice to
the genuine health service needs of the poor and the middle class, who must be willing to pay for
the services collectively. Good service conditions and performance-based payments to medical
professionals will ensure the supply of good, appropriately trained doctors and other
professionals.
May the public sector grow to fulfil the aspirations of the citizens of the Indian republic
regarding their healthcare needs.
***
Medico friend Circle is a yahoo-group of social and medical activists—individuals as well as
NGOs which present their view points and data on various topics related to health care system on
their e-mail address <mfriendcircle@yahoogroups.com>. I must gratefully thank the e-group
presentations and discussions for much of the statistical data presented in this article. Some more
data is from WHO Health Statistics available on Google search and some data from HLEG
report. No copyrights have been violated.

References
Shaw, George Bernard, Doctor’s Dilemma (1906).
High Level Expert Group, Report on Universal Health Coverage, Summary, 2012.
SAMA, India facts.in and India Development Gateway.
MEDICOFRIENDSCIRCLE – a Yahoo chat group <mfriendcircle@yahoogroups.com>
WHO Health Statistics
 CHAPTER ELEVEN
The Unholy Nexus
Medical Profession, Pharmaceutical Companies, and Regulatory
Authorities

S. Srinivasan1

The unholy nexus between the medical profession and pharmaceutical companies is no longer
news. The nexus is undesirable, unethical, and criminal, especially when lives of patients are
adversely impacted in the process. One result of the nexus is that the patient does not get the
right treatment at the right time. It is also a betrayal of trust reposed by the patient on the medical
profession.
India’s pharmaceutical market is driven by intense competition. This leads to attempts by
pharmaceutical companies to get a slice of the market without much regard for the means of
doing so. That partially explains the aggressive medical promotion—which may take the form of
gifts, vacations, and monetary benefits to doctors. These offers test the moral fibre of most
doctors. Many give in easily, often justifying that they do not get influenced by gifts and do not
prescribe the pharmaceutical company’s products. Hard to believe for an outsider to the
profession. Routinely the press reports of kickbacks by diagnostic laboratories to doctors2—a
related area crying for regulation.
Conflict-of-interest issues often do not elicit the seriousness that they deserve. This is true
even in case of members of government committees. The government probably feels that highly
learned members will point out conflict of interests on their own volition (See Box 11.1).
Yet another reason for the aggressive medical promotion that revolves around munificent gifts
to the prescriber is that India’s pharmaceutical market is driven by branded generics and many
useless, irrational, harmful fixed dose combinations (FDCs).

BOX 11.1 Conflict of Interest Not Applicable to Senior Medical Professionals?

6.4 The Committee sought information from the Ministry of Health and Family Welfare
(MoHFW) if members of the Enquiry Committee were asked to file Conflict of Interest
declarations. In response the Ministry replied: “No written Conflict of Interest declarations
 were sought from the core members of the Inquiry Committee as well as experts. It was
understood that if there is any conflict, highly learned members will point it out. (emphasis
author’s)
6.5 In order to verify the Ministry’s claim, the Committee picked just one member, that
is, Professor and HoD of the Department of Obstetrics and Gynaecology (O&G) of All
India Institute of Medical Sciences (AIIMS). It was found that manufacturers of Gardasil,
Merck was sponsoring and funding a trial in the Department of O&G at AIIMS to
determine if 2 doses of Gardasil can be used safely and effectively instead of 3 doses.
Documents received by the Committee in connection with examination of AIIMS also
revealed that the individual in question availed the hospitality of these very sponsors during
the said individual’s visit to Seoul, Korea to attend a conference. The FCRA application
form was, therefore, deliberately left incomplete to hide this truth. All these speak of a
serious conflict of interest of this member of the Inquiry Committee.
Source: 72nd Report of Parliament Standing Committee on ‘Alleged irregularities in the Conduct of Studies
using Human Papilloma Virus (HPV) Vaccine by PATH in India’, dated 29 August 2013.

Generics are drugs outside patents. With multiple variants of the same drug available in the
market, producers of generic drugs like to differentiate their specific product (of say
paracetamol) by giving it a brand name and selling it at a price as to what they think their target
market can take. Therefore, the prescriber needs to be ‘convinced/persuaded’ by being offered
personal gains—monetary or otherwise. Sometimes the prescriber joins the game and plays one
company against the other, and manages to wrangle better ‘benefits’. Pharmaceutical companies
therefore need deep pockets—and they can have these by overpricing the drug. Drugs often have
margins of 2,000–3,000 per cent, and in some cases the profit margins may go up to even 10,000
per cent.3 This means that the hapless consumer is overcharged by a huge margin, which in turn
may even cause indebtedness of patients and their families.
Incidentally, the need to have deep pockets for this kind of ‘marketing’ expenditure is also the
reason pharmaceutical companies in India resist any and all measures at price regulation and any
other measures to regulate the industry for the benefit of the consumer. The regulatory measures
are termed as impeding, to use the current phrase, ‘ease of doing business’ and written off as
hampering R&D budgets for discovery of new molecules.4
Asymmetry of information—unequal information among various stakeholders—about the real
costs of production and that of R&D not only leads to arbitrarily high prices of the newer
patented drugs like biologicals but also of medical devices like cardiac stents that are marketed
as high-technology devices capable of quality manufacture only by leading
pharmaceutical/device companies.
Some cardiologists, for instance, generously endorse the quality of costlier stents, and
therefore implicitly sanctify the legitimacy of high prices, in the absence of systematic
technology assessment studies.5 This begs the question: why should imported stents with landed
prices of Rs 40,000 be charged to patients anything between Rs 120,000 and Rs 250,000? In
addition, there are charges for the stent insertion procedure ranging from Rs 60,000 to Rs
150,000. The answer to this lies in the very nexus between pharmaceutical and medical devices
companies and the medical fraternity.
The distributor Outlook spoke (to) says he has witnessed several medical representatives of multinationals firms
deploying exorbitant forms of bait to lure doctors: gifts as well as foreign trips under the guise of medical
conferences. With such incentives involved, a lot of doctors tend to opt for costly stents, despite cheaper versions
with the same benefits being available in the market.6

If Indian criminal law was applicable here, cardiologists, cardiac surgeons, and hospital
managements could face legal action. In February 2017, the government fixed ceiling prices of
stents for less than Rs 30,000, but the lobbying and disinformation against the ceiling price order
has not died down. In line with the cynicism of corporate private hospitals, there has reportedly
been no corresponding decrease in the cost of related procedures.7 Since then knee implants and
cochlear implant have also been put under price regulation, but again, there has largely been no
significant decrease in the total cost of care.
There have been recently reports in the media of vaccine manufacturers offering gold coins to
induce paediatricians to prescribe them.8 The convener of the Advisory Committee on Vaccines
and Immunisation Practices, Dr Vashishtha, of the Indian Academy of Pediatrics (IAP) was
suspended from the IAP for exposing the nexus between vaccine manufacturers and the IAP.9
These are indeed criminal activities on the part of certain groups of medical practitioners,
implicitly trusted by parents of children.

Irrational Prescriptions and Irrational FDCs

One of the upshots of unethical and aggressive drug promotion is the prevalence of unethical and
irrational prescription practices. It results in unnecessary prescription of certain brands, even
when good quality, less costly, equivalents exist, and/or in prescribing a particular company’s
brand even when not warranted. The patient suffers not only financially but often becomes the
victim of side effects and adverse effects of overmedication, wrong medication, or under-
medication.
Combining more than one medicine has justification in standard pharmacology only under
certain circumstances. But the market is flush with FDCs, at least half of them irrational.
The National List of Essential Medicines 2015 (NLEM 2015) has 376 medicines, including
about 20 FDCs. But in the Indian market, combinations without valid scientific justification are
marketed as value additions and innovations, without adequate safety and efficacy studies to
prove the claims made. These FDCs are prevalent across all therapeutic categories of medicines
—analgesics, antibiotics, antihypertensives, antidiabetics, gastrointestinal drugs, and
psychoactive drug. While these are primarily marketed to maximize profits, they carry
substantial risks to individual patients and to public health.
In March 2016, the Central Government banned 344 FDCs because of their lack of proof of
safety and efficacy—these are FDCs that should not have been licensed, by the State Licensing
Authorities (SLAs) for manufacture, in the first place.10 However, in December 2016, the ban
notification was quashed by the Delhi High Court, on procedural grounds of not having
consulted the Drug Technical Advisory Board (DTAB), after a hotly contested appeal by a host
of pharmaceutical companies who were guilty of marketing these impugned FDCs. The
pharmaceutical companies were represented in the Court by some of the top (read high priced)
legal counsel of India that included former cabinet ministers. When the matter went on appeal to
the Supreme Court, the same former cabinet ministers were seen in action as legal counsel.
At play here are: (a) Regulatory authorities that were negligent in approving these irrational
FDCs, (b) pharmaceutical companies, many with claims to world-class quality, were complicit in
marketing irrational, and illegal, products of unacceptable safety and efficacy, and (c) dominant
sections of the medical profession which by prescribing them over the years increased the sales
of these irrational FDCs—an act of collusion by indifference and inaction to the kinds of
medicines being purveyed in the country.

Some ‘Voices of Conscience’

The pharma–doctor nexus also exhibits itself in other forms of collusion: less than conscientious
adherence to standard treatment guidelines and standard operating procedures in clinical trials,
little or no adverse drug reaction (ADR) reporting, and lax standards of pharmacovigilance. The
principle of evidence based medicine is also given a short shrift in the process even as what
constitutes evidence and what are acceptable norms of safety, efficacy, and therapeutic
justification are distorted.
Arun Gadre and Abhay Shukla, in their book Voices of Conscience from the Medical
Profession, give a litany of misdemeanours from a part of the medical profession. There are
extensive quotes in the book from honest doctors who reveal their anguish over the ‘vice like
grip of the pharmaceutical companies’ on the medical profession. Some of these voices of
conscience:
As soon as they pass out of medical college, medical representatives of pharmaceutical companies take charge of
them. They easily forget what they have learnt, even the simple treatment of fever with plain Paracetamol. They
now think only of a branded product that costs five times as much ...
But what about doctors? They too put pressure on pharmaceutical companies, telling them, ‘If I prescribe your
medicines, send me on a tour to Europe....’
A rampant malpractice is in the area of prescribing vaccines ... The practitioner gets a cut on the Maximum
Retail Price (MRP) .... The more expensive the vaccine the higher the cut. The cut is even more than the
consultation fee. The doctor gets both – the cut from the company and the fee from the patient ....
The pharmaceutical companies are like a pack of wolves.… (Gadre and Shukla 2015)

Indeed, to echo the authors, a shiver of apprehension will run through any patient if they
know about these unfortunate trends in the medical profession and the toxic influence of
pharmaceutical companies over doctors.
Annexure 11.1 is a select bibliography of the pharmaceutical–medical profession nexus that
matches the above voices of conscience.

Regulatory Capture: Pharmaceutical Companies, the Medical

Profession, and the Government
The 59th Parliamentary Standing Committee Report on Health and Family Welfare (hereafter
59th Report) on the functioning of the Central Drugs Standard Control Organisation (CDSCO),
May 2012, is a stinging indictment on the nexus between the drug regulators in CDSCO, drug
manufacturers, and experts from the medical profession (Srinivasan 2012). We reproduce some
self-explanatory extracts from the 66th Report of April 2013 (66th Report hereafter). The 66th
Report is an Action Taken Report by the Government on the recommendations/observations
contained in the 59th Report. (Para numbers refer to the 66th Report, for example, 3.51, and the
numbers at the end of each para in parentheses refer to the 59th Report, for example, 7.31):
3.51 A review of the opinions submitted by the experts on various drugs shows that an overwhelming majority are
recommendations based on personal perception without giving any hard scientific evidence or data. Such opinions
are of extremely limited value and merely a formality. Still worse, there is adequate documentary evidence to
come to the conclusion that many opinions were actually written by the invisible hands of drug manufacturers and
experts merely obliged by putting their signatures. Is the Committee mistaken in coming to the conclusion that all
these letters were collected by interested party (sic)from New Delhi, Mumbai, Chandigarh and Secunderabad and
handed over to office of the DCG(I) (Drugs Controller General of India) on the same day? If so, it is obvious that
the interested party was in the loop in the entire process of consultation with experts.... The conclusion, as in
aforementioned cases, is obvious. (para 7.31, 59th Report)
3.52 If the above cases are not enough to prove the apparent nexus that exists between drug manufacturers and
many experts whose opinion matters so much in the decision making process at the CDSCO, nothing can be more
outrageous than clinical trial approval given to the FDC of aceclofenac with drotaverine which is not permitted in
any developed country of North America, Europe or Australasia. In this case, vide his letter number 12-298/06-
DC dated 12-2-2007, an official of CDSCO advised the manufacturer, Themis Medicare Ltd. not only to select
experts but get their opinions and deliver them to the office of DCG(I)! No wonder that many experts gave letters
of recommendation in identical language apparently drafted by the interested drug manufacturer. (para 7.32, 59th
Report)
3.53 In the above case, the Ministry should direct DCG(I) to conduct an enquiry and take appropriate action
against the official(s) who gave authority to the interested party to select and obtain expert opinion and finally
approved the drug. (para 7.33, 59th Report)
3.54 Such expert opinions in identical language and/or submitted on the same day raise one question: Are the
experts really selected by the staff of CDSCO as mentioned in written submission by the Ministry? If so how can
they, situated thousands of miles away from each other, draft identically worded letters of recommendation? Is it
not reasonable to conclude the names of experts to be consulted are actually suggested by the relevant drug
manufacturers? It has been admitted that CDSCO does not have a data bank on experts, that there are no
guidelines on how experts should be identified and approached for opinion. (para 7.34, 59th Report)
There is sufficient evidence on record to conclude that there is collusive nexus between drug manufacturers, some
functionaries of CDSCO and some medical experts. (para 7.36, 59th Report)
Action Taken
3.55 The Ministry has noted the observations of the Committee.
3.56 The applications for new drugs including FDCs are now examined by the NDACs and decisions on their
approval are taken based on the recommendations of these committees.
3.57 The issues relating to the Fixed Dose Combination of aceclofenac with drotaverine would be referred to the
NDAC for examination and review.
3.58 As mentioned earlier, the Ministry had constituted a three member expert committee. The expert committee
submitted its report to the Ministry on 22.11.2012. The committee has recommended instituting an enquiry into
the matter.
3.59 As recommended by the Hon’ble Committee, the DCG(I) will constitute an enquiry committee to investigate
into the matter.
Further Recommendation (by the Parliamentary Committee, 69th Report)
3.60 The (Parliamentary) Committee is aghast to note the paralytic inertia gripping the Ministry which is
preventing it from taking action against guilty official(s) of CDSCO and others involved in proven cases of
delinquency and illegality six months should have been more than enough to not only inquire into the misdeeds of
those who had so wantonly indulged in the above cited gross irregularity but also sufficed to take exemplary
action against them so as to deter others. The Ministry by still dithering over issuing instructions to NDACs (New
Drugs Advisory Committees) and DCG(I) has abundantly proved that it has neither the intention to clean the
augean stables of CDSCO nor any concern for probity and rule of law. Hoping against hope, the Committee
expects the Ministry to at least even at this late stage take immediate action on these proven cases of delinquency
and irregularities so that a stern message is sent to all concerned that the drug regulatory mechanism is not up for
grabs for perpetuation of unethical and illegal practices.

Indeed these extracts from the report show that the drug regulatory mechanism is ‘up for
grabs for perpetuation of unethical and illegal practices’ by pharmaceutical companies. There are
regularly fixers roaming in state licensing authority offices. Online submission of various
requests for approval and processing of various permissions of forms submitted is expected to
minimize, but there remains considerable scope for manipulation. It is indeed a naïve belief that
making things online will make decisions corruption free.
The 59thReport further goes on to indicate collusion between doctors, pharmaceutical
companies, and regulators in unlawful, casual approval of several drugs. For example, it refers to
Buclizine (para 7.39 to 7.41) as ‘one of the many drugs approved in violation of Indian laws’.
With regard to Letrozole, the Report states:
In the matter of letrozole originally approved and marketed by the innovator an anti-cancer drug for use only in
post-menopausal women, was then illegally approved, without Phase 2 clinical studies and inadequate Phase 3
studies, in women of reproductive age as an anti-fertility drug.
... After approval, the sponsor, Sun Pharmaceuticals did not submit periodic PSURs due every six months as
required by law. No action was taken against the Company in such a sensitive case since India is the only country
where the drug is permitted to be used for female infertility ….the DCG(I) instead of investigating the allegations
of regulatory lapse and taking corrective measures referred the matter to clinical experts, DTAB etc. on the
restricted issue of safety and efficacy. DCG(I) is expected to take action against those CDSCO functionaries who
colluded with private interests and got the drug approved in violation of laws. The drug has since been banned by
the Ministry for use in female infertility…. (Para 7.42, 59th Report)
…. The (59th Parliamentary Standing) Committee takes special note of this case of gross violation of the laws of
the land by the CDSCO. First, in approving the drug for use in case of female infertility and thereafter, in
exhibiting overt resistance in taking timely corrective steps despite very strong reasons favouring immediate
suspension of use of letrozole for the said indication. Belatedly, the drug has been banned for use in female
infertility.” (Para 7.43, 59th Report)

In the matter of Placenta Extract, the 59th Parliamentary Standing Committee Report had this
to say:
As per Drugs and Cosmetics Rules, whenever there is either an additional formulation (such as tablets, solutions,
suspensions, injections, controlled release, gels, etc.) or proposal to use in additional indications, the drug is
deemed to be a ‘New Drug’. In violation of this clear rule, vide its letter number 4-97/89-DC dated 11th February
2000, an official of the office of the Drugs Controller General (India) wrote a letter to the manufacturer that
Placenta Extract was “not a New Drug’ and gave permission to promote placenta extract gel [a new formulation
and hence classified as a New Drug as per Rule 122.E(b)] in additional indications (Burns and Wounds, Non-
Healing Indolent Ulcers, Bed Sores, Mucositis, etc.). By including the term “etc.”(An unknown and unheard of
terminology in the history of drug approval), loopholes were left wide open to add other indications. Thus
CDSCO went out of the way to unlawfully and wrongly certify, in black and white, that the drug was “not a New
Drug” thus helping the manufacturer to market an additional formulation for additional indications.
The manufacturer’s letter dated 7th February 2000 from Kolkata reached CDSCO in Delhi and was processed
with super speed in a record time of just 4 days (inclusive of postal transit) and permission granted on 11th
February 2000 … Since then the Delhi High Court has reduced the approved indications to just two disorders:
Wound Healing (for topical gel) and Pelvic Inflammatory Disorder (for injection). (Para 7.48, 59th Report)

At several places, the 59th Report recommended exemplary action on the experts and medical
professionals involved by forwarding it to the Medical Council of India (MCI) for violation of
MCI rules among others, but nothing seems to have come of it as of date. The Medical Council
of India itself, as other chapters in this book indicate, has been a source of much of medical
corruption in India.
The response of the Ministry is clearly indicative of the fact that it wants to drag its feet when it comes to
punishing the people who have compromised the system over the years through their sheer illegal activities, which
are totally against public interest. It is incomprehensible as to what is stopping the Ministry from forwarding these
proven cases of gross illegality and proven collusion of the Medical Council of India and the medical
colleges/hospital authorities concerned for appropriate action though more than six months have elapsed since the
Committee brought these cases to the knowledge of the Parliament and the Government. The Committee,
therefore, while expressing its strong displeasure with the Ministry recommends that these cases be referred to
MCI and medical colleges/hospital authorities concerned within seven days of presentation of this Report to the
Parliament. With a view to expedite action against these errant experts who have indulged in unethical and illegal
practices without any concern for the health and well being of common people the Committee further desire the
Ministry to impress upon MCI and all other authorities concerned to act against these experts in a highly time
bound manner and report back to the Ministry at the earliest so that the Ministry is able to furnish the feedback on
all these cases to the Parliament within one month of presentation of this Report to the Parliament. (Para 3.66,
69th ATR)

Clinical Trials, Collusion, and Regulatory Failure

The 59th Report also found much that is wrong in the conduct of clinical trials. Here again is an
area replete with collusion between the trinity of regulators, medical profession, and the
pharmaceutical industry.
…a total of 31 new drugs were approved in the period January 2008 to October 2010 withoutconducting clinical
trials on Indian patients. The figure is understated because two drugs (ademetionine and FDC of pregabalin with
other ingredients) were somehow not included in the list. Thus there is no scientific evidence to showthat these 33
drugs are really effective and safe in Indian patients. (Para 7.16, 59th Report)
It is obvious that DCG(I) clears sites of pre-approval trials without application of mind to ensure that major ethnic
groups are enrolled in trials to have any meaningful data. Thus such trials do not produce any useful data and
merely serve to complete the formality of documentation. (Para 7.27, 59th Report)
Elsewhere on a scrutiny of 39 drugs on which information was available, the Parliamentary Committee found
various following shortcomings like:

• In the case of 11 drugs (28%) Phase III clinical trials mandated by Rules were not conducted.
• In the case of 2 drugs (Dronedarone of Sanofi and Aliskiran of Novartis), clinical trials were conducted on just
21 and 46 patients respectively as against the statutory requirement of at least 100 patients.
• In one case (Irsogladine of Macleods), trials were conducted at just two hospitals as against legal requirement
of 3-4 sites.
• In the case of 4 drugs (10%) (Everolimus of Novartis; Buclizine of UCB; Pemetexid of Eli Lilly and FDC of
Pregabalin with other agents), not only mandatory Phase III clinical trials were not conducted but even the
opinion of experts was not sought. The decision to approve these drugs was taken solely by the non-medical
staff of CDSCO on their own.
• Of the cases scrutinized, there were 13 drugs (33%) which did not have permission for sale in any of the major
developed countries (United States, Canada, Britain, European Union nations and Australia). None of these
drugs have any special or specific relevance to the medical needs of India.
• In the case of 25 drugs (64%), opinion of medically qualified experts was not obtained before approval.
• In those cases (14 out of 39 drugs), where expert opinion was sought, the number of experts consulted was
generally 3 to 4, though in isolated cases the number was more. In a country where some 700,000 doctors of
modern medicine are in practice such a miniscule number of opinions are hardly adequate to get diverse views
 and come to a well considered rational decision apart from the possibility of manipulation by interested parties.

(Extracts from Para 7.14, 59th Report)

…The Ministry explained that under the rules, DCG(I) has the power to approve drugs without clinical trials in
“Public Interest.” No explanation is available as to what constitutes Public Interest. How can approvals given to
foreign drugs without testing on Indians be in Public Interest? Some of the reasons given for irregular approvals
are: “Serious disease” (all the more reason to conduct clinical trials to ensure that patients in India really benefit
from such imported, exorbitantly expensive drugs), “Rare disease status according to United States Food and
Drugs Administration” (How can USFDA decide which is rare disease in India?), “Orphan drug status in Europe
and USA” (There is no provision in Indian laws to give special treatment to such foreign drugs).... (Para 7.17, 59th
Report)

Much of this laissez faire state of affairs stems not only from pharmaceutical industry
pressure in collusion with certain medical experts but the regulators’ need to justify the much
bandied label of India as a destination for clinical trials. As we explain below, the provisions in
Schedule Y of the Drugs and Cosmetics Act were changed in January 2005 to facilitate more
clinical trials of new chemical entities (NCEs) without safeguards in place.

Modifications in Clinical Trial Related Laws in January 2005

Before January 2005, phase lag in clinical trials of NCEs was mandatory. In January 2005 this
phase lag was removed. That is Phase 2 and Phase 3 trials of NCEs discovered abroad now can
be conducted concurrently. The earlier idea of a mandatory phase lag in trials of NCEs/NMEs
was because their serious adverse effects, usually emerging in Phase 2, were not even known in
the originating countries. For trials within India on NCEs originating abroad, we need sufficient
emergency and routine healthcare services, in case the trial participant is seriously affected. The
deaths in India following trials on a drug called rivoraxaban (a blood thinner) in India would not
have occurred probably if the trials had been planned after a mandated phase lag.
These trials have been and are mostly carried out by, among others, middlemen and contract
research organizations (CROs) on behalf of Western pharmaceutical companies. The
beneficiaries in India are the few researchers in academia and CROs without adding to the
research capabilities of Indian researchers in academia. Also, if you did not let the trials on these
NCEs be done in India, it does not mean they will not be marketed in India or approved abroad.
Much of the data collection as part of the drug trial has in any case, to be done in the West.
CROs are a new player in the obfuscation of what is useful and rational medicine. In their
narrative any measure to regulate clinical trials necessarily discourages the India-is-an-attractive-
clinical-trial-destination story.
According to the Ministry of Health and Family Welfare figures,11 there were 2,868 deaths of
participants in clinical trials in India during 2005–12, out of which only 89 were accepted as
trial-related, and 82 were compensated. Almost all of these 89 were due to NCEs/NMEs.

Indore Clinical Trials

The period 2005 to 2013 seems to have been a free for all with clinical trial scandals and
skirmishes tumbling one after the other out of the closet. Several unethical clinical trials were
conducted in the state of Madhya Pradesh, especially in Indore, which were thereafter a subject
of a series of questions/debates in the state’s Legislative Assembly during July 2010–2011. The
Economic Offence Wing (EOW) of Madhya Pradesh in its Report of 24 June 201112 found, inter
alia, several irregularities in 73 clinical trials conducted on nearly 3,300 patients (of which 1,833
were children) at the Maharaja Yeshwant Rao Hospital, a teaching hospital under the Mahatma
Gandhi Memorial Medical College (MGMMC), Indore. In these trials, principal investigators
(PIs) often doubled up as member secretaries of the Ethical Committees of the trials and at great
cost, including deaths, to the trial participants and at great pecuniary benefit of Rs 5.1 crores to
six senior doctors. At about the same time, nearly 60 trials involving 40 doctors (the number of
patients was not disclosed), were conducted in Indore’s private hospitals, causing at least 5
deaths.13 These are currently the subject of couple of PILs in the Supreme Court asking for a
complete clean-up of the clinical trial scenario in India.

Unethical Drug Trials in Bhopal

From 2004 to 2008, the Bhopal Memorial Hospital and Research Centre (BMHRC) was engaged
in ten different drug trials involving pharmaceutical companies such as Pfizer, Wyeth, Astra
Zeneca, GlaxoSmithKline, and so on. Trials were conducted on 279 patients, of which 215 were
‘gas patients’. There were several deaths during these trials. The jury seems to be out on whether
the deaths occurred due to the trials. While the government authorities who investigated the case
noted many problems with the conduct of trials, they let the investigated drug companies and/or
the Contract Research Organisations go with what was justa slap on the wrist.14 It is not clear
why permission to conduct clinical trials was granted by the DCGI in violation of ethical norms
of clinical trial on the victims of the Bhopal Gas Tragedy. In that sense the trials are more
immoral and unethical than illegal.

Attempts at Reform
Stung by the criticism in the media, parliament, and civil society, the government moved in to
introduce some order in the anarchic clinical trial scenario. New rules in the Drugs and
Cosmetics Act (Rules 122 DAB, DAC, DD, and Appendix XII to Schedule Y) were introduced
in 2013, covering procedures to seek formal permission to conduct clinical trial and compulsory
registration of clinical trials, compensation in case of injury or death during clinical trial,
registration of ethics committees, and audiovisual recording of informed consent. Compensation
formulas for calculating amounts in case of trial-related death and/or injury have been specified,
probably for the first time anywhere in the world.
At the heart of clinical trials is a tremendous power asymmetry, with patients and trial
participants on one side and a formidable powerful medical, technical, and professional elite on
the other. Given the financial stakes involved, clinical trials also continue to be terrains of human
rights and ethical violations, and sites of collusion between the pharmaceutical industry, trial
sponsors, and contract/clinical research organizations, medical professionals, ethics committee
members, and regulators. Patients and their relatives tend to highlight injuries and deaths as trial
related whereas almost all the other actors in the clinical trial tend to minimize the causal links
between trials, or the drug under investigation, and the injury or death caused. The presumption
that lack of causal links can be established confidently is a problematic idea, and understates the
real harm caused to trial participants.

Perfunctory Compliance
The tendency among regulators and the pharmaceutical industry is to view ethical and human
rights issues as mere procedural inconveniences. Any directions from the judiciary to restore a
sense of equity to the process, for example, in the couple of PILs related to clinical trials that
have been filed, are complied with if at all, perfunctorily.
For instance, the Supreme Court’s directions on audiovisual recording of informed consent of
trial participants have been diluted to trials involving only NCEs, after protests, some genuine
and some orchestrated, from CROs, investigators, and medical professionals.
In WP (Civil) 33 of 2012, the case of Swasthya Adhikar Manch, Indore and Anr vs Union of
India, the Supreme Court of India in its order dated 21 October 2013 directed that applications
for Global Clinical Trials (GCTs) involving NCEs be evaluated with respect to three parameters:

1. Assessment of risks versus benefits to the patients.

2. Innovation versus existing therapeutic option.
3. Unmet medical need in the country.

Under Supreme Court directions, a three-tier structure was put in place for evaluation of
application of clinical trials involving NCEs: the New Drug Application Committee (NDAC), a
Technical Committee, and an Apex Committee.
But what is of relevance is that government, in its implementation of the three criteria,
endorsed almost all clinical trial applications as worthy of trial in India. For instance, in the
documents on the approved trials submitted by the government to the court, under ‘Risk versus
benefit to patients’, the following paragraph repeatedly and mechanically appears (Illustrative
examples: Xprenor by Clingene, PF-04171327 by Pfizer etc.): ‘The risk vs benefit of the test
drug in various animal toxicity studies which include single and repeated dose studies and
clinical Phase I studies, justify the conduct of the study.’
There must be some data to claim that an experimental drug may offer any benefit to any
patient, however remote. Animal studies do not offer any evidence at all of any therapeutic
benefit since the molecule can hardly be administered to animals with human diseases. They are
mainly conducted to determine toxicity as per Drugs and Cosmetic Rules.15
After the above mentioned Supreme Court’s order of 21 October 2013 that outlined the three
criteria, the Technical Committee and Apex Committee met several times between November
2013 and January 2014 and analysed the then status of the 157 global clinical trials of NCEs16 as
under: ongoing (65 trials); completed (39 trials); not initiated by the applicant (13 trials);
withdrawn by the respective applicant without any patient enrolment (25 trials); and suspended
by the respective applicant prematurely (15 trials).
In affidavits filed by the MoHFW, the Supreme Court in Swasthya Adhikar Manch Indore and
Anr vs Union of India in WP (Civil) 33 of 2012, these 65 trials of NCEs were approved in 2012
(that is, much before the Supreme Court order of 21 October 2013). However in 2013–14 they
were deemed to have met the three core criteria. The claim is preposterous because in 2012,
MoHFW could not have known or forecasted that the Court would put these three conditions. So
how could they meet these requirements in 2012?
The government’s later affidavits said that these criteria were anyway taken account of
‘implicitly’ and therefore naturally there was no need for reversing the decisions taken. In the
days preceding the order of 21 October 2013, the only guiding principles of approval of trials
were those conditions that are stated under Schedule Y of the Drugs and Cosmetic Rules. There
is no mention of the three Court determined conditions either directly, indirectly, or even
remotely.
Therefore, one is left with no alternative but to conclude that the government as a respondent
either deliberately misinterpreted the Court’s directions to suit its own interests or redefined the
meaning of Court’s orders.
The speed at which trial applications from the NDAC were passed as approved by the two
later committees using the above two criteria makes a mockery of the goals of the process
outlined by the Supreme Court. The Apex Committee merely rubber stamped decisions of the
Technical Committee without application of mind. Possibly because one member (the DG of
DGHS) who was member of the Apex Committee was also Chairman of the Technical
Committee.
Now this is a kind of behind-the-scenes collusion/indifference by poor implementation that is
intended to make it less tough for pharmaceutical companies and thereby promote the ‘ease of
business narrative’, and promote clinical trials that should have not been sanctioned.
One fallout of this casual approach was that either by design or default the troika of NDAC,
the Technical Committee, and the Apex Committee approved dozens of placebo-controlled trials
knowing fully well that the Honourable Court’s orders on expected benefit to patients as one of
the major requirements cannot be met.

Regulating the Nexus: What Can Be Done

Clinical trials even otherwise have problems: often only positive results are published;
unfavourable information that may result a drug never seeing the light of the day are ignored,
and results as well as disease conditions are constructed/interpreted by overstating the case for a
drug, with badly (or cleverly) designed trials projecting a drug to be more effective than it is in
reality.17 Indian pharmaceutical companies, researchers, and medical professional are not
immune from these trends. These issues once considered shocking are routinely discussed in the
leading medical journals of the world.
Specific to India, many problems pertaining to clinical trials can be set right by not allowing
concomitant Phase 2 and Phase 3 trials of patented NCEs/NMEs in Indian patients by foreign
drug companies; and when they are to be marketed in India, bridging Phase 3 trials for ethnic
diversity must be made mandatory. What we are advocating here is to go back to the pre-January
2005 position. If some new drugs of foreign origin need to be urgently introduced for reasons of
health emergency, trial requirements can be selectively waived, especially after they have been
approved for marketing abroad in countries with good regulatory regimes. All disinformation to
the contrary that reintroducing the phase lag will put the clock back in making India’s medical
research capabilities must be seen for what it is: disinformation; and by recognizing that apart
from MNCs and a few select medical/science professionals and hospitals, and that except for
patients with a few critical conditions with no other cure in sight, the mass of patients do not
benefit specially from these clinical trials.
Of great importance within India is complete transparency in the matter of clinical trial-
related data as well as of agreements and arrangements with sponsors (Smith and Roberts 2016).
One can introduce transparency of data beginning with trials and studies where the government
is involved. There is a PIL pending in the Supreme Court of India requesting sharing of clinical
trial-related data related to the indigenously developed rotavirus vaccine and its subsequent
introduction in the national immunization programme based on these trials.18 The PIL was filed
after repeated refusals by the government for access to trial data—trial data that was used to
justify a major public policy change, namely inclusion of rotavirus vaccine in the national
immunization policy.
Regarding nexus of a financial nature between teaching hospitals and medical
professionals/students, a great deal can be achieved by strictly implementing a code of marketing
that prohibits, in cash or kind, direct/indirect incentives, as also deterrents in the form of fines,
punishments, and temporary/permanent deregistration. Issues in corruption in medical education,
and MCI and professional associations of doctors, also need crucial attention. The Medical
Council of India and the Indian Academy of Pediatrics (IAP) are known to have endorsed
branded water purifiers, ‘health’ drinks, branded fruit juice products, Dettol, and so on. When
concerned doctors and civil society organizations pointed that such product endorsements are in
violation of the MCI’s code of ethics Section 6.8 (introduced in 2009), the said section of the
Code was amended in 2016 to put professional medical associations outside the purview of the
Code of Ethics!19 Nevertheless, the Code of Ethics is a major improvement over the previous
vacuum and needs to be implemented seriously by MCI without vested interests taking over. As
of May 2018, it is illegal for doctors to take gifts, beyond specified limits, from pharmaceutical
companies; but it is not illegal for pharmaceutical companies to gift the same to doctors!20
An important step would be to go in for debranding of non-patented drugs, as Bangladesh did
in 1982. What this means is that single ingredient drugs out of patent can be sold only under
accepted non-proprietary or INN, names and not under any brand name. This reduces the need
on part of the pharmaceutical companies for making outré claims on theirproducts—and
consequently misleading marketing and attendant corruption.. In fact, a system for all marketing
content of pharmaceutical companies to be routinely monitored, screened, and approved by the
licensing authorities must be instituted.
Price control of all essential and life-saving medicines, rational prescription of medicines,
strict implementation of standard treatment guidelines, where possible, and licensing of only
rational medicines along with weeding out of all irrational medicines ought to go a long way. A
well-drafted mandatory code, with appropriate deterrents, to replace the voluntary Uniform Code
of Pharmaceutical Marketing Practices (UCPMP) of the Government of India must be
implemented without any dilution and concessions to the pharmaceutical industry.21 Indeed it
needs to be part of the Drugs and Cosmetics Act and not be non-justiciable guidelines. Likewise
the Ethical Guidelines for Biomedical Research on Human Subjects needs to have legal status in
the sense that violations ought to invite deterrent punishments and judicial action than mild
reprimands.

Nexus or Shared Consensus?

While the kinds of nexus discussed earlier are more or less plausible once pointed out, the other
damaging kind of nexus is a kind of shared consensus as to what kinds of political and economic
frameworks are needed for the well-being of pharmaceutical industry and medicine and
healthcare services.
In the current dominant narrative, price control of medicines (and therefore Drug Price
Control Order [DPCO] and National Pharmaceutical Pricing Authority [NPPA]), tighter
regulation of clinical trials/CROs, and on licensing of medicines, interventions by the State to
define useful and harmful medicines, restrictions on patentability (like Section 3d of the Indian
Patents Act), free sharing of medical discoveries in the interests of humanity as a whole,
alternative research models for medical discoveries, and so on are considered to be against the
functioning of free markets and ‘ease of business’.
Dominant sections of India’s ruling political and business elite have bought into this
consensus, with minor shades of difference. The NITI Aayog (the erstwhile Planning
Commission), under the guise of being a think tank, ends up orchestrating views of international
business and pharmaceutical lobbies, such as the USIBC (US–India Business Council), about
India ‘not doing enough’ to promote ‘ease of business’.22
Is the function of state to promote above all ‘ease of business’ for pharmaceutical, local and
international, at the risk of making it difficult, if not impossible, to access medicines?
Pharmaceutical and health markets are endowed with asymmetries of power and information and
therefore the balance of convenience due to State interventions that seek to redress this
imbalance, must lie with the patient, the economically poor and the socially weak, and not with
pharmaceutical companies or their protagonists.

Annexure 11.1
Select Extracts Related to Pharmaceutical–Medical Profession Nexus
‘There is also widespread corruption in the pharmaceutical industry, with doctors bribed to
prescribe particular drugs. Tales are common of hospital directors being given top of the range
cars and other inducements when their hospitals sign contracts to prescribe particular antibiotics
preferentially…’ (Berger 2014).
‘(The MCI) says doctors, hospitals and medical colleges should prescribe generic medicines
as far as possible. But NDTV’s hidden camera expose proves that doctors blatantly violate this
guideline in exchange for kickbacks from pharmaceutical firms... (Mehrotra 2014)
‘One more sting operation on doctors exposing greed and readiness to shed professional
ethics. I again appeal to brother doctors – show spine! ...’ (Union Health Minister Harsh
Vardhan, who is also an ENT doctor, tweeted this in reaction to NDTV’s expose)
‘Misleading information, incentives and unethical trade practices were identified as methods
to increase the prescription and sale of drugs. Medical representatives provide incomplete
medical information to influence prescribing practices they also offer incentives including
conference sponsorship. Doctors may also demand incentives, as when doctors’ association
threaten to boycott companies that do not comply with their demands for sponsorship....’ (Roy et
al. 2007)
‘The Indian subsidiaries of Abbott Laboratories have been particularly active in the push for
screening, with each of the company’s business divisions organising health camps.... These
camps have helped thousands of people get testing, education, and treatment for their health
problems,” Abbott India wrote in a report from 2011. ... That year alone, the company says it
screened more than 240,000 people for thyroid disorders ... Meanwhile, sales of its flagship
product Thyronorm, a branded version of thyroxine, raced ahead of cheaper competitors in India.
...’ (Joelvig 2015)
‘We report here, a new and disturbing form of entanglement being employed as a marketing
strategy by vaccine manufacturers in India and discuss briefly its ethical, scientific and public
policy implications. This strategy involves the promotion and sale to doctors of newer vaccines –
including polyvalent vaccines which are not part of the Expanded Programme of Immunisation
(EPI)—at a highly discounted price in relation to the maximum retail price (MRP)....’ (Lodha
and Bhargava 2010)
 ‘Recounting his own experience about ten years ago, Dr. Jayaprakash, an associate professor,
Paediatrician and Child Psychologist, SAT, Government Medical College, Thiruvananthapurm,
said that when he sent a child for an EEG and an MRI to a diagnostic laboratory, an executive
from the lab came home offering a commission of Rs. 3,000 for an MRI costing Rs. 6,000 and
Rs. 200 for each EEG costing Rs. 600... The laboratories provide half of the cost of the
diagnostic test like a CT or MRI to the doctor,”said Dr. Jayaprakash ... The nexus between
medical stores and doctors becomes important for both to keep the business and the practice
roaring, said Dr. Jayaprakash, who has authored a book on medical ethics in Malayalam.’
(Rajgopal 2013)
‘As Dr. Anand aptly puts it, “No one should have any doubt that the costs of industry
sponsored trips, meals, gifts, conferences and symposia are simply added to the prices of drugs
and devices. Drug industry treats doctors as prescribers and not care givers. When we attend a
sponsored banquet, we may be adding significantly to the drug prices in India ....’” (Kalantri
2004)
‘In another case, a 26-year-old married woman had been ill with fever, cough, anorexia; and
noticeable weight loss over a period of two months. Her sputum tested positive for acid-fast
bacilli, and a chest x-ray showed miliary tuberculosis. She revealed that her mother had
pulmonary Koch’s disease. In spite of sufficient evidence for a confirmed diagnosis, her
physician advised a chest CT scan which cost her Rs 4000 but did not alter the diagnosis. All this
only for a commission of Rs 1000 from the radiologist! ...’ (Bawaskar 2013)
‘The commercial needs of countless, fiercely competing pharmaceutical companies have led
them to depend on the tried and tested 3Cs: convince if possible, confuse if necessary, and
corrupt if nothing else works...’ (Gulhati 2004)
‘... A doctor, a veteran of many such annual conferences said: ‘’In every large conference of
this kind there are more doctors outside the conference than inside it. In fact the joke is that
doctors attending conferences are divided into three kinds — the hallmarkers, who stay inside
the halls, attend lectures dutifully, take notes and ask a lot of questions, the stalwarts who scour
the pharma company stalls sweeping up all the freebies and the ‘outstanding’ ones who are
always outside the conference venue making merry’’. The hallmarkers, quite obviously, were
outnumbered at Kochi. ...’ (Nagarajan 2009)

References
Bawaskar, H.S., 2013, ‘The Medical Trade’, Letters in Indian Journal of Medical Ethics (IJME),
X(4), October–December.
Berger, David, 2014, ‘Corruption Ruins the Doctor-Patient Relationship in India’, BMJ,
348:g3169.
Bhandari, M., J.W. Busse, D. Jackowski, et al., 2004, ‘Association between Industry Funding
and Statistically Significant Pro-industry Findings in Medical and Surgical Randomized
Trials’, CMAJ, 170(4): 477–80.
Bracken, B., 2009, ‘Why Animal Studies are Often Poor Predictors of Human Reactions to
Exposure’, Journal of the Royal Society of Medicine, 102(3):120–22.
Gadre, A. and A. Shukla, 2015, ‘The Toxic Influence of Pharmaceutical Companies’, in Voices
of Conscience from the Medical Profession, Pune: SATHI.
Gadre, Arun and Nilangi Sardeshpande, 2017, ‘Cut Practice in Private Healthcare’, Economic
and Political Weekly, 52(48).
Gulhati, Chandra M., 2004, ‘Marketing of Medicines in India: Informing, Influencing, or
Inducing?’ British Medical Journal, 328:778–79.
Heels-Ansdell D. and P.J. Devereaux, 2004, ‘Association between Industry Funding and
Statistically Significant Pro-Industry Findings in Medical and Surgical Randomized Trials’,
CMAJ, 170(4): 477–80.
Ioannidis, J.P.A., 2016, ‘Why Most Clinical Research Is Not Useful’, PLoS Med,
13(6):e1002049.
Joelvig, Frederick, 2015, ‘India’s “Health Camps”: The Drug Rep will See You Now’, British
Medical Journal, 351:h6413, 2 December.
Kalantri, S.P., 2004, ‘Drug Industry and Medical Conferences’, Indian Journal of
Anaesthesia,48(1): 28–30.
Krishnan, Vidya and Malia Politzer, 2012,‘Clinical Trials: Regulating Chaos’, Live Mint,
11October, available at
http://www.livemint.com/Politics/xhXDgTuPyNZOHcyFdeHyVM/Clinical-trials-Regulating-
chaos.html, accessed on 20 December 2016.
Lodha, Rakesh and Anurag Bhargava, 2010, ‘Financial Incentives and the Prescription of Newer
Vaccines by Doctors in India’, Indian Journal of Medical Ethics (IJME), VII(1), January–
March.
Mehrotra, Sonal, 2014, ‘Caught on Camera: For Bribes Doctors will Prescribe You Anything’,
NDTV, available at http://www.ndtv.com/india-news/caught-on-camera-for-bribes-doctors-
will-prescribe-you-anything-648170, accessed on 19 December 2016.
Moynihan, R., E. Doran, and D. Henry, 2008, ‘Disease Mongering is Now Part of the Global
Health Debate’, PLoS Med., 5(5):e106.
Nagarajan, Rema, 2009, ‘Docs Bunk Med Meet for Freebies.” Times of India, 21 December.
Rajgopal, Shyama, 2013, ‘Doctors Continue to be Fed and Bred by Pharma Firms’, The Hindu,
Kochi, 29 May.
Roy, Nobhojit, Neha Madhiwalla, Sanjay Pai, 2007, ‘Drug Promotional Practices in Mumbai: A
Qualitative Study’, Indian Journal of Medical Ethics (IJME), IV(2), April–June.
Smith, R. and I. Roberts, 2016, ‘Time for Sharing Data to Become Routine: The Seven Excuses
for Not Doing So Are All Invalid’, F1000Research, 5:781,
https://f1000research.com/articles/5-781/v1.
Srinivasan, S., 2012, ‘A Stinging Indictment of India’s Drug Regulation Authority’, Economic
and Political Weekly, XLVII(1).
———, 2016, ‘Is the Govt Mulling a Surgical Strike on Medicines?’ The Hindu Business Line,
25 November.
Srinivasan, S. and Malini Aisola, 2018, ‘Access to Pharmaceuticals: Role of State, Industry and
Market’ in Prasad N. Purendra and Amar Jesani (eds), Equity and Access: Health Care Studies
in India, New Delhi: Oxford University Press.
Srinivasan, S., Mira Shiva, and Malini Aisola, 2016, ‘Cleaning Up the Pharma Industry: A
Landmark Ban on Irrational Drugs’, Economic and Political Weekly, LI(14).
 CHAPTER TWELVE
People in Small Places Don’t Face Small Problems
Yogesh Jain

I work in a rather busy community health programme run by our voluntary organization Jan
Swasthya Sahyog in rural central India which is accessed by the poor. Despite our best efforts,
the waiting time to get seen by a doctor remains at an insane seven days. This is largely due to
the huge unmet need for low cost but effective care in large swathes of tribal India. But the
question is: why is this huge need not met by the existing public health system in the region?
At the root of this problem are the policies that determine public systems for the poor. The
human resources for the poor in rural areas are inadequate, both in terms of numbers and skill
sets; the infrastructure too is inadequate. Basics such as safe water, roads and bridges,
telecommunication services, power, food availability are all found wanting.
When I asked my colleagues in my rural health facility about corruption, the first response is
that there are no services, so why talk about corruption here. But can corruption not exist in the
absence of facilities, in the absence of services; does it happen only where there are transactions
such as purchase, when public works and other activities are being done by people, and when
money is being spent? Wouldn’t the lack of facilities and heathcare facilities in tribal and remote
rural areas possibly also be indicative of sequestration of resources for urban areas by the
planners and decisions-makers because that is where most of them reside? This too, according to
me, constitutes corruption.
There is inequitable distribution of resources between urban and rural areas. But what is
worse is the misappropriation and stealing of already meagre resources, worsening the situation
further. I see corruption in rural health systems denying people care close to their homes. For
instance, if someone has to travel long distances to get access to basic healthcare—150
kilometres to get tuberculosis diagnosed and treated or post-menopausal bleeding in case of an
elderly woman. Second, I find corruption is a major contributor to medical poverty due to
dishonest health providers asking for money for services delivered by them that should have
been free of charge. Third, I see corruption maintaining the status quo in terms of perpetuating
poverty and resultant hunger and more illnesses. So, there can be corruption in the absence of
facilities as well, just as it can exist in those very facilities.

Corruption Matters
It is true that the poorest suffer the most due to corruption. The poor have only these state-
managed resources to depend on for their needs, while the others can exercise the option of the
private sector as well. Also, the needs of the poor are larger.
 BOX 12.1 Housing Scheme for the Poorest: Embedded in Corruption

Chhotu Baiga, resident of Village Rajak in the interiors of the Achanakmar tiger reserve,
and belonging to the particularly vulnerable tribal group of Baigas, had been sanctioned a
grant of Rs 45,000 for housing under the Prime Minister’s Awaas Yojana. He was one
among the 45 Baiga tribal householders in his village, 20 of whom had been sanctioned
this. Soon after he received the first instalment of Rs 20,000, he was told by the secretary of
his Gram Panchayat to deposit Rs 2,000 as a kickback, ostensibly to be given to the chief
executive officer of the Janpad Panchayat. And this 10 per cent kickback was paid by all the
20 people who were sanctioned this grant, told Chhotu Baiga. Even after the second
instalment of Rs 20,000, a similar sum of Rs 2,000 per person was paid back. The last
instalment is supposed to be released only when the beneficiary family arranges money on
their own to make a sanitary toilet, and takes along a photograph of this and then makes a
claim for the third instalment of Rs 5,000. Chhotu could never make this toilet and in fact
had to leave the construction unfinished as he found Rs 36,000 he received insufficient even
to pay the labourers and the mason who worked in his house. Chhotu later learnt that the
panchayat secretary and the other officers of the scheme had withdrawn this Rs 5,000 by
showing a false picture and claiming this money. And this may have been done for most of
the other 20 poorest families in this area. Crestfallen, Chhotu Baiga continues to live in this
unfinished house of his, defeated by this structurally embedded corruption.

BOX 12.2 Mahatma Gandhi National Rural Employment Guarantee Scheme

(MGNREGS)

Jethuram Baiga, a resident of village Phulwaripara, along with several people of his village
had worked in this employment guarantee scheme to supplement their income, which was
otherwise limited to the yield from the single rainfed paddy crop. As they hailed from a
Scheduled Tribe, they could get sanction for levelling of their fields as well as deepening of
their village pond as an employment guaranteeing activity.
They worked on their fields in 2014. When their wages did not come in even a month
later into their bank accounts, on approaching the Rozgaar Sahayak—the employment
guarantee assistant—they were told that it was common for government grant money to get
delayed. When this period became three months and their patience was running dry, they
approached the block development officer. That officer informed them that their due wages
had already been withdrawn from the state treasury a few weeks ago. This led to the corrupt
Rozgaar Sahayak, who had swindled the money. Even a year later, the wages of these poor
tribals did not reach them. Prophet Mohammad had remarked regarding employment and
payment of wages ‘Mazdoor ko uski mazdoori uska Paseena Sukhney se pahley de do’
(Sunan Ibn majah, Vol. 2, 600 (Wages should be paid to a labourer even before the sweat
dries). But here not only are wages delayed inordinately, they are essentially denied.
Enough to kill the entire programme.
 The fact is that corruption is deeply entrenched in rural life, in as much is relative justice and
inequity. It is all pervasive.
In the case of ASHA, the flagship programme of the National Health Mission, the final care
provider (also called ASHA; called mitanin in Chhattisgarh) is supposed to be an activist in the
village who should demand and ensure the healthcare rights of the people. Her supervisor, called
the mitanin prerak, supervises and decides about incentives to be paid for public health tasks
done, and is almost always appointed by paying huge bribes of over Rs 20,000, if not otherwise
related or recommended by the party functionaries of the ruling party. In the MGNREGA work,
where 150 days of employment is guaranteed, in several villages of Bilaspur, information for
which is available with me, people would often be shown in the muster rolls to have worked for
20 days in a month when they would have worked for 15 days. The wage money for the excess
five days would be shared between the supervisor and the employee, with the former getting the
lion’s share. Similarly, the Chhattisgarh MGNREGA offers 30 days’ wages after delivery to any
pregnant woman registered under the programme. This is in recognition of the labour she has
performed while being pregnant. However, this money most often does not reach the women,
and may have been withdrawn by the supervisors.
One of the most talked about health programme in the context of which corruption is often
mentioned is the Janani Suraksha Yojana, which was instituted to encourage institutional
deliveries. If the woman delivers in a designated institution, then she is entitled to Rs 1,400 plus
a small travel allowance. It is common knowledge in the villages of Bilaspur district that most
women who deliver in hospitals have to part with Rs 500 out of this Rs 1,400 to the local
auxiliary nurse midwives (ANMs) to avoid spoiling relationships for the future. Not only this,
the lordly sum of Rs 500 is also given as an incentive for home deliveries to all parturient
women, to be certified by the local ANM, of which the standard practice is a 50 per cent cut for
her almost as a fee for getting the claim form filled up and the sum claimed from the state.
I know of ANMs in the public health system who are likely to be staying in the village of their
posting but charging people for medicines they are supposed to give free. They often charge for
conducting a delivery. And they also charge for expensive injections they are not supposed to be
dispensing. Despite this, many of them enjoy grudging respect for at least staying in the village
and doing their work, even if they charge for their stated official work. It is to such low levels
that people’s expectations from the public systems has sunk.
The going rates for a bribe to become an anganwadi helper, whose wage is Rs 1,500 a month,
is Rs 50,000. This obviously is recovered post employment by the helper, not as much through
her wage, but most likely by selling off the food that comes for the child beneficiaries. Several, if
not most, ANMs openly ask for and get Rs 400–500 from the amount that any woman is due to
receive. The resources that can be misappropriated by the Panchayati Raj Institutions in
Chhattisgarh can be gauged by the fact that the going bribe rates to become a gram panchayat
secretary is Rs 4–6 lacs and any job that requires to be done at the janpad panchayat has a
standard rate of 10–20 per cent kickbacks.

Can Corruption and Competence Co-exist?

Is it possible to be a good doctor and yet be corrupt? Or have a good system that delivers and is
still corrupt? Sadly, it is true, even if I find it difficult to believe that being a good doctor and
being corrupt cannot be mutually exclusive. Most of my colleagues, who seem to feel the pulse
of the community, feel that there are several doctors who are technically competent but fail on
the ethics parameter. I feel that such a person cannot be a good counsellor or teacher to his
patients. Worse still, the doctor is highly unlikely to command respect and faith since at the core
of every good doctor–patient relationship is honesty. Similarly, how would people develop trust
in a system that is manned by corrupt individuals, even if it is a system that delivers technical
solutions.

Why Corruption Goes Unchecked?

Why do we fail to counter widespread corruption? Why is the misappropriation of resources
tolerated by those who are deprived?
There can be several reasons for this:

1. People don’t think that what is being misappropriated belongs to them, in the first place.
Perhaps the most important is ignorance of the fact that these are people’s own resources that
are being misappropriated. For example, if the labour ministry offers Rs 15,000 for a pregnant
woman at the time of delivery as part of a scheme, for which they may have budgeted in the
national budget, most people don’t know that it is their due. So, if a local executive offers
them this sum against a kickback of Rs 7,500 (50 per cent), they still feel that they are getting
a largesse of Rs 7,500 for which they don’t mind paying a ‘fee’, as it were, of Rs 7,500. Or
worse, when someone pays a bribe of Rs 50,000 to become an anganwadi sahayika, she may
justify this not only as a fee to get a government job, but as an investment that she will recover
along with a significant rate of interest over the rest of her life by siphoning off resources
(food and other goodies) that ICDS provides in the anganwadis.
Not only is there no sense of ownership of the resources being misappropriated by corrupt
officers, there is no accountability for their own conduct that could have prevented such
corrupt dishonesty and theft.
2. There have been too few success stories of getting one’s due, even after complaining. Success
stories of being able to stop corrupt practices are rare, and this dampens the spirit of anyone
who is trying to set things right. There are hardly any fora in rural areas to voice or channelize
complaints.
3. The urgency to live and survive is so great that one is always looking for quick and short ways
to settle things. When you live in deprivation, the urgency of getting food, healthcare,
education, transportation, and other services is so great that one cannot afford to run the risk of
jeopardizing access by being a whistleblower, or worse, do away with these needs. There is a
great amount of dependence on these systems. This is best exemplified in the field of
healthcare. If a doctor is chronically absent from a health centre, the worst time to raise the
issue is when you actually need him or her urgently. You would rightly fear that raising
uncomfortable questions at this time might make you lose whatever care you would otherwise
be able to get. Sadly, when you are not sick, you would rarely feel the urgent desire to
question the absenteeism of the doctor from the workplace.
4. The power asymmetry is so great that it is difficult to demand accountability from those in
power. A disproportionately higher proportion of people in positions of power hail from the
upper castes or classes, making it more difficult for the beneficiaries to approach them.
5. The processes in governance and execution of activities in the rural areas, for which
panchayati raj institutions are now empowered, are too complex and difficult to understand.
 This allows them to be exploited by those who are smart (and corrupt people are often smart)
and thus a new entrant to these panchayat institutions is often forced to be part of corrupt
activities.
As an example, there was this young bright man who was elected to become the sarpanch
of his village, Davanpur in 2014. To be able to finish one project of making a drain, when he
was having difficulty in getting money immediately from the state treasury, he borrowed some
money from another unrelated bank account, which was technically improper. Using this
mistake as a threat, this honest sarpanch was made to get into a spiral of making many other
procedural errors by his smart panchayat secretary to such an extent that he was forced to
continue dishonest practices. The procedures of proposal writing, withdrawing money,
inviting tenders and awarding contracts, maintaining records and submitting reports can be
daunting and PRI leader often find their skills inadequate in negotiating their way through
them.

What Makes One Corrupt?

In the times we live in, where corruption seems omnipresent, one does come across a few
medical officers, nurses, pharmacists and laboratory technicians, community health workers,
teachers, and anganwadi workers who are not corrupt. Why are they honest among such
pervasive dishonesty? Or how can we have lesser cases of individuals and institutions being
corrupt? Women are less corrupt than men. Second, if accountability is ensured by either
community or by centralized supervisors, then corrupt practices become less. Third, if there is a
fear of being found out, there will be less corruption; for our honesty is inversely proportional to
the strength of the belief that someone else cannot detect our dishonesty. So, stronger
mechanisms can keep corruption in check. Finally, corruption tends to get concentrated. If more
than a small proportion of people in a set up indulge in corrupt practices, then incrementally
more people become corrupt.
Knowing why some institutions or people are not corrupt can help us draw lessons for what
can be done in future to address this problem.

Corruption, Quality, and Policy: Are they Related?

Is corruption more important than poor policies? In my opinion, policies that decide unjust and
iniquitous resources for the rural areas are the most important reason for the continued misery of
people here. For example, how we decide where hospitals should be set up and where small
health centres are to be establiished, or what blood investigations are possible at a community
health centre (CHC) while city hospitals would have a much larger array of investigations on
offer, or public transport be not so easily available or frequent in rural areas and rather easily be
available in cities are based on policies that seem to perpetuate this rural–urban inequity.
This is the reason that for all vital statistics and indicators in health, rural areas lag behind
urban areas. Even in the same income quintiles, the statistics are poorer for rural areas.
But on top of this iniquitous resource distribution comes in corrupt practices that seem to
compound the problems. In my opinion, corruption is a major issue, but it is less important than
the poor policies in terms of attribution of misery and deprivation that people suffer. Corruption
tends to perpetuate the raging inequities in access to healthcare and drains off the meagre
resources allocated to it.
Private Practice by Public Health System Doctors Other Health Workers
This is perhaps the largest aspect of corruption that I see as a rural practitioner. And my dismay
is that it is institutionalized and accepted at a policy level. Physicians appointed by the public
health systems are expected to serve and provide care and at the same time are allowed to do
private clinical practice. This private practice could be at different hours than the regular public
hours, and could be at a separate location, or sometimes co-located within the same premises.
But there is no check or regulation on the referral of patients from the public to the private
facility. Often, the senior physicians or surgeons indulging in private practice ask their junior
support staff such as resident doctors, operating room assistants, lab technicians, and nurses to
accompany them in their private clinic facilities for some cash or other incentives.
The system accepts this often as a blackmail for the threat to quit the government job that
could further deplete the public systems of senior physicians. And in doing that they may
withdraw the paltry non-practising allowance (NPA), which is a minuscule amount the private
practitioners would lose compared to what they make otherwise. And in a situation where the
majority of public physicians opt for doing private practice, even this small NPA is not given up.
This private practice by public system physicians could be best described as private–public
partnership (PPP) embedded within an individual. And more than other negative consequences
for systemic PPP arrangements for public health, this one is particularly harmful.
This private practice by public employees is not only indulged in by physicians, but also by
other paramedics in the health facilities, such as nurses, lab technicians and assistants,
pharmacists, extension educators, ANMs, compounders, and even ASHAs. All this results in
milking the public system dry of valuable human and material resources, all for private profit.
How does the community see this? Once the state legalizes it, there is a gradual acceptance,
and given the mindset that public services are less accountable than private services because of
the profit motive, those with any resources tend to go for private care by these public system
employees who draw their wages from the taxpayers’ money. And only those who have no
resources may come to these emasculated public systems, or may choose to suffer at home
without seeking care.
One well known pattern of this private practice by public physicians is this—a physician
posted in a primary health centre or community health centre comes for two or three days in a
month at his designated work site, one of these days being a wage collecting day, and on all other
days is absent from work. In lieu for this arrangement, the person pays a fixed amount or
proportion of his wage to the supervisor and the accounts clerk at the headquarters. This near
total absenteeism from the work site is also slowly accepted by the community. And people
accept the depleted work force in the rural health centres.
Another form of this absenteeism from peripheral rural centres is physicians and nurses
leaving their allocated clinical facility and getting ‘attached’ to a district town facility. Citing
often very specious reasons, health professionals using some clout may get their placement in a
district hospital even if there is no vacancy, and thus these more central services are often
overstaffed hugely much beyond their capacity or need when at the same time more rural
facilities will now have fewer staff due to this migration. We have seen often in Bilaspur district
that there would be 37 doctors in the district hospital against an allocated strength of 28, whereas
other CHC such as Pendra or Gaurella are running with two or three doctors. This is true of not
only health facilities, but also of education and other departments. And this brain drain is
institutionalized corruption.
How We Respond to Corruption?
When people go to a rural hospital and don’t find the doctor, how do they feel and how do they
react? Or when they are asked for money? While people don’t like it, they either don’t seem to
feel a denial of their right to health or they sometimes feel disempowered to influence the system
with demands. Worse, they may feel scared that raising a voice might deny them care in the
future. And when things happen too commonly, there is a normalization of improper things. So,
if an ANM conducts a delivery in the sub-centre or at the PHC, and then demands some money
for the job done, a lot of people in the community justify it being a fee or a reward for doing it
(when the default they are used to is a delivery not happening at all in a sub-centre). That a
doctor would be available for a certain number of hours in the health centre, or one will get drugs
and diagnostics free or other services would be available are not expectations that people have,
as a consequence of entrenched corruption and power asymmetry in rural communities.
How does a rural healthcare provider see this absenteeism and the charging for services? I am
not sure how they see this. But I have heard many doctors justify their absenteeism by citing the
need to prepare for postgraduate degree courses. Or they would lay their blame on the poorer
quality of life given the different class to which they belong. The lack of oversight or demand for
accountability by the community served is another justification.
Corruption at the entry level of employment in health services spoils the system for all time.
Whether it is for a VHW (village health worker), or ANM, or for a male MPW, or other PHC or
CHC or DH staff, if you pay money to get in, your first priority is to recover that investment.
And you would like to do that to repay the loan, and then to earn some interest on the
investment. Finally, you are more likely to become part of this corrupt system. And thus whether
it is the drugs a sick child has to get, or the extra oil that a three-year-old child deserves in her
meal at the anganwadi, she would not get this.
The effect of this corruption in selection of staff members is not only in terms of money
transacted between the giver and the powerful employer, it has a lasting negative impact on
public health. It determines and ensures permanent loss of resources that would ideally go into
public goods. Thus, drugs and food will be siphoned off and sold off and would never reach the
deserving or the intended recipients.

What can be Done to Address the Problem of Corruption?

If we want to start addressing corruption, a key variable to explore is to get accountability. As I
see it, accountability can be ensured from three basic structures: bottom up (from citizens in the
community), top down (from supervisors), and laterally (from one’s peers). In rural areas, we
have optimized for none. In fact the public health systems think only about top down. Only
occasionally, it pays lip service to bottom up without any real mechanisms. The recent
community based monitoring including Jan Sunwais (public hearings) efforts are few and far
between and often look at only symptoms of corruption at the most peripheral level, leaving
higher-level corruption completely unchecked. Even so, making people aware of their health
rights by pasting charters in health centre premises of what people should get in the health
programmes is one small way. Consumer fora are needed but are yet to start in rural areas.
Presently, we can’t even imagine the third structure of cultivating a professional culture and
sensibility that poses a peer pressure ensuring accountability and eliminating corruption.
Next, I would argue for getting policies in health that are underpinned in equity concerns. In
the absence of equity, it would be more difficult to question dishonesty or misappropriation of
resources.
When job roles, postings, and transfers are commanded and not voluntary, this invites both
apathy on the part of the professional, constraints in terms of distance from family and other such
factors, and power that is centralized—all of which invite corruption. Thus, if these human
resource issues can be made more voluntary and there is decentralization of such decision
making, corruption will decrease. Of course, we will first need more equitable development of
support infrastructure in all areas.
No public health programme can succeed in a setting in which scarce resources are siphoned
off, depriving the disadvantaged and poor of essential healthcare. Once we are trying to make
development more equal, a huge educational campaign is needed to make people aware of their
health rights. As well as training in ways of ensuring accountability of the systems. But the fact
is that all these accountability mechanisms are difficult to implement.
 CHAPTER THIRTEEN
Healthcare Corruption and Traditional Medicine in India

Kavita Narayan1

Background: The Flawed Nature of the Indian Healthcare System2

India’s healthcare system is broken. This is evident in its inability to effectively allocate existing
resources, especially in providing last-mile services. Several instances have been seen across the
country where relatives are forced to physically carry ailing or dead patients, for several hundred
kilometres, in the absence of emergency/ambulance services.3 Considering India’s geographical
challenges, such stories can be understandable, but ironically, in most of these cases, such
services were available, but were not deployed when they were necessary. In one shameful case,
an ambulance driver offloaded his passengers when the patient died, leaving a tribal couple
stranded in the middle of the road with the body of their dead seven-year-old child (Narayan et
al. 2012).
The problem is further compounded by several human resource challenges—medical and
allied professionals are either inadequate or lack sufficient incentives to serve in rural areas
(Vaidhyasubramaniam 2014). Additionally, education is constantly being commercialized.
Medical students and their parents invest highly in their education, in addition to capitation fees
(amount paid over and above tuition and maintenance). A recent report from the National
Institute of Public Finance and Policy ranked the education sector second in a list of generators
of ‘black money’ in India. It estimated that capitation fees paid to professional colleges last year
was over five thousand crore rupees.4 The legal system has gone back and forth over the issue,
with the Supreme Court issuing various judgements on capitation fees calling them arbitrary,
unfair (Venkatesan 2014), and illegal (Venkatesan 2003), or necessary to subsidize meritorious
places (D’Silva 2015). This has encouraged private medical colleges to demand capitation—a
sum that varies based on the reputation of the college and the time they are approached (students
pay less if they ‘reserve’ their spot before the admissions process starts, rather than after the
announcement of the entrance test results) (D’Silva 2015). The practice of having to pay one’s
way into the medical system devalues merit, thus decreasing the quality of professionals being
churned out into the system. Additionally, it erodes the root values and ethics of the profession,
of service to humankind and honesty, making the oath more hypocritical than Hippocratic. Thus,
considering the money they have invested in the system, few medical graduates choose to
advance their careers over relocating to underpaid, under-served rural areas (Berger 2014).
Additionally, rural postings do not provide sufficient opportunities to learn (higher studies) or
progress (in terms of a professional career). Although a one-year rural posting is now mandatory
for all medical graduates, most take the easy way out and pay the damages.
According to the latest data from the Medical Council of India (MCI), the country has 460
medical colleges with a total annual intake of 64,675 students. Of these, 54 per cent (248) are
private medical colleges with a combined annual intake of 34,870 students. This privatization
has seen a marked increase over time—in the past six years alone, 89 private medical colleges
were set up, which added 12,400 seats (MacAskill et al. 2015).
A recent Reuters investigation found that more than one out of every six of the country’s
medical schools has been accused of cheating, according to Indian government records and court
filings (Berger 2014). It showed that recruiting companies routinely sent doctors as full-time
faculty members to medical colleges only for the short duration of government inspections. The
colleges also hired healthy people to be pretend-patients to demonstrate an adequate caseload for
clinical experience in teaching hospitals. This unwelcome precedent during their training
ingrains corruption into doctors that eventually manifests as an unending cycle of referral and
kickbacks with medical institutions, leading to a lack of trust from patients as well.5
Corruption, especially in healthcare, is unfortunately a global issue. Results from the Global
Corruption Barometer released earlier this year show that approximately 90 crore—or just over
one in four people—living in the 16 countries of the Asia-Pacific region, including some of its
biggest economies, are estimated to have paid a bribe to access public services. While only 18
per cent of the Asia-Pacific region paid bribes in their dealings with the healthcare sector,
regrettably, the figure in India shot to an overwhelming 59 per cent. According to the study,
India has the highest overall bribery rate (69 per cent) and Indians have paid the most bribes to
public hospitals. This number is significant, because Indian public sector hospitals are the most
bribed among not only other public service categories in India, but also among all the countries
in the Asia-Pacific region.6
The latest advances in medical technologies are available in India for a premium, but the
inability of the vast majority to pay makes them inaccessible. For most Indians, healthcare is
already an out-of-pocket expenditure. However, corruption transcends all barriers and is
experienced by both the rich and the poor,7 and is exacerbated by a general, if not widespread
tolerance of the phenomenon. Corruption will persist as long as it is an accepted practice to offer
or receive financial or other benefits (Mackey and Liang 2012) in return for entitled services.
Corruption is not only leading to economic loss and wastage of our valuable resources but
also adversely impacting our infrastructure, financing, social determinants of health and
healthcare accessibility. Thus, it is affecting both the quality and coverage of services, leading to
price inflation for health-service unit costs. Health systems which lack transparency, regulatory
control, and adequate law enforcement in developing nations and evolving markets can result in
public- and private-sector extortion and bribes which can lead to the production and sale of
forged drugs thus leading to the export of counterfeit medicines to other global markets, resulting
in an increase in mortality and morbidity rates, pathogen resistance and decreasing drug efficacy,
wastage of resources for pharmaceutical products and services, and lack of safe access to
essential drugs.
Therefore, corruption can drain resources from already penurious and fragile health systems,
precluding access to life-saving treatment for vulnerable patient populations. So, there is a need
to stop corruption globally in the healthcare sector by enforcing several laws like anti-bribery
laws, anti-fraud units, imposing both civil and criminal fines for the submission of false claims
and for providing forms of remuneration to healthcare professionals, etc., which will bring in
major reforms to prevent corruption in health systems across the world.
 Health-related corruption comes in several forms (ranging from ‘petty’ corruption such as
absenteeism of healthcare workers, to ‘systematic’ corruption involving multinational companies
engaged in widespread healthcare fraud and abuse, and ‘grand’ corruption occurring at high
levels of government). This can invade and spread (infiltrating public and private sectors in
poorer and richer countries alike), has an enormous financial cost, is often difficult to detect and,
most importantly, is hard to treat (Berger 2014). The healthcare sector is one of the areas that is
particularly vulnerable to corruption. Corruption is the very antithesis of patient-centred care.
Driven by greed, those in power divert crucial resources away from patients in need, which
results in poor quality of care and worsening health outcomes.
While corruption occurs in various segments of healthcare, bribery in doctor-to-patient
service delivery is its most visible form. It is estimated that corruption in healthcare may be
provoked by weaknesses in the healthcare system (low salaries, relatively low levels of
healthcare spending or research budgets, close ties between the industry and healthcare
providers) or flaws and loopholes in healthcare supervision, anti-corruption legislation or judicial
effectiveness (Pal 2002).
Corruption has thus worsened the existing health system problems of access, quality, and
price, forcing people to turn to alternative sources of medicine.

Systems of Traditional Complementary and Alternative Medicine

(TCAM) in India
India has the unique distinction of having seven recognized systems of medicine in this category.
These are: ayurveda, siddha, unani, yoga, naturopathy, homoeopathy, and the recently
recognized sowa-rigpa. According to the definition used by the Cochrane Collaboration,
‘complementary and alternative medicine’ is a broad domain of healing resources that
encompasses all health systems, modalities, practices, and their accompanying theories and
beliefs, other than those intrinsic to the politically dominant health system of a particular society
or culture in a given historical period. Traditional medicine in every country where it has a strong
base has emerged out of an individual physician’s approach to the problems of an individual
patient, spreading to the family, and later to the community. It is based on the theory that energy
cannot be destroyed but if it is utilized in the wrong manner, it can cause an imbalance in its
flow, leading to diseases. Treatment and cure in traditional medicine is based on understanding
problems linked to an individual’s traits and is believed that every person belongs to a broad
stereotype. Therefore, the treatment procedure in traditional system of medicine varies from
person to person and the treatment for two people having similar complaints can be different,
unlike in modern medicine.
FIGURE 13.1 Recognized Traditional, Complementary, and Alternative Medicine Systems in India
Note: Naturopathy is missing from this diagram.

Alternative medicine is divided into four subcategories:8

1. Acupuncture and Oriental medicine

2. Traditional indigenous systems (ayurveda, siddha, unani, yoga, etc.)
3. Unconventional Western systems (for example, homoeopathy)
4. Naturopathy

Documents reveal that for centuries, various therapeutic modalities have coexisted and were
practised even before the introduction of conventional medicine. However, the regulation and
recognition of ‘unknown’ streams of TCAM need to follow a stringent legal process in India,
given that there is limited documentary evidence on the effectiveness of such practices.
Traditional medicine has been practiced across rural India covering over 70 per cent of our
population, though the recognition is dependent on the efficacy and merits as well as fulfilment
of criteria set for ensuring legitimacy of this alternate system. There have been past efforts to
gauge the efficacy of various systems including ayurveda, siddha, unani, homoeopathy, yoga,
and naturopathy, electropathy/electrohomoeopathy, acupuncture, magnetotherapy, reiki,
reflexology, urine therapy/autourine therapy, hypnotherapy, aromatherapy, colour therapy,
pranic healing, gems and stone therapy, and music therapy, to name a few, though the healthcare
system only recognizes few of these therapies as TCAM. It is evident that there has been an
increase in the practise and consumption of such therapies by the masses. The government
recognizes this and has been putting efforts to streamline some of the norms such as acupuncture
and hypnotherapy, which have been allowed to be practised by registered practitioners or
appropriately trained personnel. However, these norms or regulations made by the government
are unknown to the population, who continue to approach people practising various other
modalities of treatment and cure.9
The evolution of the TCAM has picked up pace in the last decade, with growing usage and
inclination towards alternative medicine. The Department of Indian Systems of Medicine and
Homoeopathy (ISM&H) created in 1995 was upgraded to the Department of Ayurveda, Yoga
and Naturopathy, Unani, Siddha and Homoeopathy (AYUSH) in November 2003 with a view to
focus attention on education and research in the AYUSH streams, and was established as the
Ministry of AYUSH in November 2014. Since then, several efforts have been directed to
streamline the AYUSH, including the launch of the National AYUSH Mission in 2014 for better
access to AYUSH services, strengthening of institutions, quality control as well as drugs and
availability of raw material;10 MSRs on Ayurveda, quality regulation of educational institutions,
worldwide celebration of International Yoga Day in 2015, as well drafting of a national policy on
AYUSH, 2016 rendering global recognition to the AYUSH systems of medicine. Further, the
Ministry of AYUSH, Government of India and WHO have also signed a historic Project
Collaboration Agreement (PCA) for cooperation on promoting the quality, safety, and
effectiveness of service provision in traditional and complementary medicine 2016–20. This
aims to support the development and implementation of the WHO Traditional and
Complementary Medicine Strategy: 2014–23 and will contribute to the global promotion of
traditional Indian systems of medicine. This is directed to promote the integration of the
traditional practices in the national healthcare system.11
AYUSH practitioners have also been integrated with the National Health Mission with a
rationale that there is a need to address the disease burden and it offers a choice of care to the
local people aligning with their culture and beliefs. However, it is known that malpractice is
prevalent in all domains of healthcare—such as AYUSH practitioners also practicing allopathic
medicine because there is no regulation on mixing therapeutic practices (Chaudhury and Rafei
2001).
Along with the traditional trained and certified medical fraternity in the country, another
group of healthcare providers known as the ‘Informal Providers’ (IPs) comprise a significant
component of the health system in India, especially the rural population. Several studies have
recorded the widespread access to such providers for primary care in rural India, where they
often prescribe medications for which they are not formally trained for dispensing or distribution.
Yet very little has been explored about the performance, cost quality, and size of this sector.
According to a study by the Centre for Health Markets and Innovation, they are independent and
largely unregulated healthcare practitioners, who provide a vital source of care for many in
lower- and middle-income countries, and consist over 50 per cent of the healthcare workers in
India. These providers may not be officially certified to treat patients or may have little formally
recognized training and operate outside the purview of the present regulatory systems on
healthcare, but they gain clinical expertise by experience in the field.12
 Several other types of informal providers are currently in the system. It is estimated that in
India there are more than 2.5 million rural medical practitioners who are practising without any
formal training. Among such people include those who have worked with doctors as assistants
(which may include laboratory graduates, drug dispensers, etc.) and have learned their trade over
time. None can be referred to as doctors, but considering that they may be more socially involved
with the community, they are the valued ‘pseudo doctors’ for the community, largely termed as
‘quacks’ by the medical leadership and associations. Apart from the RMPs there exist several
other forms and types of informal providers including but not limited to faith-based healers,
Bengali doctors, dais, and ayahs, to name a few, who establish their practice, cater to a niche
market, and thrive on patients’ expectations to resolve health issues.
Though the government is well informed of the existing challenges of healthcare providers
and the presence of informal providers in the system, under the National Health Mission (NHM),
it took a major stance to streamline similar providers. The Mitanin Programme proved to be a
health-sector reform, and it was later upscaled countrywide, which led to introduction of ASHAs
as community-care providers and the first informal contact personnel. ASHAs are traditionally
local women from the community who promote and propagate the concept of institutional
deliveries. The ASHA personnel, and similar care providers have been involved in several
government-led healthcare programmes such as Janani Suraksha Yojana (JSY), Janani Shishu
Suraksh Karyakarm (JSSK), etc. Thus, for instance, under JSY, expectant mothers are eligible to
receive Rs 600–1,400 when they register at a healthcare facility to give birth and similarly an
ASHA receives an incentive per delivery, which varies across states.

TABLE 13.1 Minority Concentration Districts where Both Socio-economic and Basic Amenities are Below
National Average
Source: Multi-sectoral Development Programme for Minorities based on Census of 2011.

Such an effort has increased the access to care personnel manifold in rural India. However,
the structural shortcomings in such programmes also provide new avenues for malpractice and
corruption at the ground level. The need for such providers is evident when we consider the lack
of access to care and the distribution of minority populations across the country. Table 13.1 is a
list of top districts with more than 25 per cent of the minority population where both socio-
economic and basic amenities status is below the national average. The complete list
encompasses more than 80 districts highlighting the access issues across the country.

Status of CAM in Different Countries13

Traditional medicine has been present in India since the Vedic times In fact, ayurveda is also
prevalent in Nepal, Sri Lanka, Mauritius, Bangladesh, Pakistan, Indonesia, Malaysia, Singapore,
and the Maldives. The traditional systems prevalent in Myanmar, Bhutan, and Thailand bear a
close resemblance to ayurveda. These systems are regulated by national health services under the
Indian systems of medicine and homoeopathy. The Central Council of Indian Medicine regulates
the practice and education in ayurveda, siddha, and unani. The Government of India also
established a research council, the Central Council for Research in Indian Medicine,
Homoeopathy and Yoga (CCRIMH) in 1971, which was subsequently developed into four
independent councils in 1978. In the past decade, many centrally sponsored schemes have been
launched to strengthen the systems in terms of education and research. The National AYUSH
mission maps out an implementation plan to promote the systems, strengthen the educational
infrastructure and enforce the quality control on the related drugs.
Similarly, the presence of various traditional methods and practices are prevalent across the
world. Traditional Chinese medicine commonly known as zhongyi, encompasses the use of a
combination between acupuncture, acupressure, Chinese herbal medicines, moxibustion, and
massotherapy. It is still a popular choice of treatment with the general population in China where
it is practiced along with Western medicine systems at every level of the healthcare system. The
system is overseen by the State Administration of Traditional Chinese Medicine and
Pharmacology. It is responsible for the management of traditional Chinese medicine and
pharmacology, for formulation of developing strategies, guiding principles, policies, laws and
regulations. China has successfully integrated practices from both traditional and modern
medicine. Medical students in China take mandatory courses in both Western and traditional
medicine, and actively implement their knowledge in hospitals and teaching clinics. As a result,
Chinese physicians are familiar with the strengths and weaknesses of both medical systems and
can choose the right combination to maximize the positive effects. There are different levels of
acupuncture education in China, ranging from self-study examination to high-end professional
courses.
The traditional system in Bhutan, known as gSo-ba-rig-pa, is a recognized system of
medicine under the health division of the government of Bhutan. Until the regulation of the
practice and professions, there was no uniform education for prospective doctors in the system.
However, in 1978, a five-year course was endorsed under the leadership of the government.
Measures have been taken to keep the training curriculum in line with the national health policy
of the country. An interesting initiative taken by the government is training traditional doctors in
practical allopathy after the completion of the five-year course, followed by a three-month
internship under a senior doctor in the hospitals.
In Korea, the traditional system of medicine is known as the koryo. The systemization of the
practices and theorizes has been a crucial factor in flourishing and preserving the system in the
region. Koryo has well-penetrated roots in the region, with the ministry of public health
dedicating the guidelines for traditional medicine practices. The koryo medicine institutes in the
12 provinces in the country function under the control of the state.
Indonesian traditional medicine systems, like other Asian systems, are based on the holistic
approach to treat a disease and maintain equilibrium in the system. It is commonly known as
jamu. It involves the use of traditional knowledge of herbs accompanied by the use of traditional
techniques such as acupuncture and traditional massage. This indigenous system has been use for
health promotion, maintenance, and treatment. Indonesia has achieved a greater equity in the
health for the general population. Recently with the call of going ‘back to nature’, both
government and private enterprises have made several positive efforts to promote jamu as a
modern therapy.
 Complementary or unconventional treatments are used by many doctors and other therapists
throughout Europe. Homeopathy is the most popular form of CAM in France and Belgium. The
Dutch are enthusiastic about using spiritual healing while massage is popular in Finland.
Germany licenses practitioners who are not the members of recognized health professions to
practice, provided they have passed an examination in basic medical knowledge and are
registered. These practitioners are, however, prohibited to practice specializations such as
obstetrics, dentistry, and venereology. Britain also has CAM-specialized hospitals in the public
sector. Complementary alternative medicine has gained such popularity in that country that over
35 per cent of the registered general practitioners in UK have received training in complementary
therapies. This is especially common among the younger generation of doctors. Netherlands and
Hungary have also recognized ayurveda as alternative medicine.
In Bangladesh, the ayurveda and unani systems are the major traditional systems providing
healthcare in the country. They are the preferred choice of treatment for both, the rural and urban
populations. The government has ensured their propagation through central-level administration,
that is, the Directorate General of Health Services (DGHS) and recognized training institutes.
The central board of traditional medicines has been set up under the DGHS to monitor the
practice and education of traditional systems in the country. The board also provides financial
and technical support to the institutes to offer diploma and higher-degree courses. It also
provides registration of the passing candidates in unani, ayurveda, hakims, etc. Research avenues
are also being opened under the initiative, and focus on the herbs used in these systems and
various aspects of ayurvedic medicines.
The traditional medicine system in Thailand is known as Thai traditional medicine. Its
popularity, however, has declined due to the use of western ‘biomedicine’, especially among the
urban population. There is an emphasis on the systematic blending of the traditional and the
Western system of medicines to increase the quality of treatment. To keep a check on
unauthorized practices and quality of care provided, the government has established ‘Clinical
Practice Guidelines of Thai Traditional Medicine’, which is monitored at every level via
committees.
FIGURE 13.2 Prevalent Challenges and Issues in the Healthcare System

Issues and Challenges

Globalization has impacted our health system in a daunting way; it has not only enabled trade,
travel, and communication, but has also facilitated the spread of infectious diseases across the
world, such as SARS, N1H1/A, the ZIKA virus, etc., thus, requiring a holistic shift in the
healthcare system globally. Therefore, the next pandemic is not only a threat to the world at large
and marked by new challenges to our healthcare system, but a new major threat to our healthcare
is the rampant corruption, which is impacting both developed as well as developing nations.
Corruption is the ‘misuse of entrusted power for private gain’. In healthcare, it can involve
bribery of health professionals (like doctors, nurses, etc.,) regulators, and public officials;
carrying out unethical research; stealing medicines and medical supplies; fake overbilling for
health services; truancy; informal payments; theft; prescription of spurious drugs; unnecessary
procedures and surgeries; irrelevant diagnostic procedures; use of systems with no proven
efficacy; as well as corruption in health procurement, to name just some instances. According to
the ‘Transparency International’ report, the scope and scale of corruption in the healthcare
system affects the lives of millions of individuals. As per the report, approximately billions of
dollars are lost annually due to corruption and fraud in the healthcare market globally which was
estimated to be 10 per cent of the global gross domestic product in 2009. This system not only
impacts individuals but also acts as a system barrier in meeting the Sustainable Development
Goals by weakening healthcare delivery overall. It also threatens to impact the most vulnerable
hosts (that is, women and children) of our system by delivering negative health outcomes
globally. The Indian healthcare system is complex and several instances have been explicitly
seen where corruption has been system-oriented. For example:
Medical Dominance: The prevalence of medical dominance across the healthcare system has
traditionally manifested through the professional autonomy of doctors, their pivotal role in the
economics of the health services, their dominance over other occupational groups, and the
administrative and collective influence of medical associations. This has been strategically
supported by the initiatives over several decades to promote medical education as being the most
premier of all and promoting doctors as the leaders of the pack. The notion has been constantly
dwelling in the minds of the masses, and irrespective of the competencies or qualifications one
possesses, people have preferred to refer to anyone and everyone (including informal providers)
as ‘doctors’, whom they expect that will be able to cure. Little has been done to understand the
concept of ‘team-based care’ or a ‘patient-centric approach’, and the paramount importance of
each and every provider in the system.
Shortage of knowledge, skills, and competencies among healthcare providers: It is
evident that the healthcare services and resources will not increase in proportion to the increase
in population and changing needs of the environment and it is a known fact that there will never
be enough doctors to address the challenges faced by 1.3 billion people. Having said that, the
validity of the actual shortage of providers also needs to be tested, given that there exist several
types and levels of providers in the system who have remained unidentified, unregulated, and
underutilized. The system churns out several professionals (formal providers) annually through
the existing institutions, including doctors, nurses, allied health professionals, and AYUSH
practitioners, though the outcome may be highly distinct given the absence of strong assessment
frameworks for testing skills and competencies. Several instances have also been recorded where
even fake degrees and diplomas are rendered to applicants without any examination after the
fulfilment of monetary transactions. The mushrooming of such institutions has led to the masses
being left to the mercy of the providers’ ability to judge their problem and provide a cure.
Absenteeism: Alternatively, several instances of absenteeism have been reported where
graduate doctors take up jobs in remote areas only to prepare for their further studies. The
essence of service that is integral to medicine and its practice is lost in the rat race of
competitiveness and financial ambition. Additionally, the lack of strong monitoring frameworks
has also failed to keep healthcare providers accountable for their responsibilities. A study in
2011 registered that on any given day, more than 40 per cent of doctors and medical-service
providers were absent from work.14 Further, the shortage is ever increasing where even the
government positions remain vacant in rural and hard-to-reach areas. The Rural Health Statistics
(RHS) 2014 also indicates the state of the gap in the availability of the healthcare professionals
in the system in the previous financial years, with 82.6 per cent of community health centres
(CHC) without a doctor, 45.73 per cent of CHCs and primary health centres (PHC) without a
laboratory technician, and 63.58 per cent of CHCs without radiographers. The lack of interest of
qualified professionals to take up jobs in such remote places has led people to seek care from
informal providers, leading to more cases of fraud and corruption.
Extinct family practice: The prevalent culture of family doctors is nearly extinct and an
increasing number of graduates are taking up specialization courses to compensate for the
investment in their education. Further, with the increasing understanding of issues and healthcare
challenges, there is more demand for access to specialized professionals adding to wasted cost,
time, and effort for minor ailments.
Disparate and dysfunctional policies in silos: The health workforce in the country currently
is managed and governed across various levels of jurisdictions (centre, state, ministries and
departments, etc.), vertical programmes, and themes (NHM, disease-control programmes, etc.),
without concrete sectoral and professional boundaries based on current and future needs of the
population. Several measures have been taken by the government to address the access gaps, but
efficiency and reliability on the same initiatives are questionable given that structural loopholes
in the system still exist. One such initiative has been hiring of AYUSH practitioners under the
NHM for healthcare facilities where no allopathic doctor is available. In the absence of strong
policies and monitoring mechanisms, several private healthcare facilities have been hiring
AYUSH practitioners as resident medical officers at lower salary bands to maximize their profit
and returns in the name of a shortage of doctors. To that effect, the Indian Medical Association
(IMA) also issued directions threatening strict action against healthcare facilities for hiring
homoeopaths and ayurveda practitioners to fulfil allopathic functions. Several medico-legal cases
have been registered over time for the malpractice of professionals not trained in a specific
science. Furthermore, states have been streamlining efforts for such conditions; for example,
Maharashtra, through MUHS, has introduced a certificate course in modern pharmacology for
registered homoeopathic practitioners to enable them to prescribe allopathic drugs,15 but it is
evident that this ‘system bandaging’ is not enough or even sustainable.
Regulation and inadvertent legitimization: The absence of stringent regulatory frameworks
has also compounded such issues and challenges. Existing policy and regulatory mechanisms
such as the Clinical Establishment Act has not been enacted by all the states, leaving scope for
malpractice. Additionally, a majority of healthcare professionals lack a regulatory structure at the
centre and thus are exposed to non-standardized education and training, leading to a distinct
range of competencies and thereby varied healthcare service-delivery outcomes. Quasi
legitimization of informal providers through standard clinical operating procedures, training and
strengthening the existing providers with some capacity building, and robust regulatory
frameworks, can be a solution to the problem; however, this has been constantly opposed by the
medical associations. One has to acknowledge their contribution to the system and their reach in
remote parts of India, that otherwise has been abandoned by the ‘doctors’ in pursuit of urban jobs
(Pulla 2015).
Superstition and faith-based cure: The issue of religion, belief, and faith is sensitive in the
context of the Indian population. People have access to providers who insist and propagate such
traditional and unscientific measures. This includes a variety of practices including, but not
limited to, elaborate rituals, wearing of specific stones/rings/amulets, exorcism, and sacrifices to
name a few. Their access, acceptability, and affordability is high and spreads through word of
mouth, without any documentary proof on their positive effects. The existence of such modalities
has led others to take advantage of innocent people and perform unethical practices resulting in
several unaccounted lives lost or destroyed. Though measures have been taken in the past, such
as the Drugs and Magic Remedies (Objectionable Advertisements) Act, 1954, which prohibits
advertising for drugs and remedies with magical properties; state legislations prohibiting witch-
hunting in states like Jharkhand, Rajasthan etc.; and comprehensive legislations that have been
passed in last five years in states like Maharashtra and Karnataka to protect people from
indulging in such practices. Still, the availability and acceptability of providers of such services
is widespread.
Quality of services: Quality is the biggest and commonest challenge for all the existing issues
which leads to the focus on the patients and their requirements. Though the demand for
healthcare services is huge, quality-driven service is the key. It may be challenging in terms of
regulation, providers, resources etc., but that should be the focus of the overall planning. In the
absence of robust monitoring mechanisms and regulatory frameworks, quality is bound to be
compromised at all levels.

Recommendations on Solving the Problem of Corruption

Despite its negative attributes, informal providers seem to be the preferred choices among the
rural households and other hard-to-reach areas in the country. The reason for this seems to be
convenience, affordability, and the social and cultural aspects of our society. They seem to be
primary healthcare providers that effectively reach the rural parts of the country, down to the
‘last mile’ in the hard-to-reach areas. Given that India is a large country with various
geographical limitations to providing accessible and quality primary care, it may not be possible
to eliminate systems of complementary and alternative medicine.
FIGURE 13.3 Key Areas of Focus for Ensuring Quality-driven Healthcare

In India, the human-resource policy direction in the last decade has focused on increasing the
production and retention of the two extreme pillars of health providers—doctors and frontline
workers—and equipping them with the relevant tools to provide healthcare. Given the global
strategy to progress towards universal health coverage, the current structure of the healthcare
delivery model will need additional policy interventions with a focus on tackling challenges and
coming up with innovative solutions for human resources for health, to ensure sustainable and
improved access to quality care. The government acknowledges the pressing need to ensure a
national coordinated approach in order to strategically create a skilled workforce which will be
able to meet the current and future healthcare needs of the country at large.

• To improve the prevailing situation, the problem of healthcare service delivery is to be

addressed both at macro (national and state) and micro (regional, district, and block) levels.
This is to be done in a holistic way, with a genuine effort to deliver healthcare services to the
poorest of the population;
• The undue reliance of health systems in India on fully trained MBBS doctors and specialists in
 order to provide accessible, quality, and affordable care to its citizens may be offset by
empowering other providers, strengthening and capacity building as well as building a fully
trained workforce, skilled and competent to undertake several of the routine and some specific
specialized tasks performed by medical professionals;
• Building transparency into the system with the help of strong monitoring frameworks;
• Mapping of professionals to track their availability and effective deployment;
• Standardization of educational resources and provision of short-term skilling;
• Licensing and better regulation that can build in strong penalties to serve as deterrents may
eventually build the case for the effective utilization of the potential of these grassroots-level
practitioners to change the way we view healthcare in India;
• This needs to be supported by robust overall regulation, effective policies, innovative
mechanisms, and advocacy with the patient at the centre of all.

There is in no single policy in the successful fight against corruption. However, it is clear
from our research that all successful policies in the fight against corruption are a combination of
strong, independent institutions, and a general rejection of corruption by society. The world will
not become a better, fairer, cleaner, healthier, or a more educated place until transparency,
integrity, and accountability become developmental milestones, and not just talking points in
global debates.16

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 CHAPTER FOURTEEN
Healthcare Corruption
A Consumer’s View
Rema Nagarajan

Shalini Pahwa, diagnosed with multiple myeloma, was given an injection, Novartis’ zometa, that
cost her Rs 15,200 per shot every three to four weeks, for over two years in a top private hospital
in Gurgaon. On a work trip to Bengaluru, she got an injection of the same drug at a hospital there
for just Rs 4,000. When she confronted the Gurgaon hospital about this huge cost difference, it
readily offered her a cheaper option—Cipla’s zoldria for Rs 2,800. She was outraged that she
was not told about the cheaper option in the first place. Having lost trust in the hospital, she went
to a Delhi hospital where she got the same drug under the brand name zoldonat, manufactured by
Natco, for just Rs 800 and said she felt just fine after switching to the cheaper alternative.
Accoding to an industry insider. zometa is sold to stockists for Rs 13,000. At that rate, the
hospital would make a profit of Rs 2,200. Clearly, the Rs 2,800 injection could not yield that
huge a margin.
Shalini was neither uneducated nor poor. Yet, her education, social status, and wealth could
not protect her from the predatory pricing strategies of the hospital.
Take the case of a broad-spectrum antibiotic, meropenem, used particularly in ICUs for
patients with serious infections. Cipla’s merocrit is sold for Rs 2,965 per gram by a top hospital.
The adult dose is about 1–2 grams every eight hours for about 10 days. That’s Rs 90,000–
180,000 on just one antibiotic. Merocrit is sold to hospitals for Rs 700–900 per gram. The
hospital, thereby, makes a margin of anything between Rs 70,000 and Rs 140,000 lakh on just
one patient. That’s a huge incentive, and that is on just one antibiotic. Hospitals have enormous
mark-ups on every single consumable and medicine; and with in-patients not being allowed any
purchase from outside, they are a captive market that must pay for these margins.1
Why do hospitals overcharge? The majority of hospitals are for-profit ventures and private
hospital administrators argue that pharmaceuticals or devices and diagnostics are two major
revenue earners. As a private venture, their primary goal is healthy profits for the investors or
owners. Patient care is at best a secondary objective and more often, merely the means to the
goal. It’s not about morals or ethics, and that, unfortunately, is the nature of the beast. Private
for-profit healthcare simply has to keep its own costs low while driving up patients’ charges.
Patient vs Consumer
In the context of healthcare, there is little the consumer—supposedly king in a market system—
can do to protect himself or herself at the individual level. The information asymmetry between
the patient and the provider is just too huge for any semblance of informed choice, and a
consumer with no real choice is really not a consumer. Moreover, unlike a consumer shopping
for a car or washing machine, healthcare is mostly purchased in a situation of distress or duress.
A patient diagnosed with cancer or with a heart condition cannot choose to forego treatment or
even postpone it, unlike a consumer who finds a car too expensive and can either decide to not
buy or settle for a cheaper car or perhaps even a scooter.
The label of a consumer assumes a market relationship where you have a choice of healthcare
services to buy. Unlike a car buyer, in the case of patients it is the doctors who decide what you
buy, when, and how much of it. The person who chooses, therefore, is not the one who pays,
unlike with any other market commodity.2
Using the word ‘consumer’ for a patient was sold as a way to empower patients by making
consumer protection laws applicable to healthcare. The law brought into force in December 1995
was meant to regulate healthcare delivery and protect patient interests by making doctors liable
for deficiency in services provided or for wilful negligence.3 The intent was laudable and
regulation, much needed, but the conversion of patient into consumer has neither brought
accountability and regulation in healthcare delivery nor has it empowered the patient, as Shalini
Pahwa and countless others have discovered. If anything, it has legitimized the commercializing
of the doctor–patient relationship in particular and of healthcare services in general. What the
law did not talk about was the rapid privatization of the health sector that was happening at the
time and the way healthcare was becoming a commodity to be sold for maximum profit to a
hapless patient, now glorified as a consumer.
Like so much else, the notion of patient as consumer came from the US, which incidentally
has the worst health system in the developed world. It comes from a country where healthcare is
highly privatized and sold as a commodity for profit, available only to those who can pay. But
can any civilized society—and one like India with its impoverished millions in particular—
accept that only the rich can access healthcare services?
It is also dangerous to assume that the doctor is to provide whatever the consumer demands,
which could include unnecessary tests and harmful procedures. After all, a doctor is supposed to
prescribe only what is in the best interest of the patient based on his knowledge of medicine, and
not merely give in to the patient/consumer’s demand. Thus the assumption of buyer’s choice,
fundamental to being a consumer, is flawed in the case of healthcare.
Paul Krugman, in an article in The New York Times, titled ‘Patients Are Not Consumers’,
said: ‘The relationship between patient and doctor used to be considered something special,
almost sacred. Now politicians and supposed reformers talk about the act of receiving care as if it
were no different from a commercial transaction, like buying a car—and their only complaint is
that it isn’t commercial enough.’ He concludes by stating: ‘The idea that all this can be reduced
to money—that doctors are just “providers” selling services to health care “consumers”—is,
well, sickening.’4
While no one today would recommend an entirely paternalistic model with patients as passive
receivers of healthcare, there is a compelling case for restoring the sanctity of the term ‘patient’,
perhaps a more engaged and empowered one than in the old paternalistic model.
Conflict of Interest
David Berger, director of the British Medical Journal group and a general physician practising in
Australia, has written about corruption in healthcare delivery in India.5 When talking about the
difficulty for doctors to be ethical, he said: ‘It is not hard. You just try and do everything in the
best interest of the patient. What ordinary patients want is that you do whatever is best for them.
There is no difference in this between a hill person in Garhwal, somebody in London or
Australia or wherever.’6 Why then, does the issue of conflict of interest keep popping up in
healthcare?
As Dr Berger elaborates and as is widely acknowledged, doctors are influenced by
pharmaceutical companies in their prescribing practices and by commissions from fellow doctors
and diagnostic labs for referrals. Thus, patient interest is not the central focus of their treatment
decisions.7
When commissions and kickbacks push up healthcare costs, in a largely poor country like
India, this also means a large number of people can’t access healthcare due to financial
constraints or are impoverished by catastrophic health expenses. The proportion of those ailing
who do not get treated due to financial constraints is estimated to be as high as 20–30 per cent.8
Dr Srinath Reddy, president of the Public Health Foundation of India, points out that the
percentage of people impoverished by health expenses remains unchanged at 7 per cent. As
population rises, that has meant an increase from about 77 million in 2004 to over 88 million
being impoverished by 2014. That’s almost like a population larger than Germany’s (just over 80
million) being pushed into poverty because of health expenses.9
Staggering as these statistics are, the cost borne by the patients for corruption in healthcare are
not just financial. There are also very real consequences for public health as well as individual
health. At a broad level, one pernicious impact is the movement away from preventive health to
curative health. It is no rocket science that the former is a lot cheaper than the latter. Hence the
emphasis within public health was on preventive to start with. However, during the 1990s, with
World Bank-dictated structural adjustment, as the government cut its health spending, the private
sector grew aggressively moving into the space vacated.10 Seeing little profit in preventive
health, it pushed to reorient policies towards curative health—less rational and with a higher cost
structure—where the profits lay. When the state funds the bulk of healthcare delivery, it has a
vested interest in keeping costs low and hence puts greater focus on preventive aspects. But as
the state’s presence shrank so did the emphasis on preventive health. Rather than help people
avoid becoming diabetic or develop cardiac diseases by intervening early through a network of
health workers, we have moved to a specialist-led, hospital-oriented system with soaring
healthcare costs, not to talk of rising morbidity from preventable diseases. The lack of preventive
health, especially for the poor, has meant attending to any illness only at the critical stage when it
is often too late or too expensive to treat.
In a more immediate sense, the examples of corruption impacting public and individual health
are so many and so diverse that the difficulty is in picking the most illustrative or the most
egregious in terms of adverse effects on patients.

Bribes from Pharmaceutical Companies

Not so long ago, the medical fraternity saw it as its ‘academic right’, as one doctor put it, to take
money from pharmaceutical companies ostensibly to attend conferences to keep abreast of the
latest advances in medicine. Thankfully, it has now been acknowledged as a bribe and been
banned. Yet the practice continues as plain bribes or in the guise of consultation fees, facilitation
fees, payment for bogus post-marketing studies, and so on. Doctors pretend they can’t see that
every rupee a pharmaceutical or device company spends on doctors is recovered from the patient
by pushing up the cost of the medicines.
It is estimated that the purchase of medicines constitutes 70 per cent of out-of-pocket
expenditure in India.11 The fallout of such aggressive promotion through kickbacks is not only a
rise in cost of medicines but also high rates of irrational prescriptions, to help companies boost
sales.12 This includes antibiotics. Take, for instance, a Reuters report on bribing of doctors which
describes how an oral third- generation antibiotic known as cefpodoxime, sold by Abbott under
the brand name Nupod, is pushed by its sales team through gifts, including medical textbooks, a
mosquito repellent, and a coffee maker.13 These may seem like small change, but as an Abbott
representative quoted in the report said, in India’s poorer areas, ‘if you give them a small gift,
they are happy’. Not that sponsored family trips to Vienna, Oslo, or Amsterdam are not part of
the bribes doctors are offered by pharma firms.
Such unethical promotion and consequent recklessness in prescribing is one of the reasons for
rising antibiotic resistance in India. Antibiotic resistance not only affects patients by making
many common ailments like urinary tract infections difficult to treat, it also pushes up costs as
higher-end and more expensive antibiotics are required to treat an infection that would have
responded to a cheaper, earlier generation antibiotic.14
Another fallout of such bribes is the phenomenon of the most expensive brands of a medicine
being the highest-selling ones, the market leaders.15 That might seem puzzling in a country
where more than half the population lives on just Rs 33 per day (about half a dollar).16 But this is
easily explained by the fact that the choice of which brand to buy is made not by the patient
according to her wallet, but by a doctor lured by the bribes fattening his wallet.
Doctors defend their prescription of a more expensive brand citing quality concerns about
cheaper versions. This might be true in some cases. But there are cases of virtually unknown
drug companies starting with an investment of a few crores with no manufacturing base, selling
drugs already available in the market, and going on to earn revenues of several hundred crores
within a few years. Such a company could not possibly have made crores selling drugs
competing with already established brands without getting doctors to shift prescription. So, why
would doctors who claim to be driven by quality concerns shift from known and established
brands manufactured by big companies to an unknown company whose drug are priced similar to
those already in the market? According to Tapan Ray, a pharma industry insider: ‘MRs are
trained by the respective pharma companies primarily to alter the prescribing habits of the target
doctors with information heavily biased in favour of their own drugs.’ But MRs have more than
just biased information in their armoury.17 They throw in coffee makers, vacuum cleaners,
staplers, hand sanitizers, and foreign trips to make the doctor more receptive to the virtues of the
drug they are pushing. Clearly, the quality or affordability of drugs is not all that drives
prescriptions.

Criminal Greed
In an extreme example of the consequence of corruption and greed in healthcare, tens of
thousands of women across India have had their wombs removed by unscrupulous doctors to
make money. An eerily similar modus operandi united doctors across states separated by
thousands of kilometres. The doctors scared women who went to them with complaints such as
pain during periods, heavy bleeding, or bladder infection, by telling them they had cancer or that
their life was in danger unless they agreed to an operation immediately. Most of these operations
were paid for by the Rashtriya Swasthya Bhima Yojana (RSBY), a state-funded health-insurance
scheme meant to make healthcare accessible to the poor. The beneficiaries of this scheme could
get treatment up to Rs 30,000 each year from any private healthcare facility and that suddenly
made poor women viable consumers/clients for the private sector to target them for
hysterectomies. And this happened in parts of Andhra Pradesh, Bihar, Chhattisgarh, Gujarat,
Rajasthan, and Karnataka between 2005 and 2015. It may well have happened elsewhere too, but
it is in these states that this activity has come to light.18
Most of these cases of unwarranted hysterectomies, a large number of them done on women
below 35 years, were unearthed only because they were paid for through state-funded health
insurance. In Bihar, the enquiry revealed cases where doctors had claimed payment for
hysterectomies when they had only made a superficial incision leaving the uterus intact.
The actual number of unwarranted hysterectomies could be much higher and more
widespread as many would have been paid for by the patients’ families.19 Even in the
investigated cases, so far, few doctors have been penalized and not a single one has been jailed
or lost his medical licence. The only action against the numerous hospitals where such
procedures were conducted was the shutting down of just four out of the 36 hospitals identified
in Karnataka. In Bihar, a few of the hospitals have even been empanelled again as providers in
the state insurance scheme!20 In Andhra Pradesh and Maharashtra, hysterectomies under the
state-insurance scheme are not allowed in private hospitals any more.
The few enquiries instituted into the infamous ‘uterus scams’ in various states came to the
same conclusions in most of the cases—that a majority of the hysterectomies were unwarranted.
Poorer women often develop infections because of poor menstrual hygiene but instead of treating
the infection, their uteruses, and in some cases even the ovaries, were removed. This induces
surgical menopause, which has severe effects on a young woman’s health including long-term
consequences such as early onset of osteoporosis, cardiac disease, loss of libido, and sexual
intercourse becoming non-pleasurable.

Resisting Transparency
While the uterus scam is an example of doctors indulging in a criminal act, there is an arguably
less shocking but equally serious pattern of rising caesarean sections which have become a
money-making racket. From being an emergency life-saving procedure, doctors are peddling C-
sections as the pain-free and convenient option (such as scheduling the birth on a special day)
without revealing the risks involved, such as excessive blood loss, blood clots, heart attacks,
difficulty in breastfeeding, and increased chances of repeat C-section births.21 The C-section
rates are always higher in private hospitals and private practitioners defend this by saying that
they have to respect the wishes of the patients who increasingly demand it. This brings us back to
the question of whether a patient is a consumer who can demand a particular line of treatment
even if it is not medically appropriate. Obstetricians in the private sector use the convenient
excuse of patient demand and couch it as a women’s right-to-choose issue to push a procedure
that is more remunerative for them. They rarely talk about their own personal preference for C-
sections as it takes less time and can be scheduled to their convenience. A C-section could cost
anything between Rs40,000 and Rs 1.5 lakh in the private sector.22
 Up until 2010, the C-section rate in India was 8.5 per cent. The latest round of the National
Family Health Survey (2015–16) showed that’s jumped to 17.2 per cent. The rate in the private
sector is 41 per cent compared to 12 per cent in public health facilities. In some states, the
private-sector rates are as high as 71 per cent (West Bengal) or 75 per cent (Telangana).23 The
World Health Organization considers a C-section rate of 10–15 per cent as normal. There is
incontrovertible evidence of higher C-sections rates being pushed by the profit motive rather
than patient demand. Studies have shown that financial incentives have a large effect on a
patient’s probability of receiving a C-section: in hospitals where there is a financial incentive to
perform C-sections, they have much higher C-section rates.24
Alarmed by the increase in C-section rates, Minister for Women and Child Development,
Maneka Gandhi had suggested making it mandatory for hospitals to publicly display the number
of C-sections and normal deliveries carried out. Such transparency and greater awareness was
expected to help patients make a more informed choice of hospitals and doctors.25 After all, it
has been demonstrated that your choice of hospital is likely to have the biggest influence on
whether you will have a C-section. Predictably, the suggestion was greeted with howls of protest
from large sections of the medical fraternity claiming that ‘it would develop mistrust between
patients and doctors’ and ‘could result in refusal of surgery even when required’.26 Are the
doctors saying that if patients were given the information, they might choose doctors who do
more normal deliveries and this could force doctors to refuse a required C-section so as to not
seem scalpel-happy? That’s a strange argument coming from those who claim that C-section
rates are going up because patients are insisting on them.

Ripping off Patients

Recently, when the government stepped in to regulate the price of cardiac stents, it opened a can
of worms. The government’s enquiry into the margins charged on stents showed that hospitals
were charging the highest margin, up to six times the price at which they bought the stents.27 It
was found that cardiologists were being given a cut on every stent they implanted.28 The margin
charged by a hospital on a stent could be as high as Rs 1 lakh.29 Yet, not a single cardiologist had
raised the issue of overpricing of stents before the government intervention. If doctors are
supposed to be advocates of patients and patient interest is their central concern, why did they
not raise the issue of overcharging by hospitals? If anything, cardiologists defended the high
prices claiming that stent-manufacturing companies were charging more for research and
innovations to bring in ‘new-generation’ stents. That was until a government-appointed panel of
cardiologists from top public health institutions revealed that no peer-reviewed study had found
the supposedly superior newer stent brands any better than the existing ones. So why this striking
similarity between what the stent manufacturers claim and what the doctors say? Could it be
because their pecuniary interests have converged? And stents are just one of the many items for
which patients are overcharged. The profit margins are as high or even higher on every item
from orthopaedic implants like knee and hip joints to the smallest items like syringes and
catheters.30 With such huge margins on each item, the practice of maximizing profits by
subjecting patients to unnecessary procedures and diagnostic tests is widely prevalent. With no
independent medical audits or similar regulatory systems such practices continue unchecked.31

Neither Regulation nor Redressal

Whether it is doctors taking bribes from pharma and device companies or hospitals and doctors
overcharging patients and pushing unnecessary procedures and diagnostics, there is little or no
regulation of the health sector and little protection for the patient or consumer from outright
malpractice or substandard treatment. Doctors are regulated by the Medical Council of India
(MCI) through its code of conduct for the medical profession. Patients are supposedly protected
by the consumer-protection laws and courts. Hospitals and health facilities, both therapeutic and
diagnostic, are covered by the Clinical Establishment (Regulation and Registration) Act 2010,
belatedly passed by Parliament in 2012.32 However, health being a state subject, it does not come
into force in a state until the Act is adopted through a resolution in the state assembly. So far, the
Act is applicable only in 10 states and six union territories. Even in states where the Act is in
force such as Rajasthan, Jharkhand, or Uttar Pradesh, it remains on paper. There is hardly any
move to actually implement it in the face of stiff opposition from the usual suspects—the Indian
Medical Association and hospital associations.
While doctors talk endlessly about being forced to practise defensive medicine for fear of
litigation, the reality is that patients who get a raw deal rarely sue, and even when they do, they
hardly ever get justice.33 According to a study by the National Board of Hospitals and Healthcare
Providers (NBH&HP) in 2014, of the 98,000 patients dying due to medical errors every year,
only 20–27 per cent approached the consumer court for redress. While 12 per cent withdrew
midway due to the tedious process and delays, a mere 2 per cent hung on. Only three big cases of
compensation have been awarded to patients’ families since 2010.34
Dr Kunal Saha became famous as the person who won a record Rs 12 crore as compensation,
from the Supreme Court, for his wife’s death due to medical negligence.35 Reams were written
about how such high awards could ruin hospitals and force them to shut down. What was left
unsaid was all the ways in which the Medical Council of West Bengal, the guilty hospitals’
management and doctors had tried to block the case. It took Dr Saha 15 years to get justice.
As is evident from the earlier examples, the consumer-protection laws being extended to
cover patients were of little use to the women whose wombs were removed. The MCI’s code of
medical ethics is of little use in stopping obstetricians pushing unnecessary C-sections to the
detriment of the patient. The Clinical Establishment Act was neither able to prevent hospitals
from overcharging for cardiac stents nor was it of any use in penalizing hospitals which had been
doing so with impunity.
The Medical Council of India was constituted under a law framed at a time when the private
sector was not as dominant and when corporate healthcare did not exist. To add to the problem,
the council, constituted only of doctors, has hardly ever been proactive in regulating the
profession and protecting patient interests. Instead of interpreting its own powers to widen its
jurisdiction, it chose to shrink its own ambit by passing a resolution that it had jurisdiction only
over individual doctors and not over doctors’ associations or hospitals.36 Thus, the MCI ensured
that bribing of doctors by the pharmaceutical and medical-device industry through their
respective associations could continue undisturbed. A testimony to the council’s apathy is the
fact that till today, the MCI has not moved to investigate and cancel the licence of the doctors
involved in the uterus scam despite these cases being widely reported.37 Many of the state
medical councils are not even functional and complaints lodged before these councils and the
hearings that ensue only lead to further harassment for patients’ families in most cases.
Any regulatory system is credible only if wrongdoers believe that getting caught is likely and
that if they get caught, penalty is certain. Or else, it is tantamount to non-regulation. By that
logic, there is zero regulation in India and little hope for any effective grievance redressal for
patients in the current scenario.

Public vs Private Healthcare

When healthcare is sold for profit, there is a direct conflict of interest between the provider of
healthcare and its recipient, a conflict absent in public healthcare provisioning or in the case of
genuinely charitable healthcare providers. In the for-profit model, patient interest is secondary to
profit. Earlier examples of patients being shortchanged or harmed are a direct fallout of a highly
privatized healthcare sector dominated by for-profit providers. Such shocking practices seem
inevitable in a for-profit set-up, especially in a country with hardly any regulation.
As Shalini Pahwa, the patient with multiple myeloma said: ‘I don’t want to be haggling like I
am in a mandi over my treatment costs.’ Patients don’t want to be worrying about whether they
are being cheated or whether the medical advice they are getting is in their interest or driven by
the need to meet targets or maximize profits. Yet, that is what patients are being put through.
They have to haggle to get hospital bills reduced and are forced to seek second and third
opinions in a desperate bid to get a reliable medical opinion. The poor are resigned and helpless
even if they feel they are being gypped.
The government is aware of the ways in which the private sector, ranging from the big
corporate hospitals to the smallest clinics in rural areas, is looting patients and how substandard
and often dangerous healthcare is being provided. This is obvious from its circular to its
bureaucrats asking them to seek a second opinion from AIIMS or any government hospital if a
check-up in a private hospital shows any abnormality.38 It is evident in a circular it issued
warning against reuse of disposables surgical items for which each patient is charged afresh.39 It
is evident in the decision of the Maharashtra and Andhra Pradesh governments to not cover
hysterectomies done in private hospitals.
In each of these cases, the government is implicitly acknowledging that public provisioning of
healthcare has the least conflict of interest and is more reliable than the private sector. But
consistent under-provisioning of public health has made it unviable for people to depend on it.
There are huge delays, overcrowding, and sub-par standards of care as it is perennially
understaffed and lacks accountability. However, even in a city like Delhi or Mumbai with no
dearth of private options, public hospitals are full to overflowing, an indication of the huge
demand for public-funded healthcare that is affordable and more reliable. Even those with the
capacity to pay often seek a second opinion from doctors in government hospitals who are seen
as being more reliable. What keeps the bulk of lower- and middle-class patients away from
government hospitals is the chaos and the inadequate physical infrastructure facilities. With the
government unwilling to expand public allocation beyond a mere 1 per cent of GDP (the world
average is 4 per cent), expansion of public health facilities has not kept pace with the growing
population driving patients to an unreliable private sector.
The increasing corruption in private healthcare delivery has thus been facilitated by a
shrinking public health system. As the private sector grows, it is increasingly dictating the terms
of service delivery and the government appears to be in no shape to push back. While there is
corruption in public health too, the scale is incomparable when we consider the systematic loot
by large sections of private providers. Plus, the incentive to be corrupt is far less, the scope for
regulation much higher, and conflict of interest, minimal. It is, however, true that the way public
health is administered leaves a lot to be desired, most of it due to a culture of lack of
accountability and a severe fund squeeze that leaves it understaffed, inadequately equipped, and
unable to build new infrastructure. Theoretically, it might be easier to regulate the public health
system, but it isn’t done very effectively. Hence, personnel within the public health system too
are prone to corrupt practices that include taking bribes from the pharma and device industries
and cuts for referrals to private hospitals and diagnostic centres.40

Paying with Your Health

It is obvious that the costs of corruption in any system must ultimately be borne by the end user
of that system. In the case of healthcare, that means it is the patient who pays for the bribes that
doctors get from pharma companies, the kickbacks from diagnostic labs, the huge margins that
hospitals make, and so on. Even where the state pays for services provided by the private sector,
it’s the patient (now in the form of taxpayer) who pays for any corruption. What is less obvious
is that the patient pays not just from her wallet but with her health too. But as we have seen from
the examples here, while this may be less obvious, it is no less inevitable. What’s at stake,
therefore, in the battle to end corruption in the healthcare sector, is not just thousands of crores of
rupees but the health of hundreds of millions.
 CHAPTER FIFTEEN
Corruption in Medical Research
Clinical Trials, Research Misconduct, Journals, and Their Interplay

Sanjay A. Pai1

Corruption in medical research is different from corruption in medical practice, which forms the
bulk of this book. With bribery, cut practice, and the like being the bane of the medical
profession in both private and public sectors in India, the monetary aspect of corruption comes to
the fore when one talks about corruption in medicine. Further, because research does not have
obvious financial connotations, we usually do not associate the word ‘corruption’ with medical
research. However, the financial component is often indirect and may be reflected in the form of
publications, promotions, awards, and that intangible and immeasurable thing called fame, all of
which, of course, may lead to direct material or monetary benefits.
The phrase ‘research misconduct’ is usually applied to those who indulge in unethical and
illegal research. Research misconduct includes many practices, such as fraud, fabrication and
falsification of data, plagiarism, failure to comply with legal and ethical standards, conflict of
interest, gift authorship, and negligent deviations from accepted research practice, and so on
(Wells and Farthing 2008).
However, a look at the definition of corruption is instructive. Corruption watch, the non-
governmental organization established to combat corruption, defines it as ‘the abuse of public
resources or public power for personal gain’.2 Merriam-Webster defines corruption as ‘an
impairment of integrity, virtue, or moral principle or as inducement to wrong by improper or
unlawful means or a departure from the original or from what is pure or correct’.3 Finally, the
Shorter Oxford English Dictionary defines corruption as ‘... moral deterioration [or] ...
perversion of integrity by bribery or favour’.4
Thus, nepotism and misuse of resources or of personnel also fall within the scope of the
definition (Ranade and Kumar 2015). By these definitions, any medical researcher who indulges
in research misconduct of any sort, is guilty of corrupt research practices. I shall use the
conventional term ‘research misconduct’ in this chapter.
Because research has never been considered important or relevant by most Indian physicians
and because the benefits of research have not been obvious—unlike in the West—it is likely that
research misconduct in India has been relatively less. However, as we shall see in this chapter,
‘the times they are a-changin’, to use the phrase immortalized by the Nobel prize awardee Bob
Dylan.
The players in medical research misconduct, of course, are largely physician–researchers or
scientists. Until about a decade ago, most of whatever little research was done in India was in the
large institutions. Private hospitals and their doctors had practically no interest in it. However,
after 2005, when the government of India opened its doors to Western drug companies for
performing clinical trials in India, the tide has changed. Private hospitals have thrown their hats
into the ring as well.
There are others who also contribute to the corrupt culture—pharmaceutical companies,
government regulatory bodies, and medical journal editors.

Research Misconduct by the Researcher

Misconduct may be introduced right at the inception or later during the analysis and publication
process.
During the research project, if the researcher breaks ethical and legal norms, he or she is
guilty of corruption. There are laws, codes of conduct, and guidelines in science, including in
research. Yet, the best of guidelines have flaws and loopholes; thus, while one may be within
legal limits, a project may not be morally acceptable. Using some amount of common sense and
listening to one’s conscience is always good practice in research.

Fraud in Research
Stephen Lock (1997) states that the modern history of fraud in research dates back to 1974, when
William Summerlin painted the skin of white mice with a black felt pen in an attempt to show
immunological tolerance. For India, there has been no comparable scandal. This is not because
Indian researchers have higher moral standards; rather, it reflects the fact that research in India
does not command the respect and attention that it does in the West. However, just before the
Summerlin story came to light, there was a far more egregious act—the Tuskegee scandal which
made the news in 1972 (Fairchild and Bayer 1999). In that inhuman experiment, a cohort of
African-Americans with syphilis was followed up for nearly 40 years to get an idea about the
natural history of the disease, that too at a time when the biological behaviour of the disease was
well known and despite the fact that an effective treatment (penicillin) had been discovered for
the eventually debilitating disease, less than halfway through the span of the project. The patients
were not told about their disease and were, in fact, told that they were receiving free medical care
for ‘bad blood’. India does have its equivalent of a Tuskegee moment—in 1997, journalist
Ganpati Mudur exposed a study that had taken place between 1976 and 1988. Researchers at the
Institute of Cytology and Preventive Oncology in New Delhi followed up 1,158 women with
varying degrees of cervical dysplasia to study the natural history of the disease. It had been a
well-established fact at the time that the study was done that dysplasia was often a progressive
lesion and could convert, eventually, to invasive cancer, unless treated. That a woman with even
moderate dysplasia, let alone severe dysplasia/carcinoma in situ, needed excision of the lesion
was common knowledge to even the average medical student. Thus, the research question was
heavily flawed and wreaked of recklessness—research conducted at the cost of someone else’s
life. At least nine women developed invasive carcinoma and 63 developed in situ squamous
carcinoma before being treated. Written consent was not taken from any of the participants and
the researchers used the flimsy excuse that this was because the women were illiterate. Besides,
they argued, written consent was not legally mandatory at the time the project was carried out
(Mudur 1997).
Just a few years later, in 2001, came equally disturbing news from the state government’s
Regional Cancer Centre (RCC), in Thiruvananthapuram, Kerala. Between November 1999 and
April 2000, 25 patients with oral cancer at the RCC had their tumours injected with a chemical
called tetra-O-methyl nor-dihydro-guaiaretic acid (M4N) or tetraglycinyl nor-dihydro-guaiaretic
acid (G4N). The patients had been told that they were being treated for their cancers; instead, an
experimental chemical was injected into them in order to determine its anti-neoplastic properties.
The study was initiated by Professor Ru Chih C. Huang of the Johns Hopkins University, USA,
with funding from the University. This research failed every ethical and legal norm that was
required and was not too dissimilar from what happened in Nazi Germany when unwilling
prisoners of war were forced to participate in vicious and often fatal experiments. The patients in
the Kerala study had not been informed of the chemical’s risks and were exposed to the toxic
effects of an untested drug. The trial was also conducted without the prior approval of the Drugs
Controller General of India (Srinivasan and Pai 2001; Krishnakumar 2001).
Incidents such as these made ethicists and concerned and caring physicians wary of the
decision of the Indian government to invite the developed world to use our resources—in this
case, human resources, in the form of patients. In a leader in the NEJM in 2005, Nundy and
Gulhati (2005) used the term, ‘a new colonialism’. Given that serious research misconduct had
taken place in academic centres even before the new rules which opened the floodgates to
commercial companies, they wondered what could be unleashed with such an initiative.
Not all cases of suspected fraud can be proved, one way or the other, beyond reasonable
doubt. The story of R.B. Singh is a case in point. Dr Singh, a cardiologist in Moradabad, Uttar
Pradesh, had been publishing research papers in leading general medical journals since the late
1980s. However, there were suspicions about the quality of the data and about their validity.
When the British Medical Journal (BMJ) decided to investigate the matter in the late 1990s and
the early part of this century, and asked him to provide the raw data to backup his claims (of
material which had already been published), he stated that he was not in a position to do so as
they had been destroyed by termites! The BMJ’s attempts to get an Indian organization to
investigate the matter failed for various reasons. With no definite proof of misconduct, they
chose to issue only a statement of concern (Ana et al. 2015; White 2005).
Physicians conducting clinical trials are reimbursed, often handsomely, a fact that is often not
known to research participants. Many clinical trial meetings are held at exotic locations,
something which may unconsciously bias the investigator. All of these are likely conflicts of
interest (Srinivasan 2009). Some of these physicians act as ‘key opinion leaders’ for the
pharmaceutical companies as well.
Finally, there is the added issue that perhaps because they are not informed properly, many
people misunderstand or are deceived into thinking that they are patients and do not comprehend
that they are in a clinical trial as ‘research participants’. This is illustrated in data gathered by a
Contract Research Organisation where the majority (approx. 70 per cent of ‘patients’) stated that
they were in the trial for better care or cure and for free treatment, and so on. Only 11 per cent
stated that they entered the trial to contribute to science (Srinivasan 2009).

Publication Misconduct
As stated earlier, research in medicine has not occupied an exalted position in India for much of
her history since independence. There is neither a thirst to question dogma nor a spirit of enquiry,
innovation, or creation. The existence of time-bound promotions which are unrelated to
academic output of any sort has contributed to the existing state of affairs. Thus, in a move
supposedly to add objectivity to promotions and to improve the scientific temper and research
output from Indian medical colleges, in September 2014, the Medical Council of India (MCI)
introduced some criteria related to publications. These criteria are heavily flawed. We, as well as
others, have pointed out that the ill-thought move of awarding points only to the first two authors
of a paper is likely to result in students/junior researchers being excluded from first authorship—
or indeed, authorship for their own research work (Bandewar and Pai 2005; Aggarwal et al.
2016).
Misconduct may be restricted to the writing and publication portion. There is very little
empirical data from India on the subject of publication misconduct. In fact, a book which deals
solely with the subject of research misconduct makes no reference to India (Wells and Farthing
2008). Moreover, a review article by an Indian in an Indian journal too does not refer to Indian
examples (Tharyan 2012).
Because of the paucity of data from our part of the world, we carried out a survey of editors of
biomedical journals in Southeast Asia on their experiences (Srinivasan et al. 2013). The results
and implications of our further study are in the process of submission for publication to a journal.
Some of the salient findings were: Of the146 editors contacted, 88 (60 per cent) responded. Of
these, 81 (92 per cent) editors reported that they had encountered scientific misconduct. Of the
75 editors who wrote to authors about the allegation(s), only 65 received replies from the
authors! While 44 sometimes found these to be satisfactory, 18 replies were found to be
unsatisfactory. Forty-six editors informed the authors’ institutions of the allegations; 33 editors
also asked the institution to conduct an investigation. Surprisingly—or perhaps, not so
surprisingly—as many as 21 reported receiving no reply from the institutions on any action
planned. Forty-seven editors indicated that their journals lacked a defined mechanism to deal
with misconduct before publication.
Medical journal editors in South Asia frequently encounter research misconduct. That their
communications to the authors or their institutions about the misconduct sometimes did not elicit
a satisfactory response and the fact that many journals lacked a mechanism to address the
problem were areas of concern.
When editors find that there has been research misconduct, the papers are often retracted from
the literature. Occasionally, of course, the scientist may realize an error in the science and retract
it himself or herself. T.A. Abhinandanan, a professor of material sciences at the Indian Institute
of Science (IISc), Bengaluru, analysed the data of retracted papers from India on the databases of
search engine PubMed. He found that there were no papers retracted by Indian researchers for
the period before 1990, seven retracted papers for the period between 1990 and 2000, and 69
papers for the period between 2001 to 2010 (Abhinandanan 2011). The alarmingly increasing
numbers, of course, reflect the great care that editors now take in detecting plagiarism and cannot
be directly interpreted as an increase in fraudulent science. But the message is clear—there is
fraudulent science in India and people are getting caught red-handed doing it. Whether the
numbers of retracted papers and fraudulent scientists is reflective of the real numbers or whether
it is a tip of the iceberg is anyone’s guess—Nandula Raghuram, former secretary of the Society
for Scientific Values, New Delhi, believes that it is the latter (Jayaram 2016).
In a study of 788 papers retracted from PubMed between 2000 and 2010, the reason for
retraction was more likely to be fraud for papers from India than those from other countries
(Steen 2011a). In another study, the ratio of retracted (for fraud) to published papers was nearly
double for India compared to China and the US (Steen 2011b).

Fraud by the CDSCO–Doctor–Pharma Nexus

The Central Drugs Standard Control Organisation (CDSCO), the Indian equivalent of the US
FDA) is responsible for the evaluation and release of safe medicines. A joint parliamentary
commission tabled its report on the functioning of CDSCO in 2012. Among the many
indictments, some are relevant to our discussion here, as they deal with doctors.5 The report
states: ‘A review of the opinions submitted by the experts on various drugs shows that an
overwhelming majority are recommendations based on personal perception without giving any
hard scientific evidence or data. Such opinions are of extremely limited value and merely a
formality. Still worse, there is adequate documentary evidence to come to the conclusion that
many opinions were actually written by the invisible hands of drug manufacturers and experts
merely obliged by putting their signatures.’
The committee noted that opinions were submitted by different experts and for various drugs.
The experts were from leading institutions in the nation and included, among others, professors
from the All-India Institute of Medical Sciences (AIIMS), New Delhi; RG Kar Medical College,
Kolkata; Stanley Medical College, Chennai; Lokmanya Tilak Municipal Medical College,
Mumbai; Postgraduate Institute of Medical Education and Research, Chandigarh; Christian
Medical College, Vellore; St. John’s Medical College, Bengaluru; Medical College,
Thiruvananthapuram; as well as the private hospitals, Sir Ganga Ram Hospital, New Delhi;
Lilavati Hospital, Mumbai; and Apollo Indraprastha Hospital, New Delhi.
Remarkably, the letters of recommendation supposedly written by different people located at
different places were identical. In addition, all of them went out of the way and gave unsolicited
advice, in identical language, and often, in record-quick time, to the Drugs Controller General of
India (DCGI) to give permission to the company to market the drug without conducting
mandatory clinical trials in India. Even the errors in the letters had been repeated! The only
possible explanation for this is that the same person has drafted the letters and copied them to all.
This suggests that there exists a nexus between drug manufacturers, some medical experts, and
the CDSO.
The committee found that many actions by these experts were ‘clearly unethical and may be
in violation of the Code of Ethics of the Medical Council of India applicable to doctors’. They
recommended that the matter to referred to the MCI for necessary follow up and action. They
added that for the government-employed doctors, the matter must also be dealt with the
appropriate authorities in the medical colleges/hospitals for suitable action.
To my knowledge, there has been no investigation or action, despite the above
recommendations.

Fraud by Pharmaceutical Companies

Fudging of data and hiding of important information that may be damaging to the sales and
reputation of the drug and the drug company are known. Richard Smith alludes to this in his
2005 article entitled ‘Medical Journals are an Extension of the Marketing Arm of Pharma
Companies’. In it, Smith illustrates the various ways in which data can be modified to achieve
the desired results.
 Because fraud on a large scale requires much thinking and planning, it usually needs inputs
from many people. Given that the subject is so specialized, it is extremely likely that medical
scientists who have the know-how are part of the team that carries out the fraud. One recent
example of this is from a notice issued in April 2016, when a World Health Organization (WHO)
Prequalification team found areas of concern at the Semler Research Centre Pvt. Ltd, Bengaluru
during their inspection of the facility in January and December 2015. They found gaps in the
data which were strongly consistent with data manipulation. The data included chromatographic
data as well as frank falsification. The letter states: ‘to execute this type of manipulation several
staff members on various levels within the organisation have to be collaborating and
coordinating’.6
Doctors too, in their roles as investigators, are guilty of misconduct when they breach the
rules. There are many examples of clinical trials where rules have been flouted.7 One such
example was the trial of the drug risperidone. In 2001, this anti-psychotic drug was given to
patients after a washout period in one arm of the study while there was a placebo in the other
arm. It has been pointed out that this trial was unethical as it involved a washout period during
which no medication was given for a condition as severe as mania, and subsequently offered a
placebo to one half of the cohort—although an effective treatment is known (Srinivasan et al.
2006; Patel 2006).
The HPV vaccine trials are another example. Dubbed euphemistically as a ‘demonstration
study’, it was clearly a clinical trial—and one from which drug companies would benefit. There
were serious flaws in the design of the trials, issues with consent and consent forms, absence of
insurance covers, unstated conflict of interest on the part of a member of the institutional review
board, and so on. In 2013, the 72nd Parliamentary Standing Committee on Health and Family
Welfare found that there was a serious dereliction of duty on the part of many of the institutions,
including the Indian Council of Medical Research, the Drugs Controller General of India, Ethics
Committee members, and PATH (a non-government organization which coordinated the project)
(Sarojini 2013).

Misconduct by Journals and Editors

The object, or at any rate, the endpoint of all research, is publication. Thus, in our search for the
truth in science, it is important that all avenues should be above board. Journals, however, are
often a business and the line between not-for-profit scientific investigation and for-profit
publication can easily get blurred.
The past few years have seen an explosion of pseudoscience, junk ‘journals’ where editors
accept the most outrageous of papers—based not on the science, but on the fee that the author is
willing to pay. These journals have been termed pseudo-journals or ‘predatory’ publications and
can only be condemned in the harshest words possible. Knowingly publishing in such journals is
unscientific and is corrupt practice (Pai 2014).
It has been widely believed—without any evidence—that most researchers who publish their
work in pseudo-journals do so because they are uninformed and innocent and are unaware of the
predatory nature of the journals. However, Seethapathy et al. (2016) have struck a blow to this
thesis by showing, based on a questionnaire survey of scientists in India, that only 20 per cent of
those who published in such journals were unaware of their reputations; it is likely that they
hoped to bolster their CVs for unsuspecting evaluators. Admittedly, this study covered all
scientists—physics, chemistry, biology, social sciences, and so on, and was not restricted to only
medicine. Six per cent of those who responded were from the Indian Council of Medical
Research and 25 per cent were physicians. Thus, there is no reason to believe that medical
researchers would behave in any way different from their non-medical scientist counterparts.
That 10 per cent of them used their research grants to pay the charges to the pseudo-journals is
consistent with the definition of Corruption Watch (abuse of public resources) that these
scientists are indeed corrupt.

Solutions
Much of the problems listed above are not unique to India. Indeed, they, or their variations are
common to science all over the world and a search for successful redressal has been on for years.
Thus, expecting a quick and permanent solution is foolhardy.
Many developed nations have government bodies which monitor and take action when fraud
is committed (Wells and Farthing 2008). For instance, the US has an Office of Research
Integrity. India lacks such an organization. Ranade and Kumar (2015) make a plea for such a
body. The ombudsman must investigate and evaluate suspected cases of fraud reported to it or
that they suspect de novo. There must be people of unquestionable integrity—a not-impossible
task—as leaders of this group. The office should be a quasi-judicial body and expert opinions
can be garnered from legal and subject experts. If the researcher is found guilty, an appropriate
punishment must be recommended, which must then be meted out by the researcher’s
organization. The right to appeal, by the researcher found guilty by this body, must be extant and
there should be transparency in the process. We suggest that this ombudsman should have wide
and discretionary powers and also tackle issues that have not been addressed—the mushrooming
of stem cell clinics, where ‘therapy’ is offered without the benefit of conclusive data. Yet another
bizarre example of ‘treatment’ is the project to revive dead people—a vastly unscientific and
unethical project that has been met with deafening silence by Indian authorities (Srinivasan and
Johari 2016).
The creation of the Clinical Trials Registry India in 2007 is an excellent step ahead.
Spearheaded by the Indian Council of Medical Research, it has ensured that all clinical trials are
registered online and are in the public domain. This should eliminate data manipulation,
repetition of studies with negative results, and other such malpractices (Satyanarayana et al.
2008).
Ideally, the MCI should act as a watchdog and weed out doctors guilty of any form of
corruption. However, the council itself is currently under a cloud for suspected corruption and it
is possible that it will be replaced by a new body—hopefully, one that is free of taint. Once that
is achieved, there could be a possibility of arriving at a logical and direct route to tackling this
problem. It is worthwhile adding here that the only reference to research ethics in MCI’s code of
conduct is restricted to the following:
Research: Clinical drug trials or other research involving patients or volunteers as per the guidelines of ICMR can
be undertaken, provided ethical considerations are borne in mind. Violation of existing ICMR guidelines in this
regard shall constitute misconduct. Consent taken from the patient for trial of drug or therapy which is not as per
the guidelines shall also be construed as misconduct.8

The code of conduct for the American Medical Association, incidentally, is as long as 17
pages and deals with various aspects, including informed consent, publication misconduct,
emergency situations, international collaboration, and financial compensation.9
 The most important and the best way to reduce corruption is also the most difficult and
utopian one: selection of appropriate candidates for medical schools. The situation has worsened
considerably in past quarter century or so, when corruption of an unimaginable level (see, for
instance, the essay on Vyapam in this book) has entered the field of medical education. Seats in
medical schools can be purchased with little importance being given to the intellectual quality of
the potential doctor, let alone his or her ethics. Because of the huge investment in getting
admission into a graduate or, later, a postgraduate course in medicine, there is intense pressure to
recover the large sums of money. This, not surprisingly, leads to corrupt practices among those
who were the wrong choice to be doctors to begin with. If some of these doctors decide to
perform drug trials or do research, we complete the spectrum of the corrupt medical student
becoming the corrupt doctor and, finally, the corrupt researcher.
The curriculum at both the undergraduate and postgraduate levels is strikingly bare of even
the most basics of ethics teaching—both in theory as well as in practice. This is a relatively easy
thing to address. Obviously, this alone will not change attitudes. However, it is possible to mould
young and impressionable minds, at least some of whom enter the medical profession with the
right motives, if the right approach is adopted.
Healthcare has been treated as a commodity and is an important for-profit business in
democratic India, unlike in the UK and many European countries, where it is considered a basic
need and is covered by the national government. The for-profit philosophy in medicine and
healthcare spills over into the medical research setting, blurring the boundaries and setting off
corruption in medical research.

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R&D’, Current Science, 109: 31–36.
Sarojini, N. and V. Deepa, 2013, ‘Trials and Tribulations: An Expose of the HPV Vaccine Trials
by the 72nd Parliamentary Standing Committee Report’, Indian J Med Ethics, 10: 220–22.
Satyanarayana, K., A. Sharma, P. Parikh, et al., 2008, ‘Statement on Publishing Clinical Trials in
Indian Biomedical Journals’, National Medical Journal India, 21: 105–6.
Seethapathy, G.S., J.U. Santhosh Kumar, and A.S. Hareesha, 2016, ‘India’s Scientific
Publication in Predatory Journals: Need for Regulating Quality of Indian Science and
Education’, Current Science, 111: 1759–64.
Smith, R., 2005, ‘Medical Journals are an Extension of the Marketing Arm of Pharma
Companies’, PLOS Medicine, 2(5): e138, accessed on 12 February 2018
http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.0020138
Srinivasan S., S.A. Pai, R. Aggarwal, and P. Sahni, 2013, ‘Scientific Misconduct in South Asian
Medical Journals: Results of an Online Survey of Editors’, Abstract # PRC13-0176, Seventh
International Congress on Peer Review Congress and Biomedical Publication, Chicago,
Illinois, 8–10 September.
Srinivasan S., S.A. Pai, A. Bhan, A. Jesani, and G. Thomas, 2006,‘Trial of Risperidone in India
—Concerns’, Br J Psychiatry, 188: 489.
Srinivasan, S. and S.A. Pai, 2001, ‘History Repeats Itself’, Issues in Medical Ethics, 9: 108.
Srinivasan, S. and V. Johari, 2016, ‘Response to Proposed Research to Reverse Brain Death:
More than Regulatory Failure’, Indian J Med Ethics, 1: 134–37.
Srinivasan, S., 2009, ‘Ethical Concerns in Clinical Trials in India: An Investigation’, Centre for
Studies in Ethics and Rights, Mumbai, India, February, available at
http://www.fairdrugs.org/uploads/files/Ethical_concerns_in_clinical_trials_in_India_An_investigation.pdf
accessed on 28 December 2016.
Steen, R.G., 2011a, ‘Retractions in the Scientific Literature: Do Authors Deliberately Commit
Research Fraud?’, J Med Ethics, 37: 113–17.
Steen, R.G., 2011b, ‘Retractions in the Scientific Literature: Is the Incidence of Research Fraud
Increasing?’, J Med Ethics, 37: 249–53.
Tharyan, P., 2012, ‘Criminals in the Citadel and Deceit All Along the Watchtower:
Irresponsibility, Fraud and Complicity in the Search for Scientific Truth’, Mens Sana Monogr,
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281–88.

A Note
The Medical Council of India released a circular on 5 June 2017, which contains some changes
in the authorship criteria for promotions. We have recently published an editorial to some
medical journals, pointing out that even these revised criteria have flaws (Bandewar SVS,
Aggarwal A, Kumar R, Aggarwal R, Sahni P, Pai SA. ; published in Indian J Urol 2018 Jan-
Mar;34(1):3-6. doi: 10.4103/iju.IJU_373_17, Indian J Med Ethics etc)
 CHAPTER SIXTEEN
Corruption in Healthcare
A Technology Perspective
M.S. Valiathan

Corruption looms large in India’s health sector. ‘It traps millions of people in poverty,
perpetuates the existing inequalities in income and health, drains the available resources,
undermines peoples’ access to health care, increases the costs of patient care and, by setting up a
vicious cycle, contributes to ill-health and suffering’ (Chattopadhyay 2013). While ‘petty
corruption’ in healthcare has long existed in India and is even tolerated to some extent, the
growth of corruption in the post-1991 liberalization era has startled Indian citizens who are
bombarded continually by reports of needless hospitalization and costly diagnostic tests,
unnecessary medical and surgical intervention, the physician–industry nexus, medical insurance
frauds, and profiteering in medical treatment. A disastrous consequence of these adverse reports
is the dwindling of citizens’ trust in the healthcare system. A society low on trust, where the
public regards physicians as predators and physicians look on patients as potential litigants, is
not only ominous but also economically unsustainable because states lack the resources to force
everyone to be ethical at all times.
Corruption in healthcare spares few countries in the world, though the degree of its severity
varies greatly among countries. Transparency International, an NGO based in Berlin, the United
Nations Development Programme (UNDP), and several other groups have studied the
phenomenon of corruption in healthcare which burdens or cripples such services globally.1 These
studies have identified corruption manifesting as bribes and kickbacks to officials to obtain
contracts and favours; theft and embezzlement of public assets; intentional damage to public
assets for private gain; informal payments for easing business transactions; exploitation of
human subjects for clinical trials; and institutional corruption at hospitals for medical
profiteering. The major scandals involving corruption in healthcare in India, such as clinical
trials (Sinha 2008) and the National Rural Health Mission (Shukla 2012) in recent years are by
no means isolated and have received global attention.

Corruption: A Technology Perspective

In the literature on corruption in healthcare, the elephant in the room—medical technology—is
usually missed. If instruments such as auto analysers, endoscopes, and electro-physiological
units; imaging instruments like ultrasound, CT, MRI, and PET; and implants, disposables, and
prosthetics were to vanish from India, the bulk of corruption in relation to their purchase,
maintenance, replacement, and patient care in hospitals would vanish! But the quality of patient
care too would then regress to what existed in the 1950s, which would be unacceptable to
everyone, including patients. Indispensable for service to patients at all levels and in all
specialities, technology is the best servant of a physician. The spectre of corruption appears when
a physician lets technology become a master under the influence of greed. In ancient times,
ethical codes from East and West urged physicians to abjure greed in the practice of medicine as
the sovereign prophylaxis for the disease of corruption. Lest we forget, the old moral lesson
needs to be kept in focus before the physicians in training by iterations and even more, by
example. This may sound trite, but the moral indoctrination must be an integral part of medical
training.
At the organizational level, two important and complementary programmes are necessary to
minimize, if not eliminate, corruption related to technology in healthcare. In the first place, an
effective regulatory system for marketing medical devices should be brought into legislation as
early as possible. Secondly, a national body should be constituted for the development and
notification of guidelines for the optimal use of technology in healthcare. Unfortunately, India’s
record on both these initiatives is far from satisfactory.

Medical Devices: Regulatory Mess2

In the present discussion, medical devices also cover instruments used in the practice of
medicine. The medical devices industry is miniscule in India as it claims no more than 0.19 per
cent of the total manufacturing sector; in terms of workers employed the percentage is 0.14 per
cent; and the value of output of medical devices is 0.21 per cent of the total manufacturing
output. Nevertheless, the market for medical devices was Rs 13,000 crore in 2009–10 with an
annual growth rate of 15 per cent. The minuscule statistics continue in regard to the import of
devices, which is 0.6 per cent of the total imports into India. The export of medical devices
constitutes less than 0.5 per cent of total exports. On an average, instruments and equipment
form two-thirds of the total value of medical devices production and disposables claim one-third.
Implants such as heart valves form less than 2 per cent (Mahal and Karan 2009). Domestic
production for export is focused on low-technology, high-volume devices and instruments
whereas high-tech items account for 75 per cent of imports.
Though the medical devices industry is small in the total manufacturing sector, its public-
health importance is disproportionately large and its double-digit growth indicative of its status
as a ‘sunrise’ industry. However, vast majority of Indian patients have little access to medical
devices and those who do are admitted to private hospitals, which use technology liberally. As
the Indian economy grows and the payment for medical devices gets covered by social-insurance
schemes or a National Health Scheme as envisaged by the High Level Expert Group in India, the
market for medical devices will grow sharply and give an unprecedented boost to medical
devices industry. If not backed up by a strong regulatory framework, the rapid expansion of this
industry will aggravate corruption, which has already cast a heavy shadow on it. Medical devices
are already beset, in common with other hospital services, with bribes in procurement,
manipulation of contract, theft and embezzlement, intentional damage of public assets to drive
patients to private institutions, and the unethical use of human subjects for clinical trials. All
these maladies need no aggravation, but they are aggravated by the thoroughly confused and
interminable government processes in creating a regulatory framework by legislation for medical
devices in India. The story, in fact, dates back to 1980s when the Sree Chitra Institute,
Thiruvananthapuram, developed a blood bag and transferred the technology to a joint-sector
company, which sought to approach the ‘competent authority’ for approval to market the
product. As the Bureau of Indian Standards (BIS) had not set up standards for blood bags, Chitra
had complied with those prescribed by UK-based Department of Health and Social Security
(DHSS) for developing the bag. The company’s query went from ‘pillar to post’ for several
months before an ad hoc approval was received from the Ministry of Health, which, to its credit,
began the consideration of a new legislation for devices. This became an unending saga and the
dramatis personae included Ministry of Health, Indian council of Medical Research, Defence
Research and Development Organization, Department of Science and Technology, Drug
Controller General of India, and later the Department of Pharmaceuticals. Three decades later,
medical technology is currently facing an identity crisis with the National Medical Devices
Policy, 2015 undergoing multiple iterations and deliberations over the last year. The first
impediment of creating an identity of its own is proposed to be removed by delinking medical
technology from the Drugs and Cosmetics Act. The move however, was only partially successful
as policy initiative in this direction is still not finalized.3
The absence of a legislation that greatly weakens the regulatory status of medical devices, the
absence of a nodal agency to assess and evaluate the wide range of instruments and devices to be
marketed in India, and the ad hoc manner of making decisions (like the decision to segregate
medical devices from drugs in parallel with a decision to include 3,800 devices under the Drugs
and Cosmetics Act have made us a laughing stock in the world of medical technology. This is
not surprising because an effective devices legislation has been operating smoothly in
manufacturing countries like Ireland, Malaysia, and China and importing countries such as Saudi
Arabia for many years.
The regulatory uncertainty has undermined investor confidence and industrial initiatives,
which is one of the main reasons for the tiny size of the medical devices industry in India. It has
also provided plenty of scope for corruption manifesting in the production and sale of
substandard devices, devices withdrawn from the market in developed countries being dumped
in India, marketing devices under misleading labels, and other corrupt practices in marketing
which abound and are detrimental to healthcare.

Medical Devices: Guidelines for Optimal Use

There are any number of reports in the media and much public concern regarding the overuse
and misuse of ICU facilities in hospitals and advanced diagnostic tests.4 There are also reports of
physicians having contractual obligations with hospitals to fill an allotted number of rooms or
ICU beds and order a specified number of costly investigations per month, even if they are not
required. These abominable practices not only cause great hardship and anxiety to patients and
their families but also inflate healthcare expenditure which India can ill afford. It is essential that
we move as fast as possible to establish a national body to develop evidence-based and India-
specific guidelines for the use of high technology in medical procedures. In due course, the
evidence-based guidelines for the use of diagnostic procedures could also be extended to clinical
practice. The development of such guidelines involves intensive and critical study of a
considerable literature on clinical trials and several rounds of consultation with associations of
practicing doctors, specialist associations, NGOs, industry, health-insurance experts, and other
stakeholders. The National Institute for Health and Care Excellence (NICE) of UK is a good
model to consult in this exercise. However, India’s demographic, epidemiologic, and socio-
economic conditions are very different from those in the UK and care must be taken to ensure all
recommendations are India-specific. Once the guidelines are notified, hospitals whose bills are
paid by the government and insurance companies will be forced to comply with them for
providing high-tech services. This will eliminate much of the wasteful use of technology and
corruption in hospital services. Though India made a start by setting up a National Medical
Technology Assessment Board few years ago, its ‘progress’ is reminiscent of the fate of devices
legislation. The ‘inevitability of gradualness’ casts its heavy mantle on everything India tries to
do regardless of whether it is medical devices legislation, medical technology guidelines, or
building a main battle tank! The measure of time is not years but decades.
***
The challenge of corruption in healthcare and India’s ineffective response reminds one of an
episode in Japanese history. When Japan resumed links with Europe in 1860, after 200 years of
self-imposed isolation, it sent some of its bright young men to the West to observe their best
practices in technology and industry. Foremost among them was Maeda Masana who became
one of the architects of Japan’s plan for national development, called Kogo Iken. It stated:
[W]hich requirement should be considered as most important in the present efforts of the government in building
Japanese industries? It can be neither capital nor law and regulations, because they are dead things in themselves
and totally ineffective. The spirit/willingness sets both capital and regulations in motion. If we assign to these
three factors with respect to effectiveness, spirit/willingness should be assigned five parts, laws and regulations
four, and capital no more than one part’. (Quoted in Dharampal 2016)

History bears witness to the astonishing progress made by Japan in technology and industry in
less than 40 years after the above statement was made. In the fight against corruption in
healthcare, India is not lacking in capital but has serious deficits in law, regulations, and, above
all, spirit, which call out for urgent corrective action.

References
Chattopadhyay, Subrata, 2013, ‘Corruption in Healthcare and Medicine: Why Should Physicians
and Bioethicists Care and What Should They Do?’ Indian Journal of Medical Ethics, X(3):
153.
Datta, Pritam, Indranil Mukhopadhyay, and Sakthivel Selvaraj, 2013, ‘Medical Devices
Manufacturing Industry in India: Market Structure, Import Intensity and Regulatory
Mechanisms’, Working Paper, ISID-PHFI Collaborative Research Programme, Series 02,
March, p. 2.
Dharampal, 2016, The Collected Writings of Dharampal, Vol. V, Goa: Other India Press, p. 92.
Mahal, Ajay and Anup K. Karan, 2009, ‘Diffusion of Medical Technology Medical Devices in
India’, Expert Rev. Med. Devices, 6(2): 197–205.
Shukla, S., 2012, ‘India Probes Corruption in Flagship Health Programme’, Lancet, 379(9817):
698.
Sinha, Kounteya, 2008, ‘49 Babies Die during Clinical Trials at AIIMS’, The Times of India, 18
August.
Transparency International, 2006, ‘Special Focus—Corruption and Health’, Global Corruption
Report 2006, London: Pluto Press.
 III

MORALS, POLITICS, LEGAL ISSUES, AND CONSEQUENCES

 CHAPTER SEVENTEEN
Degradation of Our Spiritual, Ethical, and Moral Heritage
A Personal Perspective
V.I. Mathan

The serene campus of the Christian Medical College (CMC) in Vellore and the traditions
established by Dr Ida Sophia Scudder, the founder, nurtured me to be a doctor. The patient was
the centre of the institution and no one was turned away for lack of money. Training of students
on a gurukul-like residential campus was the priority of the faculty. Dr Scudder, known to us as
Aunt Ida, was resident on the campus and her larger-than-life personality was the inspiration for
all. Spiritual, ethical, and moral values were imbibed by us and we were trained for the vocation
of healing, not just medicine. I retired from there in 1997 after 42 years in that community.
Fast forward to Chennai 2002 where I settled down after spending three years at the
International Centre for Diarrhoeal Disease Research, Bangladesh, an international health
research institute in Dhaka, and a year with UNAIDS in Delhi after my superannuation from
CMC. A friend with low back pain contacted me soon after arrival. A simple physical
examination showed no abnormality, but he wanted an MRI scan. A day later he came with the
pictures and the report in a sealed cover addressed to me by name. I was surprised, as the
signature I scrawled on the scrap of paper asking for the MRI was undecipherable. When I
opened the cover two crisp thousand-rupee notes came out with the report! They had asked the
patient the details of the doctor who ordered the test and decided to give me my cut to ensure
more such requests. Welcome to the reality of healthcare in the new millennium!
Aunt Ida and the traditions and ethos she established on the ‘protected’ campus at CMC
Vellore were a far cry from the realities of practice in a metropolis in India in the first decade of
the 2000s. At CMC you were part of a team whose central focus was the welfare of the patient.
In the metro in 2002, I was forcibly being co-opted into a team whose central focus was money
and the role of the patient was primarily to be provider of the money. It was apparently incidental
whether or not the patient was helped as long as he could pay. The traditions I had learnt and
assimilated as part of my medical heritage were no longer relevant in the globalized reality of
this century.

Our Heritage
The affirmation of the primacy of the patient’s welfare outlined in ancient Indian texts, the
Charaka Samhita and Susrutha Samhita, pre-dates the Hippocratic Oath by several centuries.
The moral and ethical aspects of medical care are part of our heritage, handed down over
generations in our motherland. Ethics in medical practice and research was not something that
evolved after the Nuremberg Trials following the Second World War. The Helsinki Declaration,
a reaction to the Holocaust and the crimes of the Third Reich, only codified the ancient moral
and ethical tradition of Indian and Greek healers. Is there also a spiritual dimension to the art and
science of healing?
In 2007, I, along with my wife who required therapy for her rheumatic problems, was
admitted to an ayurvedic chikitsalaya (clinic) for a three-week period of sattvic (nourishing,
healthy food) vegetarian diet, oil baths, and massages for rejuvenation. The first thing that struck
me was that the serene campus was centred around a temple where puja was conducted round the
clock. The chief vaidyan (healer) started his day with a period of quiet meditation in the temple
and at the end of the day would spend a few quiet moments there before going home late at
night. As I got to know him better I realized that Ayurveda is an inspired and not an
experimental system of holistic care for the individual. The chief vaidyan related several
instances where he was stuck for an optimal line of management for a patient’s problems and
what he should do was revealed when he sat quietly meditating at the feet of the Lord. He was
clear that what he was doing was ordained by God.
At CMC Vellore, we were brought up in a tradition that can be best summarized in Aunt Ida’s
words to me one Friday evening at tea when I was a fourth-year medical student: ‘My only regret
when I decided to respond to God’s call and come to India was that my fiancé was not prepared
to come with me and that I would not have any children. God has been wonderful to me. All my
students and my patients are children He has given me, but the eldest of them is this college, a
part of His kingdom.’ The motto of CMC Vellore: ‘Not to be ministered unto, but to minister’, is
based on the Biblical command to ‘go, teach and heal’. Although not overtly preached to, we
learnt that every patient is the image of God, and what we do to the least of these our brethren is
an offering to God. We only care for the patient; it is God who heals them. We are but
instruments in His hands.
In the middle of the twentieth century, when I began my journey in medicine, there were clear
spiritual, ethical, and moral values undergirding the practice of medicine. We in India were
privileged that the ethos of the indigenous systems of medicine complimented what had evolved
after the Second World War. The Indian tradition of Ayurveda and the Judeo-Christian tradition
of Western medicine (as it was seen at that time) complemented each other and strengthened the
spiritual, ethical, and moral aspects of medical practice. The practice of medicine, irrespective of
its inadequacies, was for the benefit of the patient.

Where was Healthcare in the Mid-twentieth Century?

The actual situation on the ground in India in the middle of the last century was determined by
the social and economic realities of that time. Healthcare was the responsibility of the states and
money allocated was meagre. Although in theory there was a state government health service
available to all, in reality, there were major disparities between the states and even in the best of
them, the available services were inadequate. Most states permitted private practice by their
doctors; in fact, they were encouraged to supplement their relatively modest salaries by their
practice. The vast majority of the doctors worked sincerely to discharge their responsibilities to
the government and gave around six to eight hours to government hospitals, which were
overwhelmed by the sheer number of patients, despite their own practices. In their private clinics,
they could spend more time with their patients and many were even known to see indigent
patients free in their practice. Doctors on the faculty of the 90-odd medical colleges in existence
then took their teaching responsibilities seriously and there are many examples of well-loved and
excellent teachers.
The doctor’s commitment to the care of patients was accepted as a vocation, which enabled a
comfortable income. Technology was relatively underdeveloped and at best a few blood tests,
urine and stool examinations, and X-ray machines were common. Doctors were good at clinical
diagnosis and tests were ordered as indicated to confirm them. Medical students were trained
well in the clinical approach to diagnosis and treatment. The cost to the patient was limited
except for those who needed surgery. Doctors with a diploma (the short MBBS course to convert
the LMP to an MBBS was still there in 1955) and with an MBBS degree were accepted as
competent to provide healthcare. Postgraduate courses were few and higher specialties were
unknown, and doctors holding postgraduate degrees were primarily for the faculty of medical
colleges.
In 1942, Dr Ida Scudder realized that private hospitals doing charity work could not continue
to depend entirely on funds from outside India and suggested that development of specialties
with facilities similar to hospitals in the West would be necessary for the independent survival of
charitable hospitals. She felt that the fee paid by those who could afford should be such that it
would subsidize the care of the poor and the marginalized. It is a strategy that has worked well at
CMC Vellore. She took the initiative to develop departments of cardiothoracic surgery and
neurosurgery at CMC Vellore in the early 1950s. A few other large metropolitan hospitals also
started to develop specialties from the middle of the twentieth century.
Primary care was mainly provided by practitioners of Indian systems of medicine and in the
state-run clinics and smaller hospitals. All state government hospitals were overwhelmed by the
numbers of patients and struggled to provide secondary care. Private practice and nursing homes
provided care to those who could afford. There were no established channels of referral through
the government health system, but the patient was still the focus of care. The system did not
ensure equitable care for all, but was not exploitative and the inadequate facilities were equally
shared by all. The very affluent had the choice to go abroad for care. At that point, India certainly
was not a medical tourism destination!

Where is Healthcare Now?

In the latter half of the twentieth century, a technological revolution occurred in healthcare.
Advances in biochemistry, haematology, pathology, microbiology, molecular biology, and
sophisticated imaging techniques have increased the speed and accuracy of diagnosis. The
discovery of an increasing numbers of antibiotics, cancer chemotherapeutics, and drugs based on
a fuller understanding of pathophysiology revolutionized the treatment of many diseases.
Minimally invasive techniques changed many modalities of surgery. There was a consequent
improvement in diagnosis and treatment with increase in the cost to patients. Reduction in
morbidity and mortality and increase in the life span occurred due to these and many other
factors, improvements in economic status and nutrition playing a major role.
The commercialization of medical education and the development of the healthcare industry,
coupled with the technological revolution, replaced the patient with the bottomline and return on
investment as the reason for existence of healthcare. The patient changed from being the focus of
care and concern to being the source of income for the ‘industry’. In fact, the healthcare industry
is one of the most rapidly growing in the country with good returns on investment. There is no
accountability, medical audit, or check on quality and quantity of diagnostic tests which
maximize return on investment. It is common for the CEOs to insist on levels of utilization of the
technological facilities, irrespective of clinical indication, to ensure healthy returns on
investments.
The government-run healthcare facilities continue to languish and the infusion of technology
was limited to institutions of national importance and government teaching hospitals in capital
cities. The proportion of GDP invested in the health sector remained at less than 2 per cent and
increases in investment in the public health sector barely kept up with inflation. Health and
healthcare was and is not a political priority. The crowds continue to throng the government
hospitals since they have no money to pay for the facilities in the corporate sector, where the
valued customer is the medical tourist. Many more nursing homes and practitioners have
appeared in tier 2 and 3 towns.
In the mid-twentieth century India had a poorly developed healthcare system, low investment
in public facilities, and an iniquitous system where those who had money could go abroad for
treatment. However, there were well-trained clinicians who truly cared about the patient and
realized that working in healthcare was a vocation, and for some people, even a spiritual calling.
The welfare of the patient was the primary concern and this was undergirded by our spiritual,
moral, and ethical heritage. In this second decade of the twenty-first century, there is a rapidly
growing system of commercialized medical education and a well-developed healthcare industry,
with facilities equal to the best in the developed world, available to those who can pay, and
which welcomes medical tourists from all over the world. There is some improvement in public
hospitals in metros, with the infusion of technology, but they remain underfunded and
overcrowded. The most striking change is that the great heritage of spiritual, ethical, and moral
traditions has been forgotten and patients are seen primarily as providers of funds for the
healthcare industry, who are being exploited to the maximum.

The Evolution of the Degradation

How did the vocation of healing change to the healthcare industry in just half a century? Several
factors—from inherent characteristics of human nature to inappropriate exploitation of
technology to political and official apathy—have contributed to this evolution.

Human Nature
A traditional positive characteristic of human nature that was exploited by the healthcare industry
was the love and commitment of families to do whatever possible for members who were sick
without counting the cost. It is anecdotally reported that looking after a patient is the commonest
cause driving families to penury in India. All of us have seen examples of this but there are no
real statistics defining the magnitude of the problem. Secondly, human nature desires a
comfortable life and increasing income and wealth are seen as the essential requisites of a good
life. Unfortunately, once you start on this path, there are no limits to the wealth you want. The
next million is always more desirable!

Capitation Fee in Medical Colleges

The demand for admission to medical colleges has always outstripped the supply and statutory
reservations further reduced the number of available seats. Many well-to-do parents wanted their
children to be doctors but knew that their chances for admission to a medical college were nil. A
group of astute businessmen in southern India saw an opportunity and in the early 1950s, started
a medical college where a seat could be reserved for a price (capitation fee) irrespective of their
academic performance and where the ‘cost of education’, or even money excess of it, was paid as
annual fees, unlike state government medical colleges where the cost of education is heavily
subsidized. The pioneers in this ‘self-financing educational industry ensured that standards were
maintained and that qualified and adequate faculty were employed. Their success stimulated the
proliferation of capitation fee colleges; currently, over 300 are functional. The standard of
education and the quality of healthcare in such institutions is variable, many such medical
colleges being interested only in the return on investment. Statutory oversight of such medical
colleges is not optimal, as several of them enjoy political patronage and protection. Though ‘self-
financing’ sounds respectable, they, in fact, commercialize medical education and are part of the
cash economy. The students and parents expect an appropriate return on their investment.
Medical education has thus become a for-profit industry, totally negating the charitable nature of
education.

Industrialization of Healthcare
The mid-1980s saw another development that led to further commercialization of healthcare.
Some doctors, who were also astute businessmen, saw the provision of healthcare facilities
equivalent to what was available in developed countries as a viable business venture since there
was a large population who could afford to pay. This was the emergence of the healthcare
industry with corporate hospitals providing luxurious facilities, expensive technology, and
charges determined by market forces. They provided an opportunity for expatriate Indian doctors
who wanted to return and skilled professionals who had retired from government institutions to
enjoy the monetary rewards of a successful industry. Graduates from capitation fee colleges
found ready employment. Returns on investment were excellent and in the metros this healthcare
industry flourished and grew. The growth was augmented by liberalization, franchising, take-
overs and the government allowing import of technology freely. The healthcare industry is now
flourishing in all metros and many tier 1 cities. Quality care is provided to those who can afford
it, while the vast majority of our citizens can only look on in despair or bankrupt themselves by
taking their loved ones for care. Investments in government hospitals and in rural areas have
been minimal and the facilities in many institutions have deteriorated during this period.

Technology is a Money Maker

Unprecedented developments in technology supporting healthcare, beginning in the latter half of
the twentieth century and still evolving, with newer imaging techniques, automation,
miniaturization, minimally invasive techniques, robotics, molecular medicine, and patient-
targeted therapy was part of the excitement of being a practicing physician. Refinements of all
technologies provided greater power for their discriminative use to benefit patients and improve
the accuracy of diagnosis and treatment. If you experience the ‘comfort’ of a laparoscopic
cholecystectomy, after earlier experiencing a conventional laparotomy, you will continue to bless
the generations who have developed the tech. However, there has as yet been no analysis of how
many unnecessary cholecystectomies have been done by minimally invasive technique. Nobody
has questioned why the cost of such procedure should be more than the conventional ones.
Technology in healthcare is capital-intensive, but the returns are phenomenal, since the CEOs of
the industry insist on adequate number of patients being made to use the technology and
investigations can be repeated ad infinitum on patients in the guise of adequate follow-up!
Technology is the genie in the bottle fulfilling all that you desire as return on investment.

Globalization of Aspirations
The economic liberalization that started from the early 1990s provided many opportunities to
individuals to utilize their skills and increase their income. This led to a surge in the population
which would be classified as middle and upper-middle class. Youngsters suddenly had money to
spend on what were till then relatively unavailable consumer goods and durables. Globalization,
instead of exporting the traditions of India actually became imitative of the worst practices in the
developed world. Keeping up with the neighbours became the goal of many, with satellite
television projecting the luxuries of the world into your living rooms. Maximization of income,
preferably without paying income tax, became the ambition and the cash economy flourished.
The capitation-fee colleges created a cadre of graduates who saw their expensive education as an
investment for which adequate returns were essential. The healthcare industry became the ideal
venue for those who had invested heavily in becoming doctors to try and recoup their
investments with profitable returns. The businessmen in charge of the healthcare industry were
only interested in maximizing their returns exploiting patients. The sad casualties were ethics and
morals.

Apathy of the Policymakers

Healthcare was a major campaign item in the last three presidential elections in the US. President
Obama established ObamaCare, which was anathema to the conservative Republicans. We are
now seeing the drama of the ‘abolition’ of ObamaCare. Health and related subjects have never
been an issue in any of the many state and central elections I have lived through in independent
India. Our constitution does not define health as a fundamental right of the citizens, although it
can be derived directly from the right to life. Most people see health as an individual concern,
not something that the society at large should be bothered about. Personalities rather than issues
of relevance to society dominate our elections. More parochial concerns such as caste or
language seem to touch the emotions of the electorate. In a recent book a former health secretary
at the centre has clearly stated that to the political policymaker, health-related issues are of no
concern and that is why health has been a neglected subject. The Ministry of Health often only
has a minister of state. This apathy is the reason why the allocation for health is so low and why,
when new projects are announced, their feasibility is seldom worked out. A good example is the
announcement regarding creation of many all-India institutes of medical sciences in several
states. The land, the infrastructure, the personnel, and the running expenses all have yet to be
found for many of them several years later. It sounds good to say ‘We will clone the AIIMS in
your state’, but the when and how is seldom clear!
From the Bhore Committee Report nearly 70 years ago to the National Rural and Urban
Health Mission in the last five-year plan, there have been outstanding plans for improving the
health of our citizens. Yes, the life span has increased and we have world-class treatment
facilities which attract medical tourists, but healthcare is no longer a vocation, but only an
excellent opportunity for return on investment. The marvels of modern medicine are found in
India, but the vast majority of our population cannot utilize the facilities. While we strive to
imitate much of the developed world, when can we have a national health service, equivalent to
that of UK or Canada? The welfare of the patient was of paramount importance to Charaka and
contemporaries. The spiritual, ethical and moral dimensions of healthcare were our inheritance.
In the pursuit of privatization, globalization, and ease of doing business, we healthcare
professionals have stood by and allowed our heritage to be tarnished, while enjoying the
monetary benefits.

We Stood By; Can We Think of a Solution Now?

Our generation stood by and allowed the commercialization of medical education, the
industrialization of healthcare, and the exploitation of patients in a cash-economy model.
Shouldn’t we now be part of a process of correction of our healthcare system?
Two developments during the last five years suggest that in spite of the profound apathy of
politicians and health officials, there are indications that they want to do something to change the
situation. The first are the attempts to change the Medical Council of India (MCI). While the
problems of the MCI are clearly known and the plan of action fairly clear, opposition to change
has meant that there are as yet no significant transformations. The second was the attempt to
introduce NEET (National Eligibility and Entrance Test) to regulate admission to undergraduate
and postgraduate medical courses. While this idea was good, NEET appears to have been
designed by people with limited understanding of the dynamics of admissions to academic
institutions. The problems have been compounded by the idea of centralized counselling based
purely on academic merit assessed by a single examination, NEET. The issue of aptitude for
training as a physician is ignored by this approach.
Admissions to over 400 medical colleges in 37 states and union territories by central
counselling ignores several key factors. The choice of the student is determined by domicile,
knowledge of local languages, proximity to their residence, reputation of the institution,
commitment to service in their state of domicile, etc. Candidates apply to colleges of their
choice, which is an important factor to be considered for admission. There are also medical
colleges which have an excellent track of service to our nation, evidenced by the fact that their
students stay on in India to serve the nation, whose time-proven methods of admission, which are
fair, transparent, and non-exploitative, are ignored by central counselling. Both, NEET and
central counselling have been beset by legal problems from the beginning. It would appear
timely to redesign them in consultation with a group of academicians who understand the
dynamics of medical admissions.
The following steps would appear to solve some of the issues that we are facing:

1. Redesign NEET as a viable and dynamic test to determine eligibility and to prepare rank lists
for individual colleges and states.
2. Have three statutory bodies in place of the MCI
a. To oversee ethical medical practices
b. To accredit hospitals and audit their functioning
c. To regulate standards of medical education
3. Nationalize all capitation-fee medical colleges.
4. Add a luxury tax to corporate hospitals and use this tax to upgrade facilities in state-
 government-run medical colleges and district hospitals and establish an effective system of
referral.

It is not possible to examine each of these ideas in detail here but they are presented for
consideration and discussion.
***
At the time that we became an independent nation, the tradition of spirituality, ethics, and morals
undergirding our indigenous systems of medicine, despite all its defects, was its strength. The
central theme was the patient and his welfare. Unfortunately, while patients still require
healthcare, business practices and the profit motive have developed the health education and
healthcare industries where the patient or his family are exploited to maximize monetary gains.
This change has occurred in less than 70 years. Are we willing to work to bring about a
correction?
 CHAPTER EIGHTEEN
The Moral Pathology of Healthcare Corruption
Abhijit Chowdhury

Discussions on morality and ethics always turn out to be turbulent. Intriguingly, when healthcare
corruption is a specific issue, such dialogues frequently invoke fiery debates. Issues on the
methods and process of corruption dominate such discourses, and moral pathology is usually not
on the table (Berger 2014; Jain et al. 2014; Chowdhury 2014). Diametrically divergent views
often clash in an atmosphere that is charged with emotions and lyrics rather than analytics and
thoughts. While that is necessary to combat corruption, it is equally, or even more important, to
decipher the extent as well as the language of the deep disruption of values and ethical principles
that predate corrupt practice (Mazumdar 2015; Nagral 2014; Pellegrino 1999).
Our attempt here is to play with the philosophy of corruption (yes, corruption does possess a
mirror and we need to look through it to be more insightful on the matter before drawing a
strategy against it) rather than use the methods as a focus. The present enquiry entails the
question of how corruption springs from subtle tweaks in our prevailing value systems, how it is
sustained by setting up an organized think tank that maintains a facilitatory socio-cultural
ambience, and, finally, how that translates into real-life scenarios. It is important that before
delving deeply into the question of morality (and breach thereof) in the medical professional and
healthcare system, a larger ambit of prevailing morality in society in general needs to be looked
at. It needs to be spelt out clearly that corruption in healthcare is only a spillover of the larger
cesspool of corruption and a decaying value system in our society.

Corruption as an Organized Process

It is hard to see a person saying loudly that corruption is part and parcel of a society that is on the
move. Somebody thought to be evidently corrupt would also religiously vouch for cleanliness in
professional and public life, harshly deploring dishonesty and corruption. Therein lies the charm
of the word and its intrinsic strength as a social asset. It may be emphasized that it is incorrect to
assume that the corrupt do not understand what constitutes corruption. They are usually
intelligent and capable beings. Their ability to play with an existing value system would
necessitate significant thought inputs, which they possess. They redesign the value template
existing in a society and reframe ideas of justice as well as morality with a fair amount of
precision. It is a survival instinct for them, following the classical Darwinian theories of survival
of the fittest. They create a neo-value system, a tinted rim of morality and principles to safeguard
their activities as a protective shell. They also try to silence the prevailing moral principles that
place them at jeopardy. One very subtle way of doing this is to blur the lines of morality and
present real life as a pragmatic assortment of activities that does not fit in with traditional
principles and precepts that have been laid down over years. As a result, it is not uncommon to
see that an average person considers honesty to be a superhuman trait and morality as a
personality attribute that is illusionary. This makes room for creation of terminologies like
‘absolute and relative honesty’. Once this design is well set into prevailing values, corruption is
sustained. It then ambitiously creates new paradigms of morality as a step forward. People come
to an understanding with what had been coined as corruption so far and tend to believe that
enduring it, rather than fighting it, is an aspect of survival. Corruption digs deeply and often
imperceptibly under this sort of conceptual haze and then settles to create an ambience that keeps
it afloat in an environment that is inimically alien to it in evolution.
Corruption can therefore be perceived as a failure of an ideologically lean society to uphold
its value assets. It can be fought only through concerted endeavours to bring conceptual clarity
on what defines corruption, what are the many different shades in which it can get shaped, and
how it threatens the basic edifices of a society, specifically in the context of healthcare.

Premises for Discussion

Before addressing the moral aspects of healthcare corruption, the general approach needs to be
placed on board.
Firstly, it is helpful to adopt classical dialectical thoughts in dissecting the moral tenets of the
issue. Ethics and morality are tied between two knots—one of which is to do good only (and
nothing else!) and the other, formed by a ‘do not harm’ ethos. It is important to note most human
traits fall between these two extremes and form a spectrum. Therefore, it is good to shun an all or
none, tubular view in such a discourse and analyse different aspects of healthcare corruption as a
broad-based entity.
Secondly, the ideas about corruption do vary amongst individuals as well as in different
societies. These are influenced significantly by the prevailing dominant political thought, its
culture and philosophy. Political thoughts are deeply entrenched into the matter of corruption and
it would be injustice to play safe from politics while discussing corruption.
Thirdly and very critically, it is good to have the insight that the ideas about just and unjust,
ethical and unethical are not infallible and can itself get corrupted. In fact, healthcare corruption
begins with this—by placing unethical and immoral as unavoidable and just behaviour. Not
denying the role of evidence in justifying routine clinical practice, tweaking aspects of evidence
to match motive is not uncommon and forms an impending threat to ethical practice in medicine.
Fourthly, one could also raise serious concerns as to whether there is something called eternal in
ethics, morality, and value systems. The set of precepts that constitute these frameworks are
dynamic entities, that make and break its fabric as time and human ideas flow, although the
primary premises should remain firmly anchored to individual welfare.
Finally, it is to be recognized that healthcare corruption is just like a water body connected
with the larger ocean of corruption in other spheres of the society (World Bank 1997; Alatas
1986; Vian 2008).
The healthcare context presents unique features, given that its impact on social well-being is
deeper than other professional circles. Healthcare corruption generates huge social anger and
agony. Society gets disproportionately disturbed and agitated on healthcare and medical
professional corruption as compared to that existing in other spheres. This may be looked at as
an expression of the emotional jolt that people get at the idea of shady activities being
perpetuated in a sector that has to do with their health. It stems, perhaps, from the trauma of
being forced to lose faith in that last pebble of the entity called civilized society that promises
unblemished care to any life that faces jeopardy.

Approaches to Curb Corruption in Healthcare

What could be the alternative face of the argument that we need to place before us while dealing
with healthcare corruption?
One way would be to look at it as a neo-classical conservative, and consider the outcry against
corruption as ‘divinity’ put to disgrace for no rhyme or reason. One could argue that all these
brickbats thrown at the system and the profession are only paranoid outbursts of a suspicious and
unstable society. Pursuit of modernity along with a haste in pace to achieve it has made all of us
highly right savvy without making us aware of our responsibilities, as one would expect in a
balanced society.
A middle class invigorated by a newfound paradise of information has suddenly started
raising doubts on integrity of anything that comes their way. This generation is desperate to shun
its traditional understandings where faith and belief had been cornerstones of ethics as well as
morality and replace that by heaps of evidence and reasoning. It is an all-pervading pursuit of
transparency and objectivity that the same society is besieged with, that perversely shears
traditional values. It is a social phenomenon that numbs people of their abilities to discriminate
self from non-self and assets with scepticism and disgust.
It is largely argued that this profession should be given some breathing space with cleaner air
to perform with pleasure and deliver its best. Precision and creative spirit get suffocated once the
primary motive is questioned and methods of work put to perennial scrutiny. Society speaks of
love and respect for the system and the profession but fails to understand that both these human
virtues could be looked at differently through eyes are covered by tinted glass.
The voice at the other end of the spectrum is progressively getting louder too and is seeking
justice in the same turf. It mentions that healthcare corruption needs urgent remedy and attention
to salvage the system as well as the profession from degeneration. While corruption is in focus as
a general issue, healthcare is particularly garnering attention since the space for corruption is
largest here and its impact deeper than elsewhere, leaving a bleeding society. An outcry is
considered as a necessary rebuttal of a society that had got grievously hurt at the hands of a
system that it had placed at such a high esteem and in august faith. It is only timely that the
healthcare delivery system and the medical profession, as its vanguard, get set to respond to
these too loud tunes of dissent and rejection that had been humming within society for long time.
The profession had ignored these in ‘divine’ defiance and elitist denial. Democracy is getting
mature worldwide and third-world countries are the bedrocks of this transformation. The issue of
healthcare corruption is only part of a pursuit for social justice in a country just discovering its
vibrant civil society. It may be treated as faith at stake, love in jeopardy, and infatuations
smothered in an arena filled with smoke and dirt of cheating and deceit that is challenging the
sanctity of the divine throne.
Any mention of healthcare corruption in the public domain incites two mutually divergent
views.
It’s like a ‘paradise lost’ song impregnated with anger and rejection from the establishment as
well as the medical profession. The arguments are usually monotonous and uniform:
a) The profession has enough corrective arrangements within its framework and any lateral
insinuation is superfluous as well as malicious.
b) The question of ethics within the medical profession has elements that are inherently intricate,
making it complex. A commoner and an outsider may not have the insight to dissect its minute
details. This is likely to lead to conclusions based on superficial understanding.
c) Dissect medical professional behaviour only when you are through with corruption in general
in the society. Trying to peep into the healthcare system only is parochial.

There are, however, a sizeable bundle of counter arguments:

a) No profession dealing with the physical well-being of individuals and operating in the public
space should be impervious to questioning. Claims to such immunity are the breeding ground
for corruption. Such a ‘fortress’ phenomenon fosters elitism. This is also is the starting point
for proclaiming sovereignty by the profession and may not be the right one to be pursued by
the society.
b) It is unsound as a principle to say that the scientific methods involved in medical care-giving
are some sort of knowledge that is shrouded in mystery and a non-professional cannot
understand it. It is corruption by itself to call it like that. Asymmetry of information is one of
the important factors for breeding healthcare corruption and uncertainty of outcomes in
healthcare settings enlarges this window. ‘You cannot understand what it means and what I
intend to do’ are frequent words that quacks use. Any scientific principle should have the
ability to withstand a testing and retesting of its methods, even by a non-professional. There
should not be any fear in the thought of facing a jury.
c) It is improper to consider the ambient society as biased against the system and the profession.
This would raise a wall of separation from the people at large—who could be your best
friends.
d) Why not start a steer on corruption from the seat of divine justice? You have enjoyed the faith
of the members of society and it is now time to prove your chastity.

Historical Perspective of Moral Violation

While arguments could flourish, it is worth remembering that there are glaring examples of
engagement of the healthcare system and the medical profession in violation of ethics throughout
history. We get to see that the first of a series of 12 trials on war crimes during the Holocaust at
Nuremberg involved doctors (Pellegrino 1997; Colaianni 2012; Lifton 1986). The stories of Abu
Ghraib and Guantanamo Bay in recent times repeat the same gory tale, reminding us that
professional immunity from ethical violation is only a relative entity (Lifton 2004). It is also
important to understand that while these acts are extreme example of deviation from morality
and a violation of faith imposed on the profession, it may not be correct to define these as mere
expressions of criminality of an individual. The Nazi doctors were rational beings. To be sure,
they acted within psychological and socio-historical contexts. They justified their actions by
what they considered to be moral reasons. During the testimony, the defending doctors and their
lawyers advanced a few moral premises. They repeatedly mentioned that they killed people not
out of their own interest or benefit. They were acting to uphold the law of the state, as a
protective measure, and law can take precedence over medical ethics, was the argument they
presented. The German physicians indicted in Nuremberg had been taught by some of the
world’s best historians of medicine and ethics. During the testimony, they made constant
allusions to medical ethics and the Hippocratic traditions. They had formulated a set of ethical
guidelines that were addressed to meet the needs of the state and the medical profession was
tuned to those. The Nazi doctors argued that not killing the prisoners would have been
treasonous and medical ethics could be set aside by law. We see here the initial premises that law
takes precedence over ethics, that the good of the many is more important than good of the few,
and that some persons (such as prisoners or the Jews in Nazi era) can lose their claims to
humanity! The lesson here is that moral premises are to be valid if morally valid conclusions are
to be drawn. A morally repulsive conclusion germinates from a morally inadmissible and corrupt
premise (Lerner 1985; Hanauske-Abel 1996).
We need to re-examine this context repeatedly since moral lessons are quickly forgotten.
Moral reasoning based on defective premises tends to recur in new settings. Some of the Nazi
physicians could have been mentally deranged, but certainly not all of them. Many believed they
were doing the right thing. Wrongdoings and organization of corruption is based on blurring the
margin between right and wrong. What the Nazi experience teaches us is that the integrity of
medical ethics is important and the premises are to be clearly defined. It is important not only
because it protects the physician’s prerogative of being responsive and moral, but because it is a
bulwark against the use of medical knowledge for purposes other than the good of the sick.
Medical power is too great to be left unregulated, the extent of misuse of such vested prowess
can vary in degree but it is also too great to be enslaved by any interest like that in commercial
endeavours or by military powers, however benign they can be.

Subversion of Moral Principles

Upholding the sanctity of ethical values and morality in a profession depends on larger social
and political contexts within which the profession functions. It needs to be emphasized that while
the general rules of morality applies to healthcare, it is only this profession that is endowed with
a specific set of ethical norms, the Hippocratic Oath (Leveen 1998). Healthcare corruption begins
with subversion of the primary principles enunciated in this oath, that is, the interest of the
patient and the patient only as the only thing to consider by the profession. Once the breach of
this line of control in any form takes place in professional behaviour and culture, it can enter into
a self-perpetuating loop of malfeasance, progressively dipping deeper into corruption. The
magnitude of the deviation may vary, from merely deriving financial dividends through minor,
imperceptible steps in medical care to meeting this objective through undue and overzealous care
that can threaten the life of an individual. Examples setting aside, the primary premises remain
the same—crossing the boundaries of care giving that is supposed to do good and good only,
nothing else. A justification of the misdeeds are then created and then organized by the corrupt to
substantiate and sustain the corruption. The corruption machinery always possesses a think tank
—the way the Nazis did—and they also set what can be looked upon as guiding principles of
ethics and morality for their performance. It would be sheer foolishness to presume that the
corrupt lack any justification for their action. The evils in moral discourse are as old as ethics
itself. Prevention of corruption, therefore, should have an inbuilt analytical system that prevents
moral disasters in thought through dialectical reasoning before planning a social combat to fight
it out.

Care ‘Giving’ vs Care ‘Selling’

The issue of corruption today is a bigger menace in those countries where the public healthcare
delivery system is progressively getting shadowed by a beaming corporate healthcare system that
sells healthcare. The culture and philosophy of the two systems are different. Unfortunately, the
language that the medical care-giving industry speaks does not differ from that involved in
marketing any other commodity. This evolution of healthcare from the notion of a care ‘giver’ to
a care ‘seller’ is changing the institutional arrangement (Davidoff 1998a, 1998b; Titmuss 1997).
The culture of the medical profession is also getting metamorphosed swiftly as a necessary
accompaniment of this change. Extension of commerce into medicine has increased the
professional distress as it has threatened to destroy the social context in which healing has
always taken place. By turning the healthcare establishment into a marketplace and professional
service into a business, corporatization of healthcare has created a brave new world that speaks a
completely new language and preaches a different viewpoint of success. Here, an endangered life
is the playground and the ultimate outcome of saving a life is assessed in terms of the revenue
earned. Though usually covertly expressed, this well-known objective of commercial healthcare
delivery challenges the very basic tenets on which healthcare and professional success was built,
the ‘guardian moral syndrome’ as it is often called. Healthcare as a ‘gift’ changed to healthcare
as an exchange. The expectations of the people, who are consumers in the new set of
arrangements, also concurrently changed. A brand new set of neo-liberal professional values that
challenge the traditional social dogma of treating the system and profession with respect only is
making deep roots. This value system within finds no fault in a doctor seeking money at any cost
and trying to get rich at a galloping pace. Incidentally, this major shift in paradigms is exactly
what is getting questioned. As an extension of this breach of traditional morality, a section of the
professionals in this system in India have started believing that there is no moral turpitude
involved in asking for cash or kind in exchange for ‘offering’ human beings afflicted with an
illness, to a drug seller or a diagnostic centre. In their argument, it is a business at the end of the
day. Why not seek an exchange for doing that, since it will benefit both, they ask themselves.
They dislike terms like commissions, hate to be called that they are being bribed, and put fancy
names such as service charge for this act.
We now need to resort to very basic moral questions that structure the society. We need to
answer whether we can allow this most sensitive and dependable pillar for sustenance, survival,
and development of the society to be eroded in a progressive design?
An even more basic question is being raised now and needs to be addressed. Does this
phenomenon merit the term corruption in profession or is it just that a backdated value system
failing to keep pace with new-age professional needs? An assessment of the evolution of the
system is necessary. The new-age value system started in this country in the early 1990s and we
are two decades down the line. The medical profession of this country had strong ethos and self-
respect built on a sense of service with dignity. All these are being challenged now and labelled
‘medieval baggage’ that needs to be shunned to make quick progress. A heaping up of
technology with innumerable gadgets for diagnosis has given medicine an opportunity to be
modern. This, despite its precision in improving management of individual cases, lacks wide
application in a country fraught with issues such as access and equity. Unaudited application of
technology has also enlarged the corruption space within the profession. It had its cost and a
violent trade-off—destroying the age-old string of professional ethics and value systems that the
medical profession of this country had enjoyed.

Changing Mindsets and the Quest for Social Justice

Healthcare establishments had been treated like seats of divine power and the medical profession
had been viewed as sitting just below God in Indian culture and belief. This perception, however,
is changing fast and the ‘next to gods’ are now being put under scrutiny. The Indian mindset is
passing through a phase of increasing restlessness for social justice. Powered by a claim for right
to information and ‘more globalized’ thinking, the cry for justice and transparency is casting
reasoned doubts about the social values of every profession. The medical profession is no
exception. Rather it is on the radar upfront. A greater demand for responsible professional
behaviour and the need for putting an end to corrupt practices in medical care-giving are all too
loudly heard now. The asymmetry of health information is accepted, but is questioned when it
pains too much. Powered by a position of near divinity, the profession has learnt to behave with
unquestioned authority. Now, the same devotees of this mythological hero-worshipping, who,
having acquired a more globalized mindset, suddenly look confused and are suspicious of their
medical guardians. The healthcare sector in this country needs to grow, but preferably not in a
way which is filarial or cancerous, as it threatens to be. While the issue of corruption in
healthcare in India is too obvious and prevalent to be ignored, a balanced judgement in the
matter might help in finding the right way forward. Bitter pills are often the best remedies and
we need to swallow those without further delay to ensure the country’s health.

An Agenda for Prevention of Moral Bankruptcy

That is what we precisely need now. However, moral precepts are better felt and thought rather
than put on paper. The moral subversion in the medical world has always happened under a
cloud of wider deviations in social justice and human rights. The present concern of violations of
ethics and socially appropriate behaviour in healthcare delivery has many similarities with those
that happened in history. Principles of morality and ethics get corrupted earlier under these
circumstances, before corrupt behaviour claims its place in the society. When a handful of
professionals dare to speak loudly against uncovering harshly real-life stories on healthcare
corruption, it is only an expression of courage that morally morbid has gained over the years
when peace-loving, work-happy silent people within the profession kept quiet. These silent
majorities are the singing birds within the profession but their melody gets submerged in the loud
yelling of the corrupt. For the profession, it is like dying while hibernating and blocks of ice
covers such corpse only to be discovered later in history.
The moral pathology of healthcare corruption needs more analytical inputs. The profession as
well as the people needs to develop intimate dialogues and cross talk with reason rather than
mutual feelings of rejection to ameliorate this. At the end of the day, it is a quest for justice, both
for the profession as well as the society. The acknowledgement cannot really wait anymore.

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 CHAPTER NINETEEN
The Consequences of Corruption in Healthcare
George Thomas

A surgeon friend of mine, who works in a private medical college, called me the other day. He
had a patient who required surgery to remove a chronically inflamed appendix. In the hospital
attached to the private medical college, it would cost around five thousand rupees. The patient
had expressed difficulty in raising this amount and requested referral to a government medical
college. My friend wanted to know if I could confirm his opinion that it would eventually cost as
much, if not more, in a government hospital. Sadly, I had to agree. Of course, not all the
expenditure would be on bribing sundry staff, some would be spent on medicines required but
not stocked in the hospital, food, and transport. Certainly, however, money would need to be
paid to various staff. This is the most direct consequence of corruption in healthcare—
impoverishing the already poor. But it is only one facet of a much larger problem.
All violations of ethical behaviour, whether covered in the code of ethics1 of the Medical
Council of India (MCI) or beyond, arise from a fundamental dichotomy in the mind of the
medical practitioner, between what scientific medicine is and what he or she practises. The
consequences of this dichotomy are multiple; they are far-reaching and have a serious,
deleterious effect on the fabric of society. It is assumed that the basic requirements of the art of
medicine—which is being caring, careful, and responsive—are already in place.
The science of medicine means synthesizing all that is known about the physiology,
pathology, and therapeutics of the disease that the patient has in order to offer a treatment plan
(Sackett et al. 1996). In the last 50 years or so, there has been an exponential growth in
knowledge about the working and disorders of the human body. There has also been a wonderful
growth in therapies, which, even if they do not always offer a cure, can certainly help to
ameliorate the disease or disorder. The growth of specialities in medicine is fuelled by the fact
that it is near impossible for any medical practitioner to keep abreast of the ever-growing
knowledge in medicine. Practising scientific medicine will automatically mean practising ethical
medicine.
Some of the commonest unethical practices in medicine are hidden fees, unnecessary
investigations, and unnecessary procedures. The errors of omission, I will come to a bit later.
‘Please tell the patient to ask for me by name, and insist on seeing me, else he will be sent to
another consultant.’ The first time I heard this I was rather shocked. Now I know that it is
commonplace. Some doctors have touts everywhere—at the hospital reception, ambulance
personnel, cab drivers, and everyone else who can influence a patient. The patient is cajoled and
convinced that the particular doctor is the ‘best’ (Anand 2015). The result is that the patient will
be treated as a business target and the aim of the doctor will be to keep this chain oiled by
extracting as much money as he can from the patient. Some of the ways of doing this are given
below.
Hidden fees: This is one of the commonest unethical practices in medical care in India.
Whether it be a blood test, an X-ray, or a scan, paying the doctor a so-called ‘referral fee’, is
common practice. The direct consequence of this is financial—the patient has to pay more than
the market value of the service rendered. The indirect consequence is a loss of trust in the
medical community. If the integrity of the doctor is highly valued by society (and evidence all
over the world shows that it is) (Tallis 2006), any event that impairs this value has far-reaching
effects on society. It would not be an exaggeration to say that it affects one of the fundamental
tenets on which modern society is built—faith in institutions. At a time in India when faith in
almost every institution has been shaken, it is vital that the medical profession protects the faith
of the public in medicine. Damage to this tenet has made it easy for the ill-informed to spread
fear about, and distrust of, many useful public-health interventions, like vaccination. If the faith
in the medical profession is strong, the debate about such issues should be scientific, not based
on fear. A lingering distrust of the medical profession makes the public suspicious of its
interventions.
Unnecessary investigations: Every doctor is taught a systematic method of arriving at a
diagnosis. Listening to the history of the problem, examination of the patient, and appropriate
investigations are expected to be done in that order. There is much evidence to show that doing a
number of investigations on the off chance that something will show up is not only wasteful, it
can engender unnecessary fear. This is because all tests have a margin of error and an abnormal
test result does not always mean a disease is present (Riegelman 2012). Tests have to be
interpreted in conjunction with clinical symptoms and what is found on clinical examination.
When tests are done merely because the doctor is financially rewarded for doing them, the harm
to the patient arises not only due to the wasteful expenditure, but due to the unnecessary anxiety
and stress that can follow the findings of an abnormal reading. Many doctors argue—against the
evidence—that doing a number of tests is ‘defensive medicine’, and something may be found.
This is a clear violation of scientific medicine, and reveals a fundamental lack of trust in the
methods of medicine. If the doctor himself does not trust the method, then how can one expect
the public to do so?
Unnecessary procedures: This is probably the most egregious of medical malpractices. The
worst form of it is probably doing an unwarranted surgical procedure, for example the
hysterectomies in Karnataka and elsewhere (Satish and Buradakatti 2017). Practising scientific
medicine would greatly reduce if not eliminate this malpractice. Every surgical procedure has
clear indications. This includes ambiguous situations as well, where special judgement may be
required. Persuading patients to undergo procedures by playing on their fears, commonly telling
them that some serious disease like cancer may ensue if the procedure is not done, does
incalculable harm to the mind of the patient. This is in addition to the dangers inherent in every
surgical procedure—these risks are worthwhile when there is a clear benefit, but doing a
procedure which is not indicated, merely to extract money, can only be called an assault. The
mind of the doctor must also be twisted to be able to offer such advice against everything that
medical training inculcates. Young doctors in training, who witness these dichotomies,
internalize them and later on, implement them. The consequence is cognitive dissonance in the
mind of the doctor manifested in irrational decision-making in other domains (Haidt 2012).
Errors of omission: In contrast to the private sector where errors of commission, mainly
driven by financial motives, is the major type of corruption, in the public sector, errors of
omission, that is not doing what is required in the best interests of the patient, are quite common.
Thus, in many public hospitals, the staff doesn’t always turn up on time. Having turned up, many
take long breaks—for tea, gossip, and what have you. In many hospitals, even emergency
surgery may not be possible because the staff is absent without leave. Many doctors argue that
they are overworked and underpaid. There is merit in this, but one rarely sees doctors’
associations raise these issues. They seem to have accepted the situation. The doctors who work
tirelessly to do the best they can for the patients are demoralized by the colleagues who do not
seem to care. Many of the latter are financially very successful, and some are well-known public
figures.
Poor standards: In one of the public hospitals in which I worked, the antiseptic solution
povidone-iodine, which normally has a deep brown colour, was nearly colourless. It was sent for
testing and found to have nearly no active ingredient, certainly well below the quantity required.
The company had paid a large bribe to get the order, and had made it financially viable by
diluting the material. A formal complaint evoked no response. Similar situations exist all over
India. In Uttar Pradesh it led to the killing of doctors who protested.2
Tendering process: In the public sector, procurement of pharmaceuticals and equipment is
done through a process of tendering so as to get the best material at the best price. However, this
system has been corrupted such that in most cases, a company will be favoured because of the
bribes that it pays. The consequence of this is that the company is responsible only to the person
who makes the decision to favour it. The consequences of this can be that the material is
overpriced, it does not work as it is supposed to, or it requires recurrent expenditure on expensive
consumables. Sometimes, the drugs or equipment is of very poor quality. There is a widespread
perception amongst patients that drugs from government hospitals are unreliable. If they have a
little money to spare, the patient will try to buy the drugs rather than depend on medicines from
the public hospitals.
Medical education: Corruption in admission to medical colleges has probably always
existed. However, it became widespread once private medical colleges became commonplace. In
the usual Indian technique where pretence is everything, the colleges were allowed to be opened
saying that the government lacked resources to expand medical education and philanthropists
were ready to provide the funds required to open not-for-profit institutions. It soon became clear
that the entire exercise was a profitable business proposition, all ‘philanthropists’ were
politicians with large amounts of unaccounted money, and the colleges were used to generate
even more by sale of seats. The insatiable hunger of the middle class for medical education made
them willing accomplices to this unhappy practice. It has led to dilution of standards of
education. It has corrupted the regulators at every level—those who inspect the colleges take
bribes to overlook deficiencies and teachers pass candidates who perform poorly at
examinations. It has resulted in widespread cynicism among medical teachers who know that
they are at the mercy of the management. Many of the students believe that money can buy
anything, including medical knowledge. Having passed examination after examination without
studying, they use their financial resources to set up establishments with a lot of expensive
equipment and employ other doctors to do the actual work. The effect of this system on those
who really work hard at college but are unable to compete in the marketplace can only be
imagined. It is common to hear doctors say in private that it’s just money that counts. They pass
on this attitude to their children. The overall damage to society is incalculable.
In summary, the consequences of corruption in healthcare are: denying medical care to many,
impoverishing the already poor, and an assault on the patient’s body if he or she has to undergo
an unnecessary procedure. It causes a trust deficit in society between the patient and the doctor.
It damages one of the vital institutions of modern society. It causes conflict in the doctor’s mind
between what should be done scientifically in the patient’s best interest and what is actually done
in the doctor’s interest. This confused thinking colours other aspects of thinking about society.

References
Anand, A.C., 2015, ‘Manjunath’, NMJI, 28(2): 93–95, available at
http://archive.nmji.in/archives/Volume-28/Issue-2/Speaking-For-Myself-II.pdf, accessed on
17 March 2017
Haidt, Jonathan, 2012, The Righteous Mind: Why Good People are Divided by Politics and
Religion, New York: Pantheon Books.
Riegelman, Richard K., 2012, Studying a Study and Testing a Test: Reading Evidence Based
Health Research, Wolters Kluwer/Lippincott Williams and Wilkins.
Sackett, D.L., W.M. Rosenberg, J.A. Gray, et al., 1996. ‘Evidence Based Medicine: What it is
and what it isn’t’, BMJ, (312): 71–72.
Satish, G.T. and K. Buradakatti, 2017, ‘Losing Wombs to Medical Malpractice’, The Hindu, 25
February, available on http://www.thehindu.com/news/national/karnataka/high-on-
hysterectomies-losing-wombs-to-medical-malpractice/article17368093.ece, accessed on 17
March 2017.
Tallis, Raymond C., 2006, ‘Doctors in Society: Medical Professionalism in a Changing World’,
Clin Med., 5(6 Suppl 1): S5–40.
 CHAPTER TWENTY
Judicial and Legislative Responses to Healthcare Corruption

Arghya Sengupta and Dhvani Mehta1

The healthcare sector in India, and the medical profession in particular, have been the subject of
reports of all-pervasive corruption and appallingly low ethical standards, especially in the last
few years (Jain et al. 2014). This includes evidence of bribery within the profession’s regulatory
body, the Medical Council of India (MCI),2 corrupt practices within the pharmaceutical industry
relating to drug approvals,3 unethical conduct of clinical trials,4 and scandals in state-run public
examinations.5 Inevitably, these issues have found their way to the Supreme Court, which has
adopted different approaches to the calls for regulatory reform that such corruption has
prompted.
In Swasthya Adhikar Manch v. Union of India,6 it responded in heavy-handed fashion to
reports on irregularities in clinical trials. It virtually paralysed the drug regulator, the Central
Drugs Standard Control Organisation (CDSCO), and ended up becoming a de facto supervisory
authority over the regulator’s actions. However, when presented with evidence of corruption
regarding drug approvals within the same CDSCO through a writ petition7 filed in public interest
by Ranbaxy whistle-blower Dinesh Thakur (Eban 2013), its response was more hands-off. The
petition seeking a direction to the government to frame a new drug regulatory law was dismissed.
More recently, while considering the validity of a Madhya Pradesh law regulating admissions to
private medical educational institutions,8 the court felt it necessary to direct the government to
consider reforms to the MCI urgently.
The parliament has been slow to respond to these mixed judicial signals. The MCI was
dissolved in 2010 and replaced by a board of governors following the arrest of its then president,
Dr Ketan Desai on corruption charges. As a short-term reform measure, the term of this board
was extended through a series of ordinances that were later ratified through amendments to the
Indian Medical Council Act, 1956. Although a more comprehensive measure was introduced in
the form of the National Commission for Human Resources for Health Bill, 2011, a
parliamentary standing committee recommended major revisions.9 Since then, other committees
and bodies have advanced suggestions for its reform, but at the time of writing this chapter, a
concrete legislative step on reform of the MCI still remains to be taken.
The parliament has similarly dragged its feet on drug-regulatory reforms. Amendments to the
outdated Drugs and Cosmetics Act, 1940 have been proposed and withdrawn without any
substantive changes being made. The progress made on the latest move—drafting a new act to
replace the existing one—is unclear.
Important questions of constitutional and administrative law, regulatory design and
institutional structure lie at the heart of judicial and legislative responses that are required to
tackle healthcare corruption. In this chapter, we aim to highlight some of these questions in order
to evaluate responses that have already been made and offer suggestions for the way forward. In
the first part, we provide a brief overview of the different types of healthcare corruption cases
that have been brought before the Supreme Court. Although the reports mentioned at the
beginning of this chapter have already provided damning evidence of healthcare corruption,
these cases are useful in understanding which issues are litigated most frequently, thereby also
suggesting those areas that are most urgently in need of reform. In the second part, one issue that
the Supreme Court has repeatedly had to deal with—admissions to private medical colleges in
general and the validity of a uniform entrance test in particular—is analysed in detail. The third
and concluding part assesses reform proposals, with a particular focus on the MCI, for their
ability to promote autonomy and accountability, while operating within the constitutional limits
of federalism. Overall, this chapter finds that continuing inaction by the parliament has left a
void in effective regulation of medical education and the medical profession, which has not been
(and cannot be) suitably substituted by ad hoc judicial interventions.

Healthcare Corruption in the Courts

Academic discourse on healthcare-related litigation has focused primarily on the enforcement of
the right to health as a facet of the right to life under Article 21 of the constitution. According to
an empirical analysis of right-to-health cases at the Supreme Court and the high courts up to
2006 (Shankar and Mehta 2008: 146, 153), 44 per cent concerned regulatory issues. A subject-
wise analysis of the cases revealed that 23 per cent dealt with medical malpractice and hospital
management, with more than half the cases on medical negligence being brought against
government hospitals and doctors (Shankar and Mehta 2008: 156). The question of corruption
does not appear to have been explicitly addressed in the exercise of the courts’ writ jurisdiction;
however, the high proportion of regulatory issues litigated suggests, at the very least, that there
are weaknesses in existing systems and structures of oversight for doctors and hospitals.
We attempted to pinpoint specific areas of healthcare corruption that have been brought
before the courts through a targeted search of Supreme Court cases.10 It is not our aim to
exhaustively catalogue healthcare corruption cases in this chapter; we only hope to provide a
snapshot of the kind of issues that are litigated through a representative sample. Of the nearly
500 cases that the search threw up, only a little over 50 were specifically related to corruption in
the healthcare sector. An overwhelming majority of these cases dealt with the Prevention of
Corruption Act, 1988. Examples include bribes to escape drug inspections, demands of illegal
gratification for providing treatment, falsification of medical records at community health
centres, private practice by government doctors, nepotism in appointments to posts in the public-
health service, corruption in the supply of medicines under the National Rural Health Mission,
and allegations of personal corruption against ministers of public health.
The predominance of government-related health corruption cases before the Supreme Court is
unsurprising given that the applicability of the Prevention of Corruption Act is limited to the
public sector. Until the government moves forward with its plans to criminalize bribery in the
private sector,11 state medical councils and the MCI are the only authorities that can take any
action against this sector, and even then, such action is restricted to disciplinary proceedings
against private medical practitioners. The only other legislation under which the actions of
private actors in the delivery of healthcare goods and services can be subjected to scrutiny is the
Consumer Protection Act, 1986. Even so, corrupt practices by private hospitals and
pharmaceutical companies remain largely immune to judicial proceedings, since bribery and
fraud cannot be investigated under this Act.12 The absence of case law on corruption within the
private health sector does not necessarily mean that it has higher standards of probity; it only
points the absence of a legal and regulatory framework to bring the sector to account.
However, the one area where courts regularly deal with corruption in the private sector, either
directly or indirectly, is that of admission to, and the management of private medical colleges.
Extraordinary admission charges, unclear admission criteria, a large ‘management quota’, and
the prevalence of ‘paid seats’ are some examples of corrupt practices in medical education
(D’Silva 2015) that have also come up before the courts. The MCI, which grants permission for
the establishment of new colleges, new courses of study or increases in admission capacity,13
also features prominently in such cases. Courts frequently deal with cases where medical
colleges have attempted to bribe MCI inspectors to receive favourable recommendations.14 (It is
interesting to note that there is a significantly higher proportion of cases of this kind after 2010,15
which is when the government dismissed the MCI and replaced it with a board of governors.)
Some of the observations made by courts in these cases are useful while thinking of regulatory
reform for the MCI. These include observations on the concurrent exercise of disciplinary
powers by the MCI and state medical councils,16 the incentivization of corruption because of the
system of inspections under the Indian Medical Council Act,17 and the need for regulations that
place more emphasis on the quality of medical education rather than on infrastructure and human
resources.18
It is difficult to draw general conclusions from this overview of healthcare corruption cases.
However, they do supplement other existing evidence of corruption in the public health system
and private medical education, strengthening the case for regulatory reform, especially within the
MCI. Such reform must meet certain constitutional parameters. In the next part, the judicial
interpretation of these parameters in the context of reforms to admissions to private medical
colleges is discussed as a case study with a view to assessing in the final part what legal reform
in this sector might look like.

Corruption in Medical Entrance: The NEET Saga

The reaction of the state to corrupt admission practices in the private sector has been blunt:
instituting a National Eligibility cum Entrance Test (NEET) for admission to all undergraduate
and postgraduate medical colleges followed by centralized counselling.19 This stripped private
colleges, including those run by minority groups, of the autonomy to admit students of their
choice. Unsurprisingly, matters reached the Supreme Court for an authoritative determination of
whether the order instituting NEET violated the freedom of trade and occupation of private
institutions,20 particularly the right of minority institutions to establish and administer
educational institutions of their choice.21
This part analyses the judgements of the Supreme Court—first holding NEET
unconstitutional, and then uncharacteristically reversing itself—as a matter of constitutional law
and policy. In terms of constitutional law, we argue that the Supreme Court was correct in
holding NEET unconstitutional qua minority medical colleges; for other private colleges, a
nuanced balance needed to be struck. In either case, the current law—that NEET is wholly
constitutional—we argue, is contrary to the fundamental rights in the constitution. Second, as a
matter of policy, NEET presents two vexed questions—first, whether private medical colleges
should be held to the same standards of accountability as government colleges. This is a
principled issue, not unique to medical colleges, but traversing a range of activities earlier
monopolized by the state where the private sector is now a critical player. Second, the acceptance
of NEET amounts to an implicit assumption that the state is more trusted to conduct fair and
transparent admissions than private colleges. The reality, as recent scandals in state-run public
examinations has shown, is considerably more complex.

NEET in the Supreme Court—A Fact File

Two notifications each were passed by the MCI and the Dental Council of India (DCI),
instituting a NEET for undergraduate and postgraduate medical and dental colleges.22 The
notifications were challenged for being beyond the powers of the respective councils and
violating the fundamental rights of aided and unaided, minority and non-minority private
professional medical colleges. On 18 July 2013, the Supreme Court, by majority, held the
notifications unconstitutional. The rationale for its judgement was that both, the text of the
constitution and precedents interpreting such text had held the power to admit students as
integral to the power to administer an institution.23 For minority institutions, the constitution is
categorical that minorities can establish and administer educational institutions ‘of their choice’
and NEET takes away such choice entirely. For non-minority institutions, it interpreted
precedents to mean that the state could lay down norms of admission only when it was found that
existing admissions methods are unfair, non-transparent, and exploitative. This was in keeping
with the constitutional position that the power to lay down educational standards did not
encompass the power to regulate admissions.
The dissenting judge held NEET to be constitutional on the basic premise that the power to
administer does not include the power to maladminister. Thus, the state could require all medical
college aspirants to take NEET; this did not affect the autonomy of the institution per se when it
came to selecting students from the pool of those on the merit list of NEET. Further, regulating
standards encompasses regulating intake, syllabus, and examinations and thus cannot be held to
exclude admission norms entirely.24
On 11 April 2016, the aforesaid order was recalled by the court in a review petition.25 It was
unusual as no reasons were provided except the summary statement that precedent had not been
considered and judgements had not been circulated prior to pronouncement, as is the usual
practice. In three subsequent applications before the court to reinstate private admission
processes, it was held that pursuant to the recall order, the NEET notifications were reactivated
and thus admission to medical colleges could only take place through NEET.26 After the recall
order, another judgement was handed down by a constitution bench in Modern Dental College v.
State of Madhya Pradesh.27 In this case, the Supreme Court unanimously held that a common
entrance test followed by central counseling is a reasonable restriction on the freedom of
occupation. In fact, such a policy of admission was held both rational and necessary to secure
meritorious students. This was quoted with approval in subsequent applications, holding NEET
combined with centralized counselling to be an analogous restriction.28 Though confusion
prevailed initially over when NEET would be effective, as a matter of constitutional law,29 it has
now been settled by the Supreme Court that NEET is a valid method for admitting students to
medical colleges.
A Flawed Constitutional Position
The practical merits of NEET curbing wanton corruption by private medical colleges is a distinct
issue from its constitutional validity. In order to assess the latter, it is necessary to understand the
scope of the rights enjoyed by private medical colleges, minority and non-minority, the extent to
which NEET places a restriction on such rights, and whether such a restriction is reasonable and
proportional.30 At the same time, it is critical to distinguish minority institutions from others—
the Supreme Court has consistently held that rights of minorities to admit students is an integral
component of their right establish and administer educational institutions of their choice.31
Set out in this way, the two rights in question are the freedom of private medical colleges to
establish and operate their institutions under Article 19(1)(g) of the constitution32 and of private
minority medical colleges to establish and administer educational institutions of their choice
under Article 30(1).33 The former right can only be curtailed by a reasonable restriction in the
interests of the general public; the latter is textually non-derogable, though the court has held that
‘regulatory measures’ to maintain educational standards may be taken.34 However, such
measures cannot substantially curb the constitutionally sanctioned autonomy of administration of
such institutions.
Let us consider the two rights in question independently. For minority institutions, as the
court in CMC Vellore held, setting up of NEET as the sole method for admitting students in such
institutions is clearly overbroad. The minority character of the institution, a critical component of
which is the freedom to admit a majority of students from the same community, would be
grievously affected. If NEET is the sole method, then it is clearly unconstitutional. To this extent,
the majority judgement in NEET is correct.
The reasoning in the dissenting judgement that carries through to the recall order and the
subsequent judgement of the Supreme Court in Modern Dental prioritizes the need for merit over
other considerations. Without entering into a debate on what merit might mean (Deshpande
2006), as a standalone principle, this is an unarguable proposition. However when the
constitution clearly contains protections for retaining the minority character of the institution,
any freestanding need for merit must be secured, taking such considerations fully into account.
Otherwise, merit can easily elide into majoritarianism. This is precisely the effect when NEET
combined with central counselling is mandated for all medical admissions. Its desirability
notwithstanding, the constitutional validity is severely doubtful for being an overbroad
infringement of the freedom of minority educational institutions.
For private institutions, the position of law has been rendered unnecessarily complex by the
judgement of the Supreme Court in TMA Pai Foundation and others v. State of Karnataka and
others.35 In TMA Pai, there is warrant for two internally inconsistent propositions. First, that the
state shall interfere in private admissions only when the processes followed by private colleges
are not rational, fair, transparent, and to ensure merit.36 At the same time, the state can take
regulatory measures to ensure academic standards that may extend to admissions.37 Further
complexity is added by the fact that certain private institutions are state-aided. This provides a
greater degree of legitimacy for state intervention.
It is precisely for these complex balancing acts that the doctrine of proportionality is pressed
into service. Unfortunately, in the NEET dissenting judgement, there is little in the nature of
proportionality analysis.38 The need for merit and academic standards appears like a trump card
serving ipso facto as a reasonable restriction in the interest of the general public. Is NEET
narrowly tailored to ensure that the autonomy of such institutions is protected? Is centralized
counselling also mandatory or can NEET serve as a screening test allowing private medical
colleges to select from within such a pool of qualified candidates on the basis of transparent
criteria? Is NEET, which is undoubtedly a restriction on the freedom of occupation, necessary for
merit-based admissions? The dissent, as well as Modern Dental, assert that it is, though it is hard
to see why the converse is not equally true.

Wider Questions of Policy

Underlying the judgement is an unmistakable assumption of the state’s probity and capability in
conducting entrance examinations in contradistinction to private medical colleges. It would be
naïve to assume that determinations of such complex legal questions would be unaffected by the
reality of private medical college admissions. That such processes have been unfair and opaque
is widely accepted. However, it is curious that it was not on the evidence of such processes that
NEET was upheld. On the contrary, a hierarchical privileging of merit over autonomy underlies
the foundation of NEET. This amounts to taking a narrow and incomplete view on the policy
questions at stake.
An analogy would be appropriate. In J.P. Unnikrishnan and others v. State of Andhra
Pradesh and others,39 the Supreme Court held that 50 per cent of the seats in private colleges
would be filled through an entrance test; the remaining 50 per cent could be filled by the
respective college on commercial considerations. The intention was to ensure a balance, thereby
facilitating those who could not afford such education a fair chance at admission through the
entrance test. Evidence, however, demonstrated that most affluent students garnered a bulk of the
exam-based seats given their school education and consequent head start. Such students were
being subsidized by those who paid the full fee, often of lesser means.40
With NEET, the policy question that must be asked is whether an examination that is
conducted by the Central Board for Secondary Education (CBSE) itself is rational, fair, and fit
for purpose. This question cannot be seen in abstraction—it is plausible that the only reason such
a function was vested in the CBSE was because the MCI, the standard-setter in medical
education is widely considered to be corrupt. Whether, however, that justifies vesting the power
to conduct a medical entrance examination to a board that grants school recognition is an open
question. It is critical that if an appropriate policy is to be made on medical entrance
examinations, the question is considered holistically and not decided on the basis of an
intuitively appealing solution.
At the same time, the approach adopted by the Supreme Court obliterates significantly, the
distinction between private and public institutions. It is widely recognized that private
institutions such as medical colleges, schools, and hospitals have certain obligations owing to
them performing public functions. However, it is critical to recognize that such obligations
cannot be shorthand for making private institutions state-like—mandating reservations,
restricting autonomy in admission, dictating hiring policies, and overseeing administration. If the
state accepts the functions performed by private institutions as ‘public’, it must be respectful of
the autonomy enjoyed by such institutions in such functioning. Alternatively, it must strive to
build state institutions that make such private institutions redundant. In the absence of either, for
the state to simply take over core administrative functions of private institutions as if it were its
own, blurs the distinction between private and public law. Space precludes a full discussion of
the issue but it would suffice to say that private remedies must exist for private institutions that
are errant in their admissions. While NEET may address such an issue, in the blunt form that it
currently exists, it is plausibly unconstitutional.
One of the ways in which oversight over private institutions may be strengthened is by
reforming the MCI, which has so far proved ineffective at regulation, as the first part of this
chapter demonstrated. The next part discusses some of the reform measures that have been
recommended for the MCI in the wider context of the regulatory reform that is required to tackle
healthcare corruption in general.

Legislative Reform Measures

MCI Reform Proposals
Reform proposals for the MCI have been primarily concerned with striking the right balance
between autonomy and accountability. They have also had to consider the degree of control that
ought to be vested in state governments and state medical councils. Varying responses to these
concerns are reflected in the different reform proposals that have been made so far. The first of
these proposals, the National Commission for Human Resources for Health (NCHRH) Bill,
2011, set the tone for the proposals that followed—the 2015 report of the Group of Experts
headed by the late Professor Ranjit Roy Chaudhury, the recommendations in the 92nd report of
the Parliamentary Standing Committee on Health and Family Welfare, and most recently, the
draft National Medical Commission Bill, 2016, proposed by the Niti Aayog.
The NCHRH Bill proposed the following major changes: an overarching body to regulate not
only medical, but all other health professionals; the nomination of independent experts over
elections as the preferred mode of constituting regulatory bodies; the creation of specialized
autonomous bodies to perform the different functions of the MCI; and vesting the final authority
to grant permission for the establishment of medical colleges in the regulatory authority created
under the Bill, rather than in the central government.41 The ambitious proposal to create a
uniform regulatory structure for all health professionals has since been dropped, but most of the
other changes have been retained with some modifications in subsequent proposals.
One of the major objections levelled against the NCHRH Bill by the 60th report of the
Parliamentary Standing Committee on Health and Family Welfare was the lack of participation
by state governments in the constitution of regulatory authorities. Under the existing Indian
Medical Council Act, one member from each state is to be nominated to the council by the
central government in consultation with state governments.42 One member from each state that
maintains a state medical register is also to be elected by practitioners enrolled on such a register.
Since these state elections were proving to be a major source of corruption, the NCHRH Bill did
away with them altogether, but also eliminated representation from state governments in the
process. This has been remedied to a certain extent under the Niti Aayog’s draft Bill, which
creates a Medical Advisory Council comprising vice chancellors from health universities or
professors from medical institutions. However, there are other ways in which states could play a
more active role. One of these is by requiring regulatory authorities to consult with state
governments about their healthcare needs before granting permission to set up new medical
colleges. The second is by strengthening the role of state medical councils.
It is not just the MCI that has proved inadequate to the task of tackling corruption; state
medical councils have also failed at regulation. Both the centre and the states can legislate on the
medical profession,43 and there are different state laws setting up state medical councils,
although there are also states that do not have such councils. Some of these laws date back to the
pre-independence era and need updating. The composition, powers, and functions of different
councils and their procedures for disciplinary action also vary across different states. State
regulatory bodies are therefore as much in need of reform as the MCI. The draft National
Medical Commission Bill takes limited steps in this direction by requiring those states without a
council to enact a law to that effect and by giving the Board of Medical Registration (a body
under the National Medical Commission in charge of licensing and disciplinary functions)
appellate jurisdiction over state medical councils. However, just like the MCI, the process of
constituting state councils also needs reform. The National Medical Commission will comprise
experts across the fields of medicine, law, economics, and management to be appointed by a
search and selection committee through a transparent process. Similar reforms should also be
encouraged within state medical councils by framing a model law for adoption by states.

Lessons for Wider Healthcare Reform

The changes proposed to the MCI are steps in the right direction for overhauling the regulation
of medical education and the medical profession. To demonstrate its commitment to reform, the
government must pilot these changes through the parliament soon, taking care to consult with
state governments through the process. However, to address the broader problem of healthcare
corruption, two critical legislative changes are needed.
First, the 92nd Parliamentary Standing Committee Report recommended that the new Board
of Medical Ethics (proposed as part of the restructured MCI) develop standards of professional
conduct, not only for individual doctors, but also for institutions of health-service delivery like
hospitals, clinics, and nursing homes. While recognizing the need for such codes of conduct, we
do not think that the MCI, in whatever form it takes, is the appropriate standard-setting body for
clinical establishments. The impulse to create stronger institutions must not lead to all-powerful,
unwieldy superstructures. Standards for healthcare establishments may be framed under the
Clinical Establishments (Registration and Regulation) Act, 2010. Instead of transferring this
function to the MCI, regulatory institutions under this Act should be suitably strengthened, and
incentives ought to be created to encourage other states to adopt this law.
Second, creating uniform standards across states is one of the biggest challenges to healthcare
regulation, given that public health and hospitals are subjects that fall within the exclusive
legislative competence of state governments.44 The answer to this does not necessarily lie in
centralization, whether through the creation of a national regulator or a constitutional amendment
giving power to the central government to legislate on health.45 Existing state-level institutions
that have the capacity to be more responsive to local needs can also be made more robust. The
proposed revamping of the Drugs and Cosmetics Act offers an opportunity to adopt this
approach. While attention should certainly be devoted to revamping the regulatory architecture
of the CDSCO, this should proceed side by side with the strengthening of state licensing
authorities. This is especially since there is nothing to suggest that the CDSCO has demonstrated
greater integrity or effectiveness than its state counterparts.
On the whole, courts in India have laid the groundwork for healthcare reform. They have
defined the contours of the constitutional right to carry on a profession, demarcated the
relationship between central and state regulatory authorities, and set standards—fair, transparent,
and non-exploitative—for regulatory processes.
However, there is a limit to the reform, both substantive and systemic, that ad hoc judicial
interventions can achieve. Systemic reform of polycentric issues in terms of narrow legal
questions may not, despite good intentions, lead to desired results. It is time for the parliament to
take forward the urgent task of regulatory reform, guided by these judicial principles and through
a participatory, consultative process.

References
Berger, David, 2014, ‘Corruption Ruins the Doctor–Patient Relationship in India’, BMJ, 348:
g3169.
D’Silva, Jeetha, 2015, ‘India’s Private Medical Colleges and Capitation Fees’, BMJ, 350: h106.
Debroy, Bibek, 2015, ‘Art of the State’, The Indian Express, 21 May, available at
http://indianexpress.com/article/opinion/columns/art-of-the-state-2/, accessed on 19 January
2017.
Deshpande, Satish, 2006, ‘Exclusive Inequalities: Merit, Caste and Discrimination in Indian
Higher Education Today’, Economic & Political Weekly, 41(24).
Eban, Katherine, 2013, ‘Dirty Medicine’, Fortune, available at
http://fortune.com/2013/05/15/dirty-medicine/, accessed 16 January 2017.
Jain, Anita, Samiran Nundy, and Kamran Abbasi, 2014, ‘Corruption: Medicine’s Dirty Open
Secret’, BMJ, 348: g4184.
Sankaranarayan, Gopal. 2013. ‘Into the Darkness’, Bar and Bench, 18 July, available at
http://barandbench.com/darkness/, accessed on 20 January 2017.
Shankar, Shylashri and Pratap Bhanu Mehta, 2008, ‘Courts and Socioeconomic Rights in India’,
in Varun Gauri and David Brinks (eds), 2008, Courting Social Justice, Cambridge University
Press.
 IV

WE ARE NOT ALONE

 CHAPTER TWENTY ONE
Global Medical Corruption
It Is Time for Individuals to Act Where Institutions have Failed
David Berger

In 2012–13, I spent a short period volunteering as a doctor in a small, non-governmental,

community hospital in the Indian Himalayan region. I published an opinion piece in the British
Medical Journal (BMJ) shortly thereafter, outlining the connection I saw between rampant
medical corruption and an obvious erosion of trust between patients and doctors in India.1 What
followed surprised me. Far from being criticized as an arrogant, patronizing foreigner, which
would have been understandable, the article served to ignite a simmering discontent that, for
whatever reason, had not hitherto found a popular voice in India. My piece was greeted warmly
and received widespread coverage in the Indian press, by sting investigations on corrupt
practitioners, and by calls for reform from many sources, up to and including the health minister
of the time.
Not unnaturally, the noise generated by all this set me to thinking and looking more critically
at corruption in the healthcare economies I have worked in, most notably those of the UK and
Australia and one of which I am a close observer, that of the US. It is too easy, and all too
frequent, for a foreigner to tut tut and shake his head when faced with evidence of corruption in
the Indian subcontinent: ‘Shocking! These people need to behave with more integrity. More like
us, in fact.’ To take such an attitude, however, is not only fatiguing and patronizing to the
millions of Indians whose lives are blighted by corruption at all levels, but is, at best,
disingenuous to the point of irresponsibility. Not only have the conditions for corruption in the
subcontinent partially been set by Western intervention—the promotion by USAID (United
States Agency for International Development) of a US-style private healthcare model in India
being the prime example in this context—but the West often proves itself no slouch when it
comes to setting standards for corruption and profiteering.
The foundations of Western medical ethics date back to the Hippocratic physicians of the fifth
century BC and find expression in various forms today, most notably in the Declaration of
Geneva, first formulated by the World Medical Association in 1948. One clause reads: ‘The
health of my patient will be my first consideration;’2
Such a simple statement, so self-evident, so fundamental to the ethical practice of medicine,
and yet in India and elsewhere around the world, the health of the patient is often not the first
consideration of the physician. In Australia, often held up as a paragon of developed healthcare
systems, there is solid evidence that a significant rise in the rate of caesarean sections and other
obstetric interventions followed a rise in the prevalence of private health insurance, caused by a
change in government policy. This was despite good evidence of such high rates of caesarean
section being detrimental to maternal and child health.3 As a medical practitioner in Australia, I
hear tales of grossly inflated rental payments from pathology providers to co-locate their services
in doctors’ practices. Are these a manifestation of the free market or are they corrupt inducement
payments by another name?
In the United States and elsewhere, the fee-for-service model has long been recognized as
entrenching perverse incentives for the physician, for whom the patient is both, patient and profit
centre, an irreconcilable conflict which leads almost inevitably to ‘too much medicine’, a malady
which can be as bad as too little.4 One solution, trialled in UK primary care in the 2000s, has
been a value-based reimbursement system, paying general practitioners (GPs) for their
performance across a range of metrics, such as rate of hitting the blood pressure targets for their
patient population. The US government healthcare payer, Medicare, is following suit, but
physicians are rebelling and for understandable reasons.5 As a former UK GP with experience of
one of the world’s first and most extensive value-based payment systems, it is clear to me that
such a system does not abolish the problem of perverse incentives to patient care, which is
inherent in a fee-for-service reimbursement system; it simply substitutes one set for another.
Instead of being a profit centre, a patient is a collection of data points which must be manipulated
and squeezed to best fit the required dataset, and hang their unique needs or wishes. Need to get
your cholesterol dataset down to the required targets? Easy: send letters to your over-90-year-
olds asking whether they want to come in and discuss taking a statin, despite major question
marks over the utility of such a therapy in such an advanced age group. Value-based
reimbursement systems will always be bedevilled by the question, ‘Whose value?’ and the
answer, as in a fee-for-service system, can never unambiguously be, ‘The patient’s’.
Nevertheless, one must applaud the sentiment behind it, for we should seek to enhance value in
healthcare delivery, albeit always remaining alive to the question: ‘Just whose value is being
enhanced here?’
But it’s not just concerns, sometimes arguable, over whose interest is really being served by a
physician’s actions: blatant healthcare fraud is a huge problem in the developed world and far
from the exclusive preserve of developing countries. In the US, healthcare fraud has been called
‘The $272 billion swindle’, a running financial and ethical sore on the face of medicine.6
And then we come to the pharmaceutical industry. At the time of writing, Mylan
pharmaceuticals in the US has pushed its price for epipens, a life-saving injectable for
individuals with anaphylaxis in which the active ingredient costs a few cents, to over USD 600
for two units, a 600 per cent rise in 10 years. This is nearly eight times the cost of a private
prescription for this product in Australia or nearly 20 times the cost of a prescription for it to
most Australian citizens under the Australian government’s Medicare system. Under this system,
the government negotiates drug prices with the pharmaceutical companies, something the US
government (unique among developed nations) does not do. Most people would quite reasonably
view this as naked profiteering, shading into outright corruption when it means increasing the
number of vulnerable people who will have to go without this life-saving product in order to
boost already fat shareholder returns and corporate salaries. In 2016, the chairman of Mylan,
Robert Coury, received USD 97 million in compensation.7
Drug prices in the US, where the government does not negotiate and regulate drug prices, are
many times those of its neighbour Canada, which does. Moreover, with legislation to make the
purchase of medicines from Canada illegal, this difference is further entrenched, at the expense
of a vulnerable patient population, many of whom either cannot afford insurance or for whom
coverage of prescription drugs by their insurance is limited at best.8,9,10
Compounding our loss of innocence, we must now turn to research, once an enterprise beyond
reproach, doubt, and suspicion in the public mind; a noble, selfless calling undertaken by
scientists and doctors in white coats for the good of all humanity. Not so fast. There is evidence
to suggest an increasing rate of retractions due to fraud.11 A study published in the BMJ in
October 2016 found that 80 per cent of China’s clinical trial data are likely fraudulent.12 A study
published in Anaesthesia in May 2017 looked at correlations with statistical outliers in retracted
papers and concluded that many non-retracted papers probably contain errors or frankly
fraudulent data.13,14
If we consider medicine as just another human enterprise and we set aside—for a moment—
the hubris that bedevils us as doctors, then it shouldn’t be a surprise that it has its fair share of
endemic corruption, sharp characters, and outright fraudsters to accompany the many laudable
practitioners we usually like to think of as representing our profession. It is also evident that
there are many shades of corruption, from outright fraud to practices that make us a little
uncomfortable that the patient’s best interests may not be being served. Whichever way you look
in medicine, whether in the developed nations or in the developing ones, you see conflict of
interest of some degree, taking us back to the clause in the Declaration of Geneva quoted earlier.
The remedy to corruption in medicine, then, is conceptually simple and embodied in that
clause crafted by the World Medical Association (WMA) and harking back to the time of
Hippocrates: ensure that all medical practitioners make the health of their patient their first
consideration. Yet, it appears remarkably hard to ensure even loose adherence to this dictum,
including at the highest levels of the profession from which leadership on this matter ought
surely to stem. In October 2016, that same WMA, that same organization which tasks itself with
upholding global standards of medical ethics, appointed as its president Ketan Desai, a former
head of the Indian Medical Association and the Medical Council of India (MCI), but also a
disbarred urologist facing charges of corruption in relation to the licensing of medical schools in
his native India. This appointment proceeded despite a global outcry over many years since the
WMA first attempted to appoint him in 2010, and clear and repeated indications to the WMA of
the question marks over their president-elect.15 This outcry continued subsequent to his
appointment and yet no statement or action on the matter was forthcoming from the WMA at
their council meeting in Zambia six months later in April 2017, a meeting attended by leading
medical ethicists from all round the world. Business as usual continued at a five-star resort on the
Zambezi River with self-laudatory press releases issued for the benefit of the domestic audiences
of attending national medical associations, accompanied by photographs of the world’s medical
leaders sharing a platform with the WMA president, a man, let us repeat once more, facing
serious charges of corruption. Honest medical practitioners and the global patient public may
draw a spectrum of conclusions from this egregious state of affairs: either the WMA is an
ineffectual member organization that is incapable of taking a stand on the most fundamental of
medical moral questions and of projecting an image of medical probity beyond reproach, or that
it is itself corrupt, or that it occupies a position somewhere between these two extremes.
Nowhere on this spectrum of positions represents an edifying location for the WMA to find itself
and if we accept that the WMA is representative, through its constituency of national medical
associations, of the global profession we are left with the inevitable conclusion that either the
organization suffers from an odd ethical blind spot, or else a deep moral malaise lies at the heart
of the profession.
Healthcare corruption in all its forms, even down to apparently occult conflict of interest,
represents one of the greatest threats to the healthcare of billions of people around the world,
sapping resource from where it is most needed. Often unrecognized or ignored, it exists to a
greater or lesser degree in all healthcare economies and, unlike the case with finding a cure for
an infectious disease or a cancer, there are no heroes in the fight against healthcare corruption.
No one becomes famous or heaped with honours by the profession for battling and rooting out
corruption and conflict of interest, a fact that should come as no surprise when we reflect that
corruption and its attendant vested interests have infiltrated the highest reaches of the profession.
The medical profession has traded on a brand of trustworthiness and selfless devotion to the
common good for over two thousand years, but that brand is looking tarnished as the new
information age shines a bright spotlight on corrupt practices in this industry, as it has done in
other spheres of life. The new communications technologies also allow ordinary people—
patients and medical practitioners—to fight back. If the global institutions of medicine are not
just ineffectual, but a large part of the problem, then the only alternative is for individual, honest
practitioners to band together to fight corruption, educate medical students and junior doctors in
ethical ways of acting, and to stand for probity and the highest values of our profession. We must
accept and proclaim that our medical system, not just in India but around the world, is riddled
with corruption and conflicts of interest and we, the doctors, are unfortunately a large part of the
problem. We must stand today against this scourge which has infected so many of our
colleagues, our institutions, and our healthcare economies. We must protest, write, educate, and,
above all, lead by example and make the welfare of our patients our first concern. Together, with
the aid of modern communications, we can and must create a grass-roots movement to fill the
moral vacuum sadly left by the luminaries of our profession. Let us work to ensure that honest
medical practitioners will continue to tend the sick and bring succour to the distressed in the
finest and most ancient traditions of our profession, long after the crooks and the swindlers have
been rooted out and consigned to the prisons, the shame, and the obscurity they deserve.
 CHAPTER TWENTY TWO
Bangladesh: Great Mysteries in Global Health Masked in Corruption
Md Khairul Islam, Shehlina Ahmed, and Shishir Moral

In 2013, Nobel Laureate Amartya Sen wrote about Bangladesh in The Lancet: ‘It is important to
understand how a country that was extremely poor a few decades ago and is still very poor, can
make such remarkable accomplishments particularly in the field of health, but also in social
transformation in general’. The appreciative remarks were made in recognition of the fact that
Bangladesh had demonstrated substantive improvement in most health indicators and fared well
in comparison with its neighbouring South Asian countries. Notable improvements were made in
the survival rate of infants and children under five years of age, life expectancy, immunization,
and tuberculosis control. Such remarkable attainments despite low investment in health attracted
the attention of the development pundits ‘as great mysteries in global health’.
While analysing the improvement in health in Bangladesh, Sen commented: ‘The impetus for
the change was linked in many different ways with the politics of liberation that made the issue
of freedom, including the liberation of women, a part of the progressive agenda of what people
wanted and were ready to fight for’. The Lancet series on Bangladesh rightly pointed out that the
main impetus for changes in Bangladesh’s health outcome was the country’s liberation war in
1971. The spirit of collective action and ideas of social justice notable in the politics and social
movement of that time were based on a progressive outlook that, in development, translated into
family planning, women’s empowerment, girls’ education, and so on. The vision of a society run
on good governance and free from corruption, including its health sector, goes in tandem with
the spirit of freedom and independence of Bangladesh. However, corruption started flourishing
immediately after the liberation war, when nine months of military action had left the nation’s
already-poor infrastructure, economy, and intellectual resources in tatters.
The founder of Bangladesh, Bangabandhu Sheikh Mujibur Rahman, in several speeches
between 1972 and 1975, warned against rampant corruption. However, it is difficult to comment
on the impact of such warnings in the absence of any authentic documentation on corruption
during that period. His last public speech seemed to reflect a scenario on corruption in
Bangladesh which is still relevant and pertinent. He said: ‘My peasants are not corrupt. My
labourers are not corrupt. Who takes bribe then? Who carries out black marketing? Who serves
as the foreign agent? Who does money laundering? Who is hoarding/stockpiling? It is us, the 5
per cent of educated people. The bribe-takers and corrupted ones are amongst us, the 5 per cent
educated people. We must change our characters and purify our souls.’

Trends in Corruption
Following Bangabandhu’s death in 1975, military governments held power from 1975 to 1991,
under the pretext of curbing rampant corruption. However, corruption did not reduce over this
time, but rather kept growing, even in the post-1991 democratic regimes. The global Corruption
Perception Index (CPI) published by Transparency International since 2001 shows that
Bangladesh was rated as the most corrupt country of the world for five consecutive years, from
2001 to 2005.

TABLE 22.1 Position of Bangladesh from 2001 to 2015 in Ascending Order

*Counted in the scale of 0–10 from 2001–11; and 0–100 from 2012–15
Source: Transparency International Bangladesh.

Bangladesh’s efforts to curb corruption became visible in 2007 and its rank in the CPI began
improving. The election manifesto of the current ruling party Awami League, prior to the general
election in 2008, categorically mentioned curbing corruption as one of the major agendas and
took a number of measures after coming to power in 2009. However, Bangladesh still remains in
the top 20 countries notorious for corruption worldwide, and significant efforts towards
improving this position are yet to be seen. This is especially striking in contrast to the country’s
admirable position in South Asia in terms of social indicators. For the past three years, the
country has scored far below Nepal, Pakistan, and India in the CPI.
Corruption in Health
Corruption in the health sector of Bangladesh should be viewed in context of the overall and
overwhelming perception about corruption in each and every sphere of life. The National
Household Survey, 2015, by Transparency International Bangladesh (TIB) found that 67.8 per
cent households experienced corruption while accessing social services. Amongst the surveyed
households, 86.1 per cent availed health services, of which 37.5 per cent experienced corruption
in one form or another. Transparency International Bangladesh found that on an average a
household spent Taka 196 informally for accessing health services. Nationally, Taka 57 crore has
been estimated as the drain on households due to corruption in health. Some rough calculations
show the unacceptable estimate that one in five households experiences some forms of
irregularities in accessing healthcare.
The TIB report further indicated that poor households were more likely to suffer from
corruption in the sector compared to upper-income quintiles. The issue, therefore, is not only
about the amount of money being wasted by corruption, but also about the rights of people,
especially the poor, which are compromised through corruption in the health sector.
There are number of frameworks available in the literature to analyse and explain corruption
in a country’s health sector. Through the lens of equity and rights, the corruption in Bangladesh’s
health sector is described as follows:

1. Petty corruption where poor people suffer the most and their dignity and rights get
compromised (for example, healthcare services)
2. Institutionalized corruption where everyone, irrespective of socioeconomic status, is a victim
of corruption (for example, drugs, diagnostics, and devices)
3. Political corruption where a few powerful people make money on a major scale (for example,
procurement of items, human resource management especially in hiring, medical education,
etc.)

Petty Corruption in Healthcare Services

In Bangladesh, people usually perceive corruption as informal payment or bribery. They may not
associate other irregularities such as abuse of power or position as corruption, rather defining the
limits of corruption only within the payment of extra sums of money. However, Transparency
International’s definition of corruption as an abuse of entrusted power for private gain captures
the depth, scope, and real impact of the malaise and is significant, especially in the analysis of
systems. In this context, we would like to highlight that 16.7 per cent of the households that
experienced some form of irregularities or corruption mentioned in the TIB study referred to
earlier, had to pay bribe or informal payment to access health services.
The government has substantially increased supplies of medicines in the public facilities since
2009. Yet, 13.8 per cent of households experienced irregularities related to receiving medicines.
These irregularities include non-availability of the required medicine, not receiving medicines
despite having them in stock, and not distributing the medicine without informal payment.
Private diagnostic centres or clinics were recommended to 6.2 per cent; 4.8 per cent did not find
doctors and other health assistants in their hour of need; and 1.2 per cent experienced a breach of
privacy as medical representatives were present while they were examined as patients.
Limiting our attention to the 16.7 per cent of the households who paid bribes as victims of
corruption misses the pervasive abuse of entrusted power that other unethical practices present.
As is evident from the above findings of the TIB study, these abuses might have resulted in
greater losses when considered as a whole, compared to the amount of money being paid
informally. Without accounting for such experiences of irregularities (time loss, compromise of
dignity, extra cost incurred due to the purchase of medicines from outside, etc.), we risk taking a
reductive view of corruption that undermines the true extent of damage caused to the victims and
the weaknesses of the system. There is a strong case to be made here for expressing such losses
in monetary terms and including them in the expression of corruption.
In 2015, a total of 179 million patient visits took place at the outpatient departments (OPD) of
16,167 public health facilities in Bangladesh; 13,336 community clinics handled more than 100
million visits, while 24 million were handled by the upazila health complexes (government-run
health facilities in rural areas), and 7 million were taken care of by the medical colleges. The
Bangladesh Health Bulletin 2016 reported that the higher institutions had a greater outpatient
load. A medical college hospital, on an average, served more than 1,700 patients daily while an
upazila health complex treated about 200 patients per day.
When it comes to corruption, TIB reports suggest that most of the people experienced
irregularities and corruption in accessing services in the upazila health complexes (38 per cent)
followed by medical college hospitals (35.1 per cent), and finally other institutes like tertiary
hospitals and universities combined (36.8 per cent). In the case of households having to pay
informal payments, medical colleges were the worst offenders (18.9 per cent of households had
to pay bribes), followed closely by upazila health complexes (18.6 per cent).
The 2016 bulletin also mentioned that a total of 5.7 million patients were admitted to public
facilities in Bangladesh, where upazila health complexes had 2.4 million in-patients and medical
colleges had 1.4 million. If we compare these figures to the TIB’s Household Survey result, the
average amount of informal payment was highest in the medical colleges (Taka 283) and lowest
in the community clinics (Taka 31). These figures are to be interpreted in the light of the total
out-patient and in-patient load; for instance, over 100 million patients are being served in
community clinics, which are also facilities that mostly serve the rural poor.
Let us take the example of the country’s busiest and biggest hospital, the Dhaka Medical
College Hospital (DMCH). On an average, DMCH has 3,500 in-patients against an approved bed
strength of 2,600, with a bed occupancy rate of 135 per cent. Around 5,000 out-patient services
are rendered by DMCH, which is about three times higher than the average of a medical college
service figure. About 150 surgeries of different scales of complexity take place in DMCH.
The highest circulated national daily of Bangladesh, the Prothom Alo, published a series of
three investigative reports in early 2016 on the DMCH. The daily reported that medicines from
the hospital had been smuggled out; the taxi and ambulance services were being controlled by
the staff association, including the transportation of dead bodies; and informal payments had to
be made to get discharged from the hospital.
Transparency International Bangladesh’s special report on DMCH (November 2014) also
came up with similar findings. Doctors were absent in some units; some doctors suggested
patients visit their private chambers; medical representatives were present while patients were
being examined; doctors suggested diagnostic tests in specific private centres; the support staff
was not around when required; and, in some cases, medicines and supplies were
misappropriated. Informal payments also had to be given to the support staff in order to get a bed
on the floor; to see a newborn child or for the release of a child; for the use of a trolley; to
expedite blood tests and X-ray investigations; to jump the queue for MRI scans; to insert a
catheter; issue gate passes, etc. The TIB report even gave an account of the rates of each of these
services.
While it is indeed encouraging to note that most of the recipients of public facilities are from
the low-income quintiles, and a testament to the founding spirit of the country that healthcare is
available even at the grass-roots level, the rampant corruption and irregularities in healthcare
service violates the rights of the poor and the vision of a socially just society that drove the
liberation war.
There has not been any systematic study about the root causes of the petty corruption in
healthcare services. Globally, some studies attribute the poor motivation of government
employees to their poor pay scale, which can also be applied in Bangladesh. However, the
Government of Bangladesh has increased the salaries of its employees by more than 100 per
cent, an unprecedented raise. The government and the development partners consistently lobbied
for their salary increase in the expectation that corruption would reduce after the pay rise.
However, we are yet to see the impact of this salary rise in the public sector.

Institutionalized Corruption
Drugs
Bangladesh’s economy has grown at roughly 6 per cent per year since 1996, despite political
instability, poor infrastructure, corruption, insufficient power supplies, slow implementation of
economic reforms, and the 2008–09 global financial crisis and recession. In 2015, the per capita
GDP of Bangladesh at current prices was USD 1,385. Figure 22.1 shows that the per capita
public expenditure on health as a percentage of GDP remained very low (around 1 per cent) and
static over the years, while the per capita health expenditure has been increasing, and currently
stands at around USD 26. As the public expenditure in health has been low, the overall
expenditure has been compensated by out-of-pocket expenditure (OOP). The OOP figure in
health in Bangladesh is one of the highest in the region (63 per cent).
The cost of medicines, accounting for 66 per cent of the OOP, is one of the main sources of
corruption in the health sector. In the private sector, medicines are largely sold by almost
200,000 vendors-cum-informal health providers, the main conduit of retail for a two billion
dollar pharmaceutical industry. The Bangladesh Health Watch report published in 2010 revealed
that poly-pharmacy (prescribing a number of medicines in one prescription) was on the rise. The
use of essential drugs in primary healthcare facilities was decreasing, the use of antibiotics was
increasing and they were the most-prescribed drugs by pharmacies (60 per cent). Indiscriminate
use and incomplete courses were contributing towards a loss of efficiency and growing
resistance to antibiotics in Bangladesh as well.
FIGURE 22.1 Per capita Public Expenditure on Health as a Percentage of GDP (USD)
 Most importantly, anarchy prevails in the pricing of essential drugs. Aggressive and unethical
marketing by more than 20,000 medical representatives and unregulated care provision, coupled
with low citizen awareness, are driving up health expenditure. The National Health Policy 2011
regards the ‘unskilled’ informal providers as the first contact point, but remains silent on their
regulation. Poor quality medicines are mostly being sold through informal providers using
various unfair techniques, violating the codes of pharmaceutical marketing. In other words, the
people of Bangladesh are paying more for medicines than the international market, and poor
people are made to buy poor-quality medicines at disproportionately higher prices.
This is a deep-rooted issue. Physicians are, in a sense, dependent on the medical
representatives for product information. Such product information may contain less cautions,
fewer side effects, fewer contraindications, and more than the approved indications. Alongside,
promotional gifts and costs for inducing doctors to prescribe a specific company’s medicines are
ultimately passed on to and borne by the patients. The scale of the problem is such that gift items
may vary from grocery to foreign tours. According to one doctor, ‘It’s not easy to say what they
don’t offer us’. Most importantly, medical representatives eat into the doctors’ valuable time
which they could have spent attending to the patients who come to public institutions, who are
mostly impoverished. It is interesting to note that although 16 pharmaceutical companies are
listed in the Securities and Exchange Commission and regularly trade in the stock market, their
audit reports never mention any irregularities in following the code of pharmaceutical marketing.
The weak state of drug governance stems from the weak capacity of the Office of the Director
General of Drugs Administration (DGDA). There are only two testing laboratories for testing
around 1,100 generic drugs with almost 24,000 brand names. The membership composition of
different committees of the DGDA can often reflect conflicts of interest, and there is no
transparent criteria for membership selection. Most importantly, the DGDA has failed to
demonstrate the competence required of it as the focal institution for drug governance at critical
times, as is evident from Box 22.1.
The cabinet recently approved the draft of the revised National Drug Policy after a lengthy
review process. The revised policy attempts to address some of the critical issues mentioned
earlier, especially it mandates the sale of antibiotics through a prescription-only process along
with recommendations related to informal providers.

BOX 22.1 28 Children Died after Taking Toxic Paracetamol Syrup: Accused were
Acquitted

On 28 November 2016, seven years after death of at least 28 children reportedly caused by
toxic Paracetamol syrup manufactured by Rid Pharmaceutical, the court acquitted all
accused officials of the company. It should be noted that the then health minister confirmed
presence of toxic ingredients in a batch of Temset syrup produced by Rid Pharma, with
confirmation from the official investigating committee in 2009. Investigations found the
substantially cheaper and toxic diethylene glycol, also used in tanneries and rubber
industry, being used in manufacturing of the Paracetamol syrup instead of propylene glycol.
The court cited a procedural flaw—in collection and processing of evidence—as a key
reason why the prosecution failed to convict. The evidence submitted to court had been
 collected from the ‘Shishu Hospital’ instead of the Rid Pharma factory, making it difficult
to conclusively prove in court that the toxic samples were manufactured by Rid Pharma.
The samples were required to be preserved by four separate entities—the plaintiff, the
defendant’s lawyer, the laboratory, and the court—this particular process was not followed.
The court found negligence and inefficiency of drug administration’s official, also the
plaintiff of the case, for his failure to collect evidence properly. The factory, thankfully, had
been sealed off a few days after the incidences were reported.

Diagnostics and Devices

As per the last report of the National Health Accounts of Bangladesh, 8.64 per cent of the OOP
expenditure on health is spent on diagnostics. It is common knowledge in Bangladesh that
anyone visiting a doctor or even an informal service provider will be advised to undergo a
number of investigations from specific private diagnostic centres. In lieu, the doctor or the
referee will get ‘commission’ as a percentage of the total cost of the diagnostics procedures. The
going rate is 40 per cent as per newspaper reports. Hence, a doctor with a visit fee of Taka 500
may earn an additional Taka 800 by advising diagnostics tests of face value of Taka 2,000. Such
a practice obviously leads to over-prescribing and unnecessary investigations. It is alleged that
laboratories maintain separate books of accounts, meticulously recording the referee of the
investigation and pay the due commission at regular intervals. Patients are therefore overcharged,
with the additional amount being split between doctors and laboratories—a highly unethical and
corrupt practice.
Recently, the immediate past vice chancellor of Bangabandhu Sheikh Mujibur Rahman
Medical University commented that medical expenses of patients can be reduced by 40 per cent
if doctors stop taking commission from diagnostic facilities. This sparked a great hue and cry on
social media, but he is yet to withdraw his comments. A number of newspapers published reports
on the issue while talk shows openly discussed the extent of the problem. However, so far, no
study has been done to review the issue.
A TIB study shows that the price of medical investigations varies widely from laboratory to
laboratory; those with organizational integrity charge less while others charge more. However, it
is difficult to prove that the prices vary because of the added commission of doctors. Similarly,
in absence of any systematic prescription audit, it is difficult to comment on what percentage of
the diagnostics tests were given unnecessarily or could have been avoided—and how much
money patients are wasting each year for paying for the doctors’ ‘commission’.
The issue of medical devices is another open secret; patients have almost no choice but to
surrender to the suggestion of the doctor. Stents, pacemakers, implants, and other medical
devices, of a specific brand and specific sources, are regularly purchased by patients based on the
advice of the doctors. Frequently, the hospital/doctor supplies the device and then charges the
patient. In most cases, the patient does not get any opportunity or time to assess the market and is
compelled to rely blindly on the service provider.
Anyone with reasonable internet skills can compare the paid price of a device with that of
international market after adding the required tax and VAT—and may find the prices to be
several times higher. Usually, the addition of the ‘commission’ and extra profit of the mediating
hospital increase the price of the device. Unlike diagnostics, there is a rare chance of the
necessity of the device being questioned. These hidden charges and ‘commissions’ represent the
very worst of corruption in the health sector, systematically weakening healthcare provision and
exploiting patients and their families at their most vulnerable. We’d like to add a disclaimer note
here, as these cases are taken from newspaper reports and talk shows, where such issues are
being discussed openly. Perhaps agencies like the intelligence wing of the National Board of
Revenue (NBR) or the Anti-Corruption Commission can investigate this and help improve the
situation in favour of the patients.

Political Corruption
Procurement
Procurement of medical equipment is associated with a kind of corruption which is rarer than the
kind of practices discussed so far, but wastes huge sum of taxpayers’ money. Only a few people,
close to the power base of politics and the government, benefit from the process. However, due
to their strong power base and connections to the political elite, the people involved in this
practice enjoy impunity from punishment, with very less likelihood of action being taken against
such individuals. Procurement and hiring of human resources in public sector, permission for
setting up a medical college or increasing their capacity, promotions, transfers, etc. are areas
which offer scope for such corruption.
Procurement is a key area for corruption in the health sector in Bangladesh, possibly because
of the large amount of money involved and the fact that in many cases, it does not attract
attention until such a time that an audit is carried out, or news about it gets published, or an
aggrieved party which failed to secure the business deal lodges a complaint. Corruption in
procurement takes place in almost all the stages of the cycle, starting from planning to the
conclusion of the procurement process, as well as in managing the supply chain. By and large, it
involves collusive practices, false billing, and fraudulent behaviour. The following sections
describe several instances of corruption in procurement.
At the planning stage, a common tendency is to include high-end expensive equipment in the
package despite the lack of any real need for these at health facilities. Such procurements are
usually made as a standalone activity, without ensuring use or necessary maintenance. For
example, while procuring the linear machine for Sheikh Abu Nasr Hospital in Satkhira, Khulna
division, it was well known that there was hardly any specialist doctor (oncologist in this case)
who could lead the use of the machine, nor anyone trained on properly operating and maintaining
it. The expensive machine remained packed and sitting in the premises for more than two years
and was eventually shifted back to Dhaka.
Several tactics are commonly used to ensure that the outcome of the bidding process is as
‘desired’. The favoured supplier may himself submit all three quotations—the minimum
requirement—under three different names, forms, and rates. The decisions of the bid evaluation
committee are commonly influenced by including officials who are likely to ‘cooperate’. These
tactics also contribute to driving up the unit cost compared to the market price, and as a result,
cheaper goods are bought at a higher rate, as was done in the case of procuring and supplying
very poor-quality bicycles for community clinics. There have also been several reports on not
finding the equipment at its planned destination.
Often, musclemen are employed to scare away other potential bidders as well as to intimidate
government officials involved in the procurement process. Such behaviour by a notorious
supplier of a very senior official of the Ministry of Health and Family Welfare (MoHFW) was
reported on many occasions around three years ago. In fact, he was widely known to all.
Unfortunately, with the change of leadership in the ministry, this way of doing business has just
shifted to new hands.
False billing is another common practice, as evidenced by audit reports. Often, the quantity
and rate of items procured are tampered with and overbilled. In case of certain activities of the
MoHFW, where an advance is drawn, accounting for the actual expenditure of the funds is
highly manipulated. This is commonly seen in the case of training, where ghost trainees are
shown with claims of money for their food, transport, and training materials, and false signatures
collected and invoice submitted. In another instance, certain MoHFW officials claimed
remuneration for acting as ‘resource persons’ or against official attendance on several occasions
in different locations at the same time. Such fraudulent behaviour often goes unnoticed or
unreported, as several officials are involved.
Another major area for corruption has been construction, repair, and upgradation of health
facilities and other infrastructure. Estimation of construction costs includes the share of payments
to officials at different levels from the very beginning. Construction is of poor quality and often
does not match the specifications shown in the approved budget. The construction of community
clinics all over the country is a vivid example of such fraud at a significant scale, as the same
clinics, built with NGOs engaging the communities themselves and using the same budget, were
found to have much better construction and with all the necessary facilities.
In an attempt to streamline the procurement and supply chain process, specifications for
commonly procured items, a table of equipment and asset-tracking system, and recently, e-
procurement systems for some of the items have been introduced through initiatives of a few
officials and pressure from donors for reforms. However, much remains to be done to seal the
loopholes. Most importantly, strong political determination and actions against corruption will
need to be demonstrated, especially by the leadership.

Medical Education
The criteria for establishing medical colleges and health-related technical schools are not only
challenging but also unrealistic in the current context. As such, it creates avenues for bribing in
order to surpass the approval system for setting up such institutions. Several studies have shown
that the newly established medical colleges—especially the private ones—do not have the
minimum required number of teachers/faculty members, nor do they meet the criteria on
proportion of hospital beds to students.
There is no standard fee structure for medical colleges in the country. Socially and in terms of
economic security, becoming a doctor is a prized profession, and as such, the demand for
studying medicine is much more than the number of institutions. Therefore, guardians often give
in to the ‘requirements’ and costs of unethical admission practices rather than questioning these.
A study on medical colleges found that the approval for establishing new institutions, both in
the public and private sectors, was largely politically driven. Medical colleges had been set up
without meeting the physical, teaching, clinical, curricular, and extra-curricular standards.
Despite these failings, private medical colleges were able to increase the number of their students
much faster than the public ones.

Human Resources Management

In 2009, the government took a commendable initiative to revitalize the 13,500 community
clinics in the country, one for every 6,000 rural residents, by recruiting a similar number of
‘community healthcare providers’. At about same time, 1,800 health assistants, 3,500 family
welfare assistants, and 6,000 doctors were also recruited throughout the country. As reported in
the media, except the one for the doctors, these hires were all politically influenced, with or
without informal payment that reached all those who matter up the political chain.
A common phenomenon observed is that promotions and postings in favoured locations
swing like a pendulum between the supporters of the two major rival political parties. The wide-
scale transfer and promotion in a number of positions over the last few years, as expected, went
to officials known for their support to the ruling party. Not only that, even if one supported the
ruling party in student life, a better posting in or near major cities rather than distant rural
facilities can be managed. The first medical university named after the Bangabandhu Sheikh
Mujibur Rahman is a classic example of political postings and promotion. A number of court
cases, verdicts, and appeal processes are still ongoing around political allegiance and irregularity
in appointment and promotion.

Positive Deviance and Way Forward

Though the scenarios discussed so far portray a grim picture about the health sector of
Bangladesh, a number of initiatives undertaken in the recent past provide some ray of hope.
In a bid to reduce pilferage of medicines from the public sector into the open market, all the
government-procured medicines now have green and red coloured packaging with a clearly
written warning that it is the government’s property. Since then, the leakage of government-
procured medicines into the open market has reduced remarkably.
The Bangladesh Medical and Dental Council (BMDC) has recently been revitalized by
restructuring the committee and revising the relevant act. Although BMDC has cancelled
registration of only two doctors over the last four decades, the newly formed investigation
committee now has external representation. A recent incident, where some doctors became
victims of medical negligence, led to the lodging of complaints by one section of doctors against
another. As a result, BMDC has started looking into core issues like treatment protocol, medical
records, etc.
We also note with appreciation, the positive effects on corruption in the health sector, of the
current government’s efforts to increasingly digitize its systems as part of executing the Right to
Information Act. The online tracking of logistics for family-planning services has led to timely
procurement, uninterrupted supply, and reporting on their distribution. A 24-hour call centre
managed by the directorate of health services provides necessary health information and advice
to the people and responds to patient complaints as feasible. The HR information system has
made it possible to take management decisions in impressively short time. A pilot intervention
for monitoring the attendance of service providers through smart cards is pending scale-up. Also,
the increasing fairness in terms of student admissions to the various medical colleges and
institutes over the last few years and particularly in 2016 can be partly attributed to increasing
transparency in the process. The full potential for digitization and its impact on corrupt practices
is yet to be seen, but the early signs are promising.
However, the recently approved Drug Policy needs to be implemented with utmost
importance. Following international practices, there is a need to make public the audit findings
on unethical payments made by pharmaceuticals to public limited companies violating codes of
pharmaceutical marketing. Similarly, the diagnostic centres should be guided by a code of
conduct related to integrity and ethics and be amenable to public scrutiny. The role of the Anti-
Corruption Commission, and the research and studies by TIB and other civil society
organizations cannot be overemphasized. The watchdog role of the civil society organizations
working in the health sector is critical.
Though these measures may help improve the petty corruption situation to some extent, the
institutionalized and politically driven corruption in the health sector, especially efforts to defuse
the beneficiaries of political corruption, pose a great challenge. Political leadership is the
ultimate driver of curbing corruption. We call forth the key political parties to recall their
election manifesto and walk the talk.
 CHAPTER TWENTY THREE
Business Corruption of Personalities
The Case of Sri Lanka
Harendra de Silva

When I was a kid of probably around 10 or 12, I was told this story by an older cousin from
south Sri Lanka. A general practitioner (GP) was a family friend of theirs, and according to the
father, any patient suffering from a cough would always ask for an X-ray to be done. He had an
old broken X-ray machine with a fake light and a cloth screen. He would go behind the screen
and slam an open drawer to make noise, making it appear that the machine was at work. He
would then tell the patient to come back in the afternoon for the report. When they did, he would
present an X-ray from some old collection that he had saved, and make his diagnosis. This was
the first instance that I realized that doctors are not always honest.
Then during our medical school days in the 1970s, the director of health services, Professor
K. Rajasuriya, banned private practice for specialist doctors after hours. This was a turning point
in the cycle of corruption. The private hospitals and exclusively private specialists were not well
established at the time. The demand for prioritization of services by well-known practitioners for
rich patients was not possible in crowded government hospitals where these popular doctors
were working, and after the ban, they could not earn the additional money they previously
enjoyed. This led to under-the-table payments, and the famous Ian Wickramanayake, the bribery
commissioner, was responsible to personally lay traps with plain clothes policemen to nab errant
doctors. This resulted in several famous practitioners being arrested and sentenced to jail.
A colleague’s husband related a story about his grandmother. When she was sick and
admitted to the hospital, his father had to keep 50 (Sri Lankan) rupees under the pillow. After
examining the patient, the doctor would lift the pillow and take the money. One day, when the
grandmother expired, the doctor came to speak to the family and commiserate with them, and on
his way out, lifted the pillow, probably out of habit.
When I was a house-man in a medium-sized government hospital in the Kegalle district, one
of the obstetricians had to be paid to do caesarean sections. One day, after I was done with my
ward rounds, I realized that one delivery wasn’t progressing well; the baby had foetal distress
that warranted a section. When I told him this he avoided the issue and said he was leaving the
station for a few hours. I realized the danger to the mother and child. There was a nurse in the
ward who used to tout for him. I told this nurse in passing that if anything happened to the
mother or child, I would go to the newspapers. It worked! Within minutes the obstetrician came
running and did the section quickly and went away.
There was a famous surgeon in the private sector who used to get medical students to assist
him during surgeries for a modest fee. A medical student known to me used to assist him.
According to my friend, after an appendectomy, the surgeon used to take the non-inflamed
appendix in his gloved hand and crush with his fingers, and then take it to where the relatives
were eagerly waiting outside to announce, ‘it just ruptured in my hand as I was removing it!’.
Such was the strategy used by the flamboyant surgeon to promote himself.
Another professor of paediatrics, a GP, and I decided to write a book for the general public. In
the course of a discussion one day, the other professor, who had been a GP early on in his career,
narrated an incident he had witnessed during his practice: He had referred a young boy of 13 or
14 for a hydrocoelectomy to a surgeon. Time went by with no word or visit from the adolescent.
Then one fine day, he came back with the father, this time, to treat another illness. When my
professor colleague enquired as to why they had not visited after the surgery, the ignorant father
replied that the surgeon was so good that he reviewed his son on a monthly basis. But that wasn’t
all. This surgeon used to take the boy’s semen to his hand (after masturbation), and he tested it
by probing it with his finger, and then declare that he was well and fertile! Such are the sexual
predators in medicine! There is no doubt that hundreds of thousands of sexual predators use their
power, dependency, and trust of the patient to sexually exploit children and adults all over the
world.
The Hippocratic Oath or modifications which we all are supposed to abide by may not even
be known to some practitioners, neither are they legally binding. Applicability may also have
changed, for example, ‘…will not give to a woman a pessary to cause abortion …’ in the context
of family planning and legal changes. However, the principles of the Hippocratic Oath are still
very much applicable in today’s context.
There are many factors that contribute to the exploitation:
1. The patients and relatives are often emotionally troubled and may not be rational,
especially when stricken with a severe illness or what parents/patients interpret as ‘severe’. Their
position could be made worse with the doctor’s overemphasis of the gravity of the problem
rather than giving the true picture with reassurance, which is what is needed. This provides a
platform for some doctors to manipulate their patients by giving unnecessary medications,
admission/consultations, or investigations. For example, when a child presents with a febrile
convulsion (fit associated with fever), the parents are agitated by the child’s appearance. In such
situations, many doctors would tell the parents that ‘when the child gets fever s/he is likely to get
fits, and it will lead to brain damage’. Some may even say this when the child has fever but has
never had fits! This causes parents to panic even when the child gets mild fever and come
rushing back to the doctor! The simple truth is that only 3 per cent of children below the age of
five are ever vulnerable to getting fits, it will recur in only 30 per cent, and only a small
percentage of them, especially with prolonged fits, are likely to get any brain damage! A fair
proportion of doctors would opt to go with the fictional explanation rather than stick to facts and
reassure parents.
2. The belief that doctors are infallible. Patients often hero-worship the doctor. Faith may not
be harmful and at times, it is definitely useful, but it could also lead to manipulation. And when
that faith is proved to have been misplaced, it could lead to severe animosity, which could also
have legal consequences for the doctor.
3. Once a patient/parent is desperate (at least in the Asian culture), they are not worried about
expenses. The mode of thinking is: ‘Cost is not an issue, do not question it.’ This frame of mind
will also make them go ‘doctor shopping’, in search of supernatural cures, which could make
them susceptible to falling prey to quacks.
4. A new issue is insurance. Patients are often not bothered when they are insured. In fact,
they may also manipulate the system by getting a non-insured relative in insured person’s name.
Of course, the doctor and administration may be aware. They also try to get doctors to prescribe
other things like milk foods.
A combination of these factors makes the patient and the system vulnerable to exploitation.
This may be more so in purely business-oriented private hospitals that may exploit doctors by
making them exploit patients in turn.
The biggest problem that has arisen more recently is the appearance of large conglomerate
hospitals compared to the small GP practices and private consultation chambers that were
prevalent at one point. These business entrepreneurs have realized that health is a business that
yields big profits. For instance, the organization gets more than 50 per cent of the consultant’s
fees for ‘arrangements’. In medicine, there are no ‘guarantees’. Whether cured or dead, the price
has to be paid. There is hardly any accountability, no balance sheets, and no reasoning out of the
bill! Unlike in an ordinary business where the client needs clarification of every detail, in the
case of hospital bills, there is often no clear breakdown. And very rarely is it challenged. Few
will be bothered to go through complicated legal processes, except perhaps in developed
countries, where suing is an organized business by itself. In other words, there is no independent
monitoring authority to make processes accountable. The cost for a specific surgical procedure
may vary from hospital to hospital, doctor to doctor, or country to country. The same surgical
procedure may cost 10 times more in Singapore than it does in India. So much so, some
international insurance companies do not cover countries that encourage ‘health tourism’. The
same tablet of paracetamol (Panadol/Tylenol/Acetaminophen) is charged 20 times or more than
the street price. The cheaper the drug, the more times the price is multiplied. Often, the drugs are
indented from the outpatient pharmacy at an inflated price. A friend had to get injections
regularly at the outpatient pharmacy. When she bought it from the government pharmaceutical
corporation where it was much cheaper, the hospital refused to administer it unless it was bought
from them saying, ‘it is not possible to ensure effectiveness and or absence of allergic reactions’.
What is also interesting is the investment made in hospitals by Sri Lanka’s richest
entrepreneurs. This is neither secret, nor is it fiction, as the information is available for public
consumption on the website of the Colombo Stock Exchange. One of the biggest and oldest
private hospital’s major shareholder is a business magnate. Recently, more than 25 per cent
shares were bought by one of the richest persons in Sri Lanka who is a stock market
entrepreneur, hotelier, and the owner of one of the largest casinos in Sri Lanka. Another large
private hospital started by a doctor ran into a financial crisis and was salvaged by another big
name in the financial world who also owns a construction company and is an arms dealer.
Another hospital is owned by a construction company while the other, by a multi-sector
conglomerate, including some pharmaceutical companies. Basically, most private hospitals are
owned by the richest in Sri Lanka with wide business interests, other than medicine, which are
purely profit-oriented institutions. What is interesting is that the wealthiest people who earn big,
quick, and easy money in other businesses are attracted by the private health sector.
Not so long ago, I was seeing outpatients in a private hospital, when I noticed the young nurse
aide jotting down notes while the consultation was going on. After the patient left, considering
the confidential nature of a consultation, I wanted to know what she was writing. She confessed
that the management wanted to know whether we (verbally) asked the patients to buy drugs at a
pharmacy outside or referred them to another laboratory for investigation. The same nurse aide
also told me (later confirmed by others) that our prescriptions are photocopied at the pharmacy
and sent to the management to find out whether we prescribe more expensive ‘original’ drugs or
less expensive generics. The private hospital pharmacies that are usually 10–20 per cent more
expensive also may not stock cheaper generics and also substitute them with the more expensive
variants. Obviously the percentage mark-up will give more or less profit! The photocopies also
give more information on expensive, sometimes unnecessary, investigations ordered from the in-
house laboratory or radiology. One of my neurology colleagues confided that when she wrote on
the prescription to do an EEG at another hospital (merely because of quality), the nurse aide who
was a regular asked her not to write on the prescription but to give a separate note, since she
would be ‘discovered’ by the photocopy. If she was not a regular, she would have written on the
note what she is supposed to submit! At the same time there are laboratories that give a
percentage kickback on referrals!
Another interesting phenomenon happens with urine cultures. Normally, a culture yielding
1,000 organisms or less is negative, 10,000 is doubtful, and 1,00,000 is conclusive of an
infection. The payments are for the colony count and if positive, a further sum is charged for the
antibiotic sensitivity test (ABST). In urine infections, the full report (FR) will show pus cells in
significant numbers (pyuria); rarely does an infection occur without a pyuria. Often (more often
in some labs), the culture colony count is given as 10,000 (doubtful) and the second fee is also
taken for the ABST; more often than not, there is no pyuria. They may even give counts of
1,000–10,000. This will spin off a lot of money. If the complying doctor accepts it, he will give
antibiotics for about seven to 10 days, review the patient, repeat cultures, do other unnecessary
investigations such as ultrasounds, earning money for himself, the microbiologist, the hospital,
and other staff. I am sure there are innumerable ways in which people earn dirty money in health.
Many, if not most, private hospitals will also keep a count of the consultant’s admissions to
the ward and more importantly, to the intensive care unit (ICU) or more expensive special units.
My response was to refuse to come for consultations to that hospital. It was after this that they
put me on the indefinite leave list. When patients phoned, they were told that I was on leave and
suggested one of their ‘favourites’.
Consultants are categorized according to what they generate for the hospital. They are then
favoured with clear instructions to the staff, especially when referring patients and other facilities
provided. Some doctors get the ‘message’ and comply while others who don’t face the
consequences. I was told by a paediatrician colleague how she was summoned by the
management and told not to come for consultations, simply because she did not admit her private
patients to the hospital in question but to other hospitals.
The receptionists also have the ability of influencing the patient to divert them to doctors of
their choice. This will not benefit the hospital. One hospital records all calls to check when there
are complaints. One channel receptionist was caught when she requested loans to ‘build her
house’ from consultants who probably gave ‘non-payable’ loans. She would not have been
caught if she restricted it only to a few, but she overdid it by going to many and her priority list
got diluted and doctors complained when the yield was low.
The medical officers in the outpatients’ department (OPD) are often given specific
instructions by the management to admit a particular number of patients, especially those coming
at night, and reprimand them when there are fewer admissions. They are often given an
additional 1,000 rupees for each such admission. I remember when my sister-in-law was treated
for cancer, frequent admissions were needed and the hospital administration, in spite of my wife
and I being doctors, insisted that normal rooms were not vacant, admitting her to the ICU
unnecessarily for a day, till a normal room was vacant. We were, of course, charged accordingly.
A recent story of a dead patient who was brought to a hospital, but was supposedly resuscitated,
ventilated, and treated in the ICU has been doing the rounds, but there is no documented proof of
this.
A few paediatricians were chatting at tea during a clinical exam we were conducting. One
boasted that he gets 20 per cent for all vaccinations from a particular vaccine company. Although
I had heard about it, this was the first time anybody had admitted it! At another doctor’s
gathering, I simply mentioned this, and a GP blurted out, ‘How come 20 per cent? I get only 10!’
I then spoke to two former management personnel who worked for that company and they
agreed that they were the people who introduced it. I then spoke to the management who agreed
to meet me. Three of them came for the meeting, and while entertaining them with ‘plain’
(black) tea and vadai (vada), I confronted them with the issue of bribery. They said it was not a
bribe but an ‘incentive’! Whether it is called a ‘commission’ or ‘incentive’, I explained that a
bribe was a bribe. Whatever the justifications, there was a conflict of interest. When you get a
profit from what you prescribe, you earn more! Hence began a new breed of specialists called
‘vaccinologists’!
My observation was confirmed subsequently with this same company paying billions of
dollars in fines to the US and Chinese governments for corruption. Some of my colleagues say
that their technique of injecting is better than nurses! If so, why don’t the specialists take over
giving injections in the wards (where there is no ‘incentive’)?
However, there are some doctors who do give vaccines, but not to get incentives; they do so
because they want to maintain their practice by gaining the patient’s confidence. Another
negative aspect is the fear psychosis the children develop upon seeing doctors.
On one Saturday night, I got a call from a friend who sounded agitated. His son-in-law had
developed pain in his shoulder after playing golf. He had then been seen by a cardiologist who
did an exercise tolerance test and declared that he has ischaemic heart disease and has advised
him to put a stent the following morning. Although it was not the mandate of a paediatrician like
me, a simple history over the phone revealed that the man was 32 years old, neither diabetic, nor
hypertensive. Regular six-monthly lipid profiles were normal. There was no family history of
diabetes, hypertension, ischaemic heart disease, or premature deaths. I arranged for another
cardiologist and a friend, a British cardiac surgeon, to review him. They found only a muscle
strain and declared that the first exercise tolerance test was normal. Yet another cardiologist
independently found him to be normal. Although many cardiologists are honest, kickbacks for
stents is a known phenomenon all over the world and many medical representatives are known to
roam the corridors of cardiology units with bags. The minister of health recently intervened to
buy stents at a reasonable price! I got a friend in customs to check CIF prices and taxes for
stents. The discrepancy in the market price beyond a reasonable price probably reflects
kickbacks. I suppose many other items that need recommendations from doctors or specialists
such as cataract lenses, surgical items, or medicines are subject to the same phenomenon.
Recently, at a wedding, I met a medical marketing man who I have known for decades.
Having already consumed a few drinks, he was in a rather talkative mood, and spilled the names
of doctors who take as much as 30,000 rupees per prescription for an anti-cancer drug he sells.
He also named many who do not take any bribes and some who don’t prescribe his drugs
because he bribes others! Most of these drugs may be prescribed in government hospitals, where
the government itself procures the drug for the patient. He also mentioned the bribery within the
approval system in the health ministry, starting right from peons who move the file from clerk to
clerk, members of the accounts department, to even doctors! It is no wonder then that these drugs
are so expensive.
On another occasion, I met a doctor at a cocktail party and he mentioned this to me: A relative
was in need of an anti-cancer drug, which was prohibitively expensive. As a doctor, he had
promised to intervene and had gone to the importer to get a discount. He was told by them that
the kickbacks are so high that they hardly have a profit margin in order to compete with other
products!
It would be one in a few thousand doctors who would not take a pen, paperweight, or a
prescription pad given by doctors. We need to arrive at an absolutely perfect world to eliminate
this!
The sponsorship of doctors and their organizations by pharmaceutical companies is another
issue that should be looked into when discussing corrupt practices. I can hardly think of people
who have not received funding. I personally believe that conferences cannot be held without
such funding, unless a UN organization or governments pocket these expenses. However,
considering the rapid development of medical sciences, this would be practically possible. There
are two aspects. The organization of the congress, the venues, the speakers, and the food, etc.
would cost the organizers, while the participants would incur expenses for registration, travel,
lodging, and food, among other things. Some governments, for example, Thailand, wanting to
encourage people to visit the country may give grants but not everything. UN organizations will
also give grants under specific conditions. Delegates would hardly be sponsored by governments
or UN unless they have a specific role. In developed countries, the hospital may reimburse costs
on the CME (continuing medical education) programme. However, there are limits in developing
countries, which may be unheard of elsewhere. The other issue is the earnings of a senior
consultant in a developing country, which maybe around USD 1,500 per month or less, while
even a junior specialist in a developed country would get 10 or more times, which makes it
difficult to attend conferences without sponsorship. This leads to a dilemma in terms of whether
one would be right in calling it corruption. Of course, even if it is not directly linked to a product,
indirect preference may be influenced. World health leaders should work out ways in which this
type of challenge can be addressed.
 CHAPTER TWENTY FOUR
Corruption in the Healthcare System of Pakistan
Shershah Syed

Karachi is the biggest city of Pakistan with a population of more than 20 million, where the
majority of people live in subhuman conditions without basic amenities. They struggle to get
water for daily consumption and spend a lot of time experiencing power breakdowns or ‘load
shedding’. Every day, people from all over Pakistan come to Karachi for treatment of acute and
chronic health conditions. They will find taxi drivers at airports, railway stations, bus addas, and
taxi stands to take them to different private hospitals, nursing homes, famous physicians,
consultant surgeons, and other specialists for treatment and management.
Usually these taxi drivers do not charge any money from these patients. They are paid by
hospital owners or their consultant physicians. Once the patient is under their control, his fate is
decided by the doctors and the hospital. The patient will be shunted back and forth for different
kinds of treatments and investigations. It is possible for a gynaecologist to receive a patient with
a spinal injury, accept the patient initially, and sell him or her to a neurosurgeon who, in turn,
may find that the patient also needs treatment for her chronic renal or liver disease and send her
to a nephrologist and gastroenterologist. For each referral the doctor will receive a commission.
Poor or rich, the patients will have same management. The majority of patients will pay from
their savings or by selling their jewellery, houses, crops, or cattle. It has been reported in the
press that doctors know that sometimes people even sell their children, especially daughters, to
pay the inflated hospital and consultation bills.
It is normal to see a crowd of patients from major government hospitals go to private centres
for basic ultrasound examinations. For example, hundreds of women are referred every day to
these clinics to confirm the well-being of the foetus. For a five-minute procedure they will be
charged about Rs 800 to 1,500 and the referring doctor will receive a commission of Rs 200 to
500 per case. Most of the time the patient doesn’t really need this investigation.
The majority of pathological laboratories, with very few exceptions, will give commissions to
family physicians, consultants, and hospitals in cash or kind. A battery of tests is usually
performed on patients who do not need them at all. As the secretary general of the Pakistan
Medical Association, I was speechless when the chairman of the Southern Gas Company showed
me bills of two private hospitals in which some of their male patients had been charged for
pregnancy tests. It is not unusual for private hospitals to run a string of unnecessary tests,
especially on patients from corporations and multinational companies when the bill is being paid
by their employers.
Investors without any medical background are running centres with MRI and CT scan
facilities. Their agents marketing these facilities on their behalf and convince physicians to send
patients for scans in return for a commission. Usually, these investigations are not required and
have been prescribed just to get commissions from the owners of these centres. This has now
become a frequent practice and is helping doctors to become rich quickly without any
consideration for ethics, morality, or honesty.
The above mentioned are just a few small examples of corruption amongst doctors in the
health system not just in Karachi, but in the entire country. Every big city has a doctors’ market
where they work and compete against each other to make money. These are individual doctors
and hospitals, the majority of whom have no ethics, and neither is there any control or oversight
of their practice. The government, watchdogs, regulatory agencies, civil society, and even the
professional bodies are least bothered about the corruption of physicians and exploitation of
patients. Occasionally, members of the electronic and print media highlight the corruption of the
doctors but they are usually ineffective because there is no method to follow up or investigate the
corruption, or even compensate patients who suffer because of this rotten system.
In a country where corruption has become a normal way of life, so much so that even
educated people defend corrupt members of parliament, the government, and military officers, it
isn’t realistic to expect honesty from doctors. Apart from corruption at the individual and
hospital levels, it is important to analyse the deteriorating conditions in the different areas of our
healthcare system to better understand this phenomenon. Corruption is widespread and it seems
that it is not going to be manageable without revolutionary steps to check it. I have listed below
the bodies and areas where organized corruption in the health system has increased enormously,
causing suffering to patients directly and indirectly.

The Pakistan Medical and Dental Council (PMDC)

The PMDC is a regulatory body established by adopting the 1933 Indian Medical Council Act in
1947. The council was reconstituted under the medical and dental council ordinance in 1962. The
PMDC is supposed to regulate undergraduate and postgraduate medical education and training. It
is a regulatory authority for practitioners and medical students. Unfortunately, the council has
become an institute to destroy medical education for the benefits of crooks and mafia
organizations. Under the last military government in Pakistan, the registrar of the PMDC was
arrested and released after a plea bargain by making a payment of Rs 180 million. He was found
guilty of recognizing sub-standard medical colleges, fake foreign degrees, and ignoring other
irregularities.
After the return of democracy, politicians understood the potential of the PMDC for
corruption and made sure that the body would not work as an independent, autonomous, and
powerful organization. Both major political parties were in agreement to have a loose structure of
the PMDC working under health ministry for the benefit of rich and powerful people. The
political group with their agenda got rid of the new and honest registrar and constituted a new
council with the appointment of another registrar to run the affairs of the PMDC in the interest of
the owners of private medical colleges and vested interest groups in the public sector.
I was an elected member of council from the province of Sindh but was not allowed to attend
the meeting for more than 15 months. It was only after I got a court order that I was allowed to
attend. It was impossible to function in a council with handpicked members who were only
working for the benefit of politicians and unethical businessmen in the medical profession. In
one of the meetings, the council decided to increase the seats of three medical and dental colleges
from 100 to 150 without considering the facilities and requirements of the PMDC. The initiative
was taken just to enable these schools to make more money by giving admission to more medical
students. The council also allowed the opening of a night medical college for private students in
one of the public medical universities. This decision was revoked by the order of the Supreme
Court when the Pakistan Medical Association challenged the decision.
In the last 10 years, the PMDC has recognized many medical and dental colleges against its
own minimal criteria. They have recognized medical colleges without hospitals and faculty
members in both the public and private sectors in complete violation of its own rules and
regulations. It is not surprising, therefore, that now Pakistan has 101 medical schools and 43
dental schools, each of which has at least 100 seats with some having more than 300.
It is very depressing to note that with the exception of the Aga Khan Medical college in
Karachi and the Armed Forces Medical College in Rawalpindi, none of the medical and dental
colleges in the public or private sectors in Pakistan fulfil the minimal criteria of the PMDC.
The PMDC does not want to annoy the government by not recognizing medical colleges in
the public sector because of political and financial reasons. The government is opening new
medical colleges just to please voters and local party bosses. By introducing a scheme of self-
financed seats in public-sector colleges, the local administrators have access to millions of rupees
in funds which are not audited on a regular basis.
The PMDC is also very liberal in recognizing private medical colleges. In 99 per cent of
cases, these medical colleges have been opened just to make money by giving admission to
students who are not able to enter the public- sector medical colleges and are ready to pay huge
amounts of money as fees and donations to get admission and become doctors. The PMDC is not
at all bothered about the standards and quality of education and facilities available in these
colleges and hospitals. As mentioned above, they have allowed even those medical colleges
without enough number of beds in hospital and the required number of faculty members to run a
medical school.
Establishing medical and dental colleges in the private and public sectors is an example of
corruption in the health sector. It is an easy investment to multiply money without going through
the trouble of following different laws. That is the reason why many industrialists and politicians
are investing in this sector and are not worried about the end product and its impact on our health
sector and future.

The Mushrooming of Medical Universities

During the last military dictatorship in Pakistan, a retired general from the medical corps became
the health minister in the provincial government of Sindh. He was a graduate of the Liaqut
Medical College in Hyderabad, which was planning to celebrate its golden jubilee year. The
professors in the college decided to use the influence of the retired general to convert their
medical college to a university by an announcement during one of the celebrations. The charter
was duly given by the military government.
This started a chain reaction to open medical universities, which proved to be a very good
method to make money. Immediately after the announcement of a medical university in Sindh,
the military-supported health minister in Punjab announced the opening of the Punjab University
of Health Sciences with the plea that as a bigger province, the Punjab should have its own
medical university. In the meantime, the Urdu-speaking political forces in Karachi were upset
about the medical university in Hyderabad. They were able to convince the military ruler that
Karachi should have a medical university as well. The Dow Medical College was declared a
university through a single announcement on television. The ambitious professors at the King
Edward Medical College then came out with the idea that if Sindh could have two medical
universities why could Punjab not have another medical university? And suddenly, the King
Edward Medical College was upgraded. The professors at the Khyber Medical College in
Peshawar were following these events and they also came up with a demand and got the desired
university status.
The first democratic government after military rule ended converted the Fatima Jinnah
Medical College into a medical university in the Punjab and the Sindh Medical College in
Karachi, People’s Medical College in Nawabshah, and Chandka Medical College in Larkana also
got the status of medical universities. The Bolan Medical College was also upgraded into a
postgraduate medical centre.
The second democratic government was also convinced about the benefit of medical
universities and they declared the Nishter Medical College at Multan, the Faisalabad Medical
College, and the Rawalpindi Medical College as universities. The federal government opened a
medical university in Islamabad at the Pakistan Institute of Medical Sciences, and also
announced that they would open medical universities in Kashmir, Gilgit, Biltistan, and in the
federally administered areas along the borders of Afghanistan.

Why Medical Universities?

The answer is very simple. With the announcement of a university you receive special funding
from the Higher Education Commission (HEC) whose budget was increased enormously during
the last military government and enough funding is always available for universities. They also
receive funds from their provincial governments. The universities spend billions of rupees on
construction of new buildings to establish new departments. They also purchase new, expensive
instruments for newly formed departments. Everyone is aware that construction and purchasing
are the two areas where corruption is easy and quick.
The other type of organized corruption is in the form of the appointments in new universities.
The provincial governments appoint vice chancellors, pro vice chancellors, registrars, different
kinds of deans in different departments, and project directors for new projects on heavy salaries
and perks. It is not surprising that, with the exception of one or two, none of the vice chancellors
were appointed on merit by a procedure laid down by the Higher Education Council. The
governor or the chief minister of the provinces appoint their own favourites to these posts
because of political or other reasons. None of these are full-time universities. All vice
chancellors and faculty members, with the exception of a few, are involved in private practice
after 2 p.m. How can a vice chancellor or a faculty member run a university and his department
on a part-time basis with such divided interests? This is the reason we are producing poorly
trained specialists with no ethical considerations in their practice.
These medical universities are also involved in other kinds of corruption. For example the
Dow University has opened a Dow International Medical College only for foreign students
without consideration of the PMDC requirements. They are charging enormous fees and making
false claims to attract overseas students.
As mentioned above, another university had opened a night medical college to make money
but this was closed by the orders of the Supreme Court. Many universities have opened
commercially run diagnostic centres supposedly ‘to earn money to run the university’, but they
are not bothered about the patients in the attached tertiary-care hospitals or their standards of
undergraduate medical education and postgraduate training.

Pharmaceutical Industries
A few multinational and most of the local pharmaceutical companies are heavily involved in
bribing doctors to promote their medicines in the market. Besides giving expensive gifts, air
tickets, organizing family parties, and even contributing to the weddings of doctors’ children, the
companies have come with unique ideas for promotion of their drugs. Local companies are
organizing charted flight full of doctors to destinations like Dubai, Istanbul, Tashkent, the
Maldives, or some other exotic places in the name of continuing medical education. They
organize a two- or three-day stay at five-star hotels where a speaker delivers one or two lectures
and they return to the country after the luxury holiday ready to prescribe the medicines made by
their hosts, with or without indications.
In a country where one can buy any medicine over the counter and store keepers can also dole
out drugs after listening to a customer’s symptoms, some pharmaceutical companies are now
targeting these medical stores to sell their drugs. This collaboration between the shopkeepers and
pharma representatives is causing havoc in the community and is largely responsible for the
increase in the number of resistant organisms, morbidity, and unnecessary deaths.

Corruption in the Health Department

The ministries of health in each province are responsible for providing basic and emergency care
to the people of Pakistan. The Punjab and Sindh governments have accepted their failure in
delivering healthcare and controlling corruption by privatizing their health facilities. In the
Khyber Pakhtunkhwa province, the government is trying to run heath centres by banning private
practice of the doctors by increasing their salaries, but are still facing very strong opposition
from healthcare workers, especially doctors.
In the present system, doctors are posted in the basic heath units (BHU), rural health centres
(RHC), taluka headquarters (THQ), and district general hospitals (DGH). There, they work
according to their convenience for a few hours and do private practice for the rest of the time. In
some cases, they do not even come to the health centre and draw their salaries after paying a
small cut to the concerned authorities. This system is very well organized and it is difficult to act
against it.
Surprisingly, these hospitals have state-of-the-art equipment but no personnel. During some of
my surgical camps, I found a very expensive operating microscope in a rural health centre in
Khuploo in Biltistan, a state-of-the-art anaesthesia machine with a ventilator in Mastong,
Baluchistan, and expensive laboratory equipment in Shekhopora, Punjab.
In Karachi, the government has bought four, very expensive robotic surgical operating
systems where the hospitals have no clean water supply and no human resources to operate and
maintain these machines. Just recently, the chief minister of the Punjab announced that the
government was buying CT scanners and MRI machines for every district general and tertiary-
care hospital.
The provincial governments are very keen to buy expensive equipment and are not bothered
about the human resources required to operate these instruments for the benefit of the people.
Many expensive mammogram machines are not functional because the hospital has no female
technicians. In BHUs, one can find expensive dental chairs covered under plastic sheets and in
disuse for years, waiting to be used by a dentist.
There is a very organized system of corruption in health departments in all provinces of
Pakistan. Every year, government officials in connivance with doctors, will buy expensive
machines at inflated prices and everyone gets a commission for his or her part in the deal. No
wonder why it is not possible to provide basic health and emergency care to the majority of the
people of Pakistan. In the last 70 years, the government has failed to invest in preventive
medicine. We have no safe drinking water and sewage systems for more than two-thirds of our
population. It is heart-breaking to see our rivers being used for the disposal of sewage.
One can only praise the initiative of the Sindh government in their decision to activate every
BHU in their province by training paramedics and midwives in massive numbers and hiring
doctors at very good salaries and benefits and not permitting private practice. This is the only
scheme which will improve maternal and neonatal morbidity and mortality, f this is allowed to
continue undisturbed for the next few years. It is not surprising that this scheme is under fire
from the traditional wheelers and dealers of the heath department.

Vertical Health Programmes

Family health projects, the polio eradication programme, malaria control programme, the
HIV/AIDS initiative, DAIE training, and the family planning programme, along with similar
initiatives were funded by the UNICEF, WHO, UNFPA (United Nations Population Fund), and
other donor agencies have failed in Pakistan. The reasons are very simple. In all these projects,
the government appointed a project director (PD), but the appointment was not merit based. The
PDs are well paid, drive luxury cars, and spend money as per their desires and act against the
benefits of the project. Unfortunately, the donor agencies also ignore their wrongdoings because
of political reasons and corruption. This is the reason Pakistan has not been able to get rid of
polio despite more than 150 rounds of vaccinations. We also have very poor family planning
services for an ever-growing population.

The College of Physicians and Surgeons of Pakistan

The College of Physicians and Surgeons of Pakistan (CPSP) was established by the act of 1962
to organize postgraduate education and training in Pakistan and act as an examining body for
postgraduate students. Initially, this college did a lot in organizing postgraduate education and
training by helping tertiary-care hospitals and medical students to create specialists in different
medical streams. Gradually, however, it was converted into a profit-making institute. Students
have to pay enormous examination fees, and even pay for compulsory courses to enable them to
appear for the exams. Potential examiners have to pay for courses to become examiners. The
CPSP should have helped tertiary-care centres in the public sector to make them state-of-the-art
institutions. They should have also trained a new generation of trainers and examiners by
facilitating them in their training instead of charging heavy fees from them. The college is
involved in massive investments in building and real estate from the profits they are making
from postgraduate examinations.
Recently, the president of CPSP announced that the college was going to open four state-of-
the-art private hospitals by spending Rs 40 billion initially, and will even attract overseas
patients. This is a unique kind of intellectual and financial corruption with no similar case
anywhere in the world, where an examining body becomes involved in business instead of
facilitating postgraduate teaching and training.
Corruption in the heathcare system in Pakistan has deep roots and currently at least, seems
impossible to eradicate. Everyone in our society, including doctors, is after money and power
and they are ready to violate their oath for personal benefit. Recently, a group of doctors were
arrested for kidnapping children and young people and removing their kidneys by force and
transplanting them into overseas patients. There is an organized system of buying organs from
donors despite a law against this practice. The corruption in the healthcare system will only be
stopped if the government fixes its priorities in favour of the masses. The will of the government
should be reflected in its actions. The action should be strong enough for people to start trusting
the state. Without this trust, nothing will change, and our people, especially the poor patients,
will continue suffering from misery, hardship, disease, and death.
 V

GOVERNANCE AND HEALTHCARE CORRUPTION

 CHAPTER TWENTY FIVE
Patient-Centric Healthcare: Through Institutional Regulation
Meeta and Rajivlochan*

It would seem self-evident that curing the patient in optimum time and at optimum cost should
be the main goal of any healthcare system. Yet, in many ways the patient does not seem to be the
centre of most healthcare systems in this country. This is true in both the public and private
sectors. All healthcare facilities have to constantly manage a variety of conflicting goals. In
private facilities, the need to provide good-quality patient care sometimes goes against the need
to improve footfalls, to utilize beds, to improve profit margins, and so on. In public facilities, it is
not just a lack of resources that undercuts patient care; often, the need to satisfy different
stakeholders like lawmakers, civil servants, hospital administrators, and patients, produces
contrarian results. These needs may or may not be congruent with good-quality patient care. We
remember arguing long ago with an insistent legislator (a doctor) that unless the staffing needs of
existing facilities were fulfilled, merely opening more public-sector facilities, would serve little
purpose. While agreeing, he explained that his goal was to make a public announcement that a
new government hospital would be opened; whether it would be staffed, and if staffed, whether it
could actually attract doctors and could provide services, was a secondary issue. In many states,
doctors and nurses in government hospitals are assigned 12-hour shifts routinely, irrespective of
the impact this might have on quality of decision-making and stress levels of care providers.
Resource allocation in the public sector often bears little relationship with needs on the ground.
In the private sector, resource crunches are just as important and to make matters worse,
organizational goals do not always promote quality patient care. The result is that very often,
many healthcare providers, whether doctors, nurses, or technicians, in a private healthcare
facility or in a public one, are left fighting a lonely battle for the patient in the face of
indifference from the management.
Managements are far more powerful than mere individuals and in the absence of any
legislation or institutional requirements to put the patient first, it is difficult to see why and how
they would do so. In the circumstances, how to tweak institutional systems in a manner so as to
align goals of different stakeholders towards providing primacy to the patient remains the major
problem to be tackled. In this chapter, we shall argue that institutional efforts to strengthen
standard protocols and to collate data could be one mechanism to overhaul healthcare systems
and make them patient-centric.

Why Protocols?
Medicine is governed by protocols of all kinds. Whether it is the protocol on how to treat a
patient with pneumonia, what kind of checks are to be conducted before declaring a patient fit for
surgery, or how to take a simple blood test, there is a protocol for nearly every task. Perhaps the
reason for so many protocols is the high level of complexity involved in many tasks, the fact that
so many providers have to work together on a single patient, and most important of all, many
decisions can mean the difference between life and death. So students in medical colleges have
to internalize protocols. It is these protocols that play an important role in protecting both the
patient and the care provider. For example, any provider who suffers an inadvertent needle prick
while treating a patient has to take a post-exposure treatment immediately to pre-empt infection.
Doctors and nurses spend a lot of time in memorizing medicines with similar-sounding names,
so as not to confuse two drugs.
However, once they leave college and enter the real world, the healthcare provider finds that
things are very different from college textbooks. In India in particular, where jugaad or local
innovation is prized above all, people find it difficult to stick to protocol. And in many settings,
for a variety of reasons, protocols are simply short-circuited. The reasons may not necessarily be
to make more profit. For instance, doctors are expected to use gloves while examining a patient
so as to minimize the chance of passing on infection; but public-sector hospitals in India simply
do not have the kind of resources needed to provide the large number of gloves required. In
private-sector settings, saving on cost is just as important. But there are plenty of other factors as
well, such as a dearth of trained care providers. In many government-run insurance schemes,
there simply are not enough super-specialists available even in the private sector and especially
outside metropolises. An MD who has enough experience is often allowed to treat a patient with
kidney disease. There is no DM available. The alternative is to let the patient die.
The great shortage of doctors and nurses in the country is a very significant factor. The result
is that if intensive care units (ICUs) demand one nurse per ventilated patient and one nurse each
for three non-ventilated patients, these norms are hardly ever followed. The toughest norm
prescribed by health accreditation councils relates to employment of sufficient numbers of nurses
and doctors as per prescribed patient–nurse ratio. So facilities often save on the numbers of
doctors and nurses that are required as per norms and prefer to employ persons of lower skill.
Secondary care requires a general nurse midwife (GNM), but hospitals make do with auxiliary
nurse midwives (ANM) who get only part of the training of a GNM.
Another complicating factor for doctors in the private sector is the existence of managements
who want to see maximum numbers of patients treated. In self-owned small facilities, such profit
motives matter too. Hence, over-diagnosis and over-treatment is routine. In this process, the
standard protocols on diagnosing disease and treating patients are often short-circuited.
Sometimes, to give just one example, the standard fitness test before surgery is done in a very
cursory manner. The implication is clear: the patient is to be found fit for surgery. Or in
complicated cases such as heart procedures like angioplasty, surgeons are not always available
on call in case any complications arise; the services of heart surgeons, after all, come at a
premium price.
Our point is simply this: all these anomalies and short-circuiting of protocols is possible
because there are no laws that require these to be followed. There is no law to mandate the
presence of a cardiothoracic surgeon for complicated angioplasty procedures or indeed, for any
angioplasty procedure. There is not even a law that requires proper recording and reporting of
key performance indicators in medical facilities. The fact is that systematic recording of adverse
events like infections and errors help to save lives over time, but maintaining those kinds of
records takes both time and money. Without a law, there is no compulsion on anyone to invest
that kind of time and money. It is, therefore, up to the hospital manager or owner to record
hospital-acquired infections, adverse events like blood transfusion reactions, etc., and it comes as
no surprise that hospitals choose not to do so. It is only the most serious adverse outcome that
needs to be reported to government, namely death. Even here, the medical cause of certification
of the death form is not automated, so the information cannot be easily retrieved. It is also not
necessary to enter information like the International Classification of the Disease or the
procedure code, hence we cannot find out the procedure-wise risk adjusted mortality rate for any
hospital.
It is this kind of data which would allow the detection of anomalies; this, in turn, would allow
improvement in patient-care processes in a hospital. Currently, hospitals don’t even know the
number of lives lost due to adverse events. Data empowers practitioners and protects patients.
The fact of the matter is that though many facilities do maintain such data in every ward, they see
no need to collate it for the entire hospital and over time. It is data collated over time for a
facility which can help in the standardization of processes. International mortality rates may
carry less relevance in Indian settings. We need to collect our own data and establish our own
benchmarks. Today, there is a perception that this kind of patient data can only be useful for
research. There may also be fears that it could be used to victimize professionals. In other
countries, there is a provision for anonymous reporting of adverse events. That kind of system
could always be worked out; provided there is a will to do so.
In the absence of any requirement to maintain data or to follow protocols, two kinds of things
happen. Managements are simply emboldened to put pressure on doctors whom they employ, to
deviate from standard patient-care norms. Those who do not conform are marked out and often
isolated. Secondly, in the absence of systematic recording of data, it is not possible to identify
anomalies or take any corrective action.
With the increase in the size and commercial power of hospitals and medical chains,
managements have appropriated more and more power over care providers. One kind of response
from the medical community to this systematic pressure has been the emergence of a movement
called ‘evidence-based medicine’. Simply put, this is a concept that says that diagnosis and
treatment need to be based on adequate information about the patient. Above all, the protocol is
given importance.
However, we need to remember that individual or even group initiatives, howsoever well
meaning and influential, cannot be a substitute for organized action on the part of the state. The
state alone has the power and authority to enforce norms of behaviour through law. Unless the
government demands that protocols be followed, it is difficult to see how any kind of compliance
could be ensured. Quality- control managers, adequate numbers of doctors and nurses, regular
calibration of laboratory equipment—all these have a cost. Unless the law demands that the
protocols be followed, there will be a high propensity to ignore these.
Governments in India have made an attempt to enforce some kind of order in the healthcare
space but it is not enough. One of the major criticisms of the Rashtriya Swasthya Bima Yojana
(RSBY)—a health insurance scheme for the poor that is sponsored by the Government of India
—has been that it hardly focuses on issues of clinical governance. Let us see what happened in
one case where the government did make a systematic intervention of this kind in the healthcare
market.

Case Study of How Clinical Protocols were Used to Strengthen Patient

Care
In the state of Maharashtra, a health-insurance scheme was implemented for three-fourths of the
population of the state from November 2013 onwards, which means about 22 million families
were covered. Before this, the scheme was run in a pilot phase for less than a quarter of the
population, that is, for around 5.4 million families, from July 2012 to November 2013. Once the
success of the pilot demonstrated the feasibility of the scheme, it was implemented throughout
the state. This publicly funded scheme provided insurance cover of Rs 1,50,000 (about USD
2,205 at the exchange rate of, say, 1 USD = 68 INR) per annum to each family covered in the
scheme. The premium payable by the government was Rs 363 including taxes (this equals
roughly USD 5.4). The families covered did not have to pay anything. They only needed to show
one of two kinds of ration cards1 to be eligible for coverage. A public-sector insurance company,
the National Insurance Company, agreed to provide the insurance cover on payment of advance
premium by the government for all those covered. The insurance company would empanel
hospitals and run the scheme through a third-party administrator. The budget of the scheme was
around Rs 820 crore in one 12-month period in the year 20152 (roughly USD 120 million at
current exchange rates).
The insurance covered a range of surgical treatments. The system of diagnosis related groups
was not used for the scheme; rather, 971 specific interventions across 30 different specialities
were included. Some fairly common procedures included were angioplasty, hospitalization for
different kinds of cancers, treatment of fractures, and so on. Both secondary-care and tertiary-
care treatments were included.
The mechanism was as follows: patients who were covered were to present themselves in
hospitals empanelled under the scheme. If the treating doctor felt that any procedure was called
for, he would raise a pre-authorization request, which would be sent via a software application to
the insurance company. It was incumbent upon the insurance company to reply within 12 hours
to the request. Once the doctor received a ‘yes’, he could go ahead with treating the patient and
post treatment, send in the bill to the insurance company.
After a few months of running the scheme, it was noticed that large numbers of patients
treated for heart attacks using non-invasive means, showed normal post-treatment angiograms,
that is, angiograms were not indicative of significant coronary artery disease. Data over a one-
month period showed that, in two hospitals, the figure reached as high as 55 per cent of patients
treated for heart attacks using non-invasive means, showing normal angiograms post treatment.
Leaving out these two outliers, in hospitals that showed anomalous data, overall 32 per cent
patients showed normal angiograms post-treatments. When the hospitals were asked why this
was so, no reply was received.3 Normally, not more than 10 per cent patients show normal
angiograms post a heart attack. It was at this point that many concerned doctors suggested that
some mechanism was needed to standardize norms of diagnosis and to determine appropriateness
of use. At this time, the scheme was still in its pilot phase and covered slightly less than one
quarter of the population of the state or about 5.4 million families.
The state government then introduced an algorithm developed by doctors in various highly
rated government institutions such as AIIMS (All-India Institute of Medical Sciences) New
Delhi, PGIMER Chandigarh, Grant Medical College Mumbai etc., in an attempt to standardize
the diagnosis of patient conditions. Such an algorithm was developed for a large number of the
treatments covered. Each algorithm began by listing the various possible clinical indications for
that procedure. The treatment provider was expected to answer the questions regarding each
clinical indication identified and send it in with his treatment request. To give one example, the
protocol for angioplasty for chronic stable angina was developed by a faculty member at AIIMS
and was as follows:
CORONARY ANGIOPLASTY: Chronic Stable Angina4

1. Select the Procedure from drop down of various cardiology procedures available:
Coronary Angioplasty
2. Select the Indication from the drop down of various indications provided under this head:
Chronic Stable Angina
Acute Coronary Syndrome, Unstable Angina
Acute Coronary Syndrome
Non-ST Elevation MI
Recent STEMI
3. Does the patient have Angina class III-IV: Yes/No
4. If the answer to question 3 is yes,
a. Does the patient have >70% diameter stenosis in <2 major coronary arteries, AND no
significant left main disease: Yes/No (Upload Angiogram)
b. Is the patient receiving aspirin and statin AND at least 2 of the following classes of drugs:
long acting nitrates, beta-blockers, calcium channel blockers: Yes/No (Attach Prescription)
5. If the answer to question 3 is No, has the patient had a stress test: Yes/No
6. If the answer to question 5 is Yes, Is the stress test moderately or strongly positive: Yes/No
(Attach Stress Test Report)
7. If the answer to question 6 is Yes,
a. Does the patient have >70% diameter stenosis in <2 major coronary arteries, AND no
significant left main disease: Yes/No (Upload Angiogram)
b. Is the patient receiving aspirin and statin AND at least 2 of the following classes of drugs:
long acting nitrates, beta-blockers, calcium channel blockers: Yes/No (Attach Prescription)
Once an algorithm was developed by any faculty member, it was validated by another faculty
member from a different institution. Subsequently, it was pilot tested for one to two months
before being standardized and released to participating hospitals.
In cases where the patient to be treated did not conform to the algorithm and the provider still
felt he should be treated with the specific intervention, he was asked to record the reasons for the
same. In a few cases, second opinions were also taken.
In one study of the introduction of these algorithms in the scheme, scholars found that, ‘...
There was a 12.3% reduction in the proportion of PCIs performed in the 1-year period after the
introduction of appropriateness-based reimbursement.’ Further, the study compared these figures
with a similar scheme and noted that, ‘data from another government funded health insurance
scheme in the state of Tamil Nadu (Chief Minister’s Comprehensive Health Insurance Scheme,
CMCHIS), where appropriateness criteria are not in use, showed no reduction in PCIs. On the
contrary, in keeping with national trends, there was an increase in the number of PCIs (as a
proportion of all procedures) in the first 6 months of 2014 (1.3% to 3.4%), compared to 2013’
(Karthikeyan et al. 2017).
 Another result of the introduction of the algorithms was some normalization of the responses
of the insurance company to treatment requests. Mostly, insurance companies use a least-cost
approach to treatment requests. However, the approach that is the least costly is not necessarily
the appropriate one. For that, extant protocols would be a much better guide than anything else.
And once the protocols are developed by care providers themselves and are in line with current
treatment guidelines, the possibility of denial of care gets reduced. In this particular programme,
it was found that the insurance company agreed to 96 per cent of treatment requests. There was
some difference of opinion in very few cases.
Currently, the State Health Assurance Society that administers the scheme continues to use
these algorithms to take a decision on many treatment requests received.5 Overall, the response
to the algorithms was reasonably positive. Often, the treating hospitals did suggest improvements
that were referred to a group of expert doctors for a decision. The setting up of this system began
in 2013 and gradually began covering most of the procedures. It continues to underpin the
insurance scheme till date.
With a view to further strengthening emphasis on compliance with protocols, the Maharashtra
government also introduced a more rigorous accreditation mechanism for empanelling hospitals
for the scheme. Till 2013, the insurance company merely looked at the infrastructure available
and the numbers of doctors available for empanelling any hospital for a specific super-speciality.
This was a minimal method of verification. But in view of the fact that the numbers of hospitals
accredited by the NABH (National Accreditation Board for Hospitals & Healthcare Providers) in
Maharashtra was hardly more than 10 at the time and that the company needed 300 hospitals to
service the entire state, there seemed to be little option. Hence the government developed a
separate set of 85 indicators for purposes of empanelment. These indicators were a mix of
infrastructure, human resource, process indicators such as hospital-acquired infections, etc. and
outcome indicators like mortality rates. These indicators were grouped into nine separate
chapters, namely: 1) Human Resources 2) Infrastructure and Facilities 3) Infection Control 4)
Medication Monitoring 5) Patient Medical Records 6) Standard Operating Protocols 7) Quality
of Patient Care 8) Transparency in Pricing and 9) Patient Satisfaction Indices. The chapter on
Patient Satisfaction Indices was introduced with a view to ensuring that the facility provided
forms for patient feedback, that it took patient consent before surgery, and generally informed
the patient about their rights. The chapter on Transparency in Pricing was introduced with a view
to persuading the facility to provide detailed prices to the patient and a list of tests and items used
to treat them, at the time of discharge.6
The government instituted extensive training programmes for hospital managers and doctors
about what these indices were and why they should be followed. The overall response was quite
encouraging. At the time the exercise was initiated, some of the smaller hospitals openly said
that these patient-care norms could only be applied to rich institutes catering to NRI tourists and
these were too tough for the small nursing home. Today, such sentiments are the exception rather
than the norm.
Using such methods, the government endeavoured to build greater consciousness about the
need to maintain high standards of quality when it came to patient care and to persuade hospitals
to upgrade their facilities. One significant result that this device had was that hospitals which had
achieved an ‘A’ grade in this scoring process began to use the scoring as a publicity device and
to build brand value. Given that in India, hospitals mainly use the reputation of doctors rather
than accreditation as a means to inform people about the quality of care, this was a significant
step. Today, institutes like the Krishna Institute of Medical Sciences Karad in the Satara district,
Pravara Medical College in the Ahmednagar district, and even ‘five-star’ hospitals like Seven
Hills in Mumbai used the Society grading as an indicator of high quality of care.
The scoring process is mandatory for government hospitals as well. Many hospital
managements in the public sector use the scoring process to put pressure on their superiors to
increase their staff and to improve infrastructure. Data available was used to upgrade systems at
the facility level and many facilities made serious efforts to improve their ratings.
Additionally, the availability of data in standardized formats led to research studies, which
provided valuable insights for policy formulation (Duggal et al. 2016). Overall, the mere fact that
there is a system of documentation and a quality check helps to ensure a more patient-centric
approach in healthcare. That such approaches have a long-term impact is visible in the recent
study by IIM Ahmedabad on the healthcare sector, which places Maharashtra at number one spot
in the country in a matrix that relates outcomes to inputs provided (Sinha et al. 2016).

Conclusion: Asking Managements to be Accountable

Today, the Government in India funds a large part of insurance- based healthcare in the country.
Of the Rs 22,726 crore (USD 3.34 billion) worth of premium paid for health and personal
accident insurance in the country for financial year 2014–15,7 government-sponsored health
insurance, both in the central and state governments, accounts for nearly one-third. That is a lot
of money and market power. Such power can be used easily to improve quality of care and to
encourage a patient-centric approach. Even otherwise, to set up norms of clinical governance is
surely part and parcel of the government’s job.
This is not to make a case for ‘big government’, merely responsible government. The idea of
an Orwellian ‘big brother’ government is quite popular in public discourse. However, seen in the
Indian context, it seems quite inappropriate. The government is no longer the service provider in
most sectors, with the exception of public utilities like electricity, water supply, and railways.
Rather, going by recent history, the quantum of services provided directly by government
providers has been steadily going down. Today, the private sector is so deeply imbricated within
government by way of providing services, whether in public health or education, that it is
practically impossible to roll the clock back. Given their abilities and market presence, private
providers should participate in providing public health services to generate a universal platform
of service delivery. Leaving private providers out merely because of their location would only
generate conflicts and limit the scope of services provided. The point is that these services should
adhere to some norms of service delivery.
In all the debates generated by the budget every year, there are vociferous demands made for
an increase in public funding for health. Much of this funding does go to the private sector. What
the private service providers are really saying is that they should be given more funds, but no
questions should be asked about performance indicators or about how the money is utilized. That
being the case, irrespective of any norm setting, funding of private service providers through
public funds is very likely to go on. In the circumstances, it makes sense for the government to at
least enact legislation to provide for quality checks. Interestingly, looking at the implementation
of the Clinical Establishments (Registration and Regulation) Act of 2010 enacted by the
Government of India, it has not been followed by setting up the kind of norms described above at
the level of state governments. Few large states have followed suit, either to accept this
legislation or to enact legislations of their own.
In case we hope to encourage a more patient-centric approach to healthcare services, patient
data needs to be maintained, protocols followed, and some performance indicators put in place.
A system of accreditation of medical facilities, which is based on collating data on key
indicators, would help generate a more patient-friendly system.
Here it is important to note that the mere fact of maintaining records accurately and
consistently creates imperatives that serve to improve patient care. The ability to access patient
history across institutions, and within an institution across time, can save many lives.
Secondly, it is important to recognize that norms of service delivery can only be set up by the
government. No private agency has the legitimacy or the locus standi to do so. The idea of a self-
regulated industry has not functioned in the past 50 years. It is high time that the government
lived up to its own responsibilities.
We have already pointed out that it needs firm backing of law and the state to encourage
hospital managements to put patients first. Collation and maintenance of patient data is in the
best interest both of doctors and of patients. The trouble is that individual practitioners are
powerless against managements and patients even more so.
No doubt conscientious medical professionals have done a great deal to generate awareness
on these issues. A movement for evidence-based medicine and a demand for inclusion of patient
rights in the various state-level versions of the Clinical Establishments Act are only some
examples. However, it is unfair to place the entire burden of the task of being conscience keeper
on the shoulders of a few individuals. Nor is it likely to be fruitful in the long term. A few
individuals or organizations, howsoever influential, are no substitute for law.

References
Duggal, B., S. Saunik, M. Duggal, et al., 2016, ‘Mortality Outcome in Patients Undergoing
Coronary Revascularization with Drug-eluting Stents versus Bare Metal Stents in India’,
Poster session presented at Annual Meeting and Expo of American Preventive Health
Association (APHA), Denver, Colorado, USA.
Karthikeyan, Ganesan, Umesh Shirodkar, Meeta Rajivlochan, and Stephen Birch, 2017,
‘Appropriateness-based Reimbursement of Elective Invasive Coronary Procedures in Low and
Middle Income Countries: Preliminary Assessment of Feasibility in India’, National Medical
Journal of India, 30: 11–14.
Sinha, Piyush Kumar, Arvind Sahay, Surabhi Koul, 2016, ‘Development of a Health Index of
Indian States’, Indian Institute of Management Ahmedabad, Facilitated by OPPI (Organisation
of Pharmaceutical Producers of India), p. 21.

* The views expressed in this chapter do not necessarily reflect those of the authors’ respective employers.
 CHAPTER TWENTY SIX
Regulating Healthcare Establishments
The Case of the Clinical Establishment Act, 2010
Sunil Nandraj

There has been a spate of allegations reported in the newspapers regarding the unethical,
irrational, and corrupt practices by healthcare providers,1 especially in the private health sector in
India. These include irrational and inappropriate treatment, tendency to conduct unnecessary
surgeries, illegal clinical drug trials, and excessive use of higher technologies and over-
prescriptions. Complaints have been reported that even where the patient had died, bodies are not
handed over till the dues have been cleared, and the refusal to admit accident and emergency
patients. Medical records pertaining to treatment provided are also not given to prevent
consumers seeking legal redressal of their complaints. Financial aspects of this problem include
disproportionate and excessive billing, demanding money before the operation, non-transparency
or irrational rate differentials in fees and charges, forcing patients to purchase consumables and
drugs from only specific vendors, suspicious referral patterns, and the widespread practice of
‘cuts’ and ‘commissions’ for referrals which are unethical and inflate costs. A widely shared
grievance is that there is a total lack of transparency about charges for treatment (in the majority
of private clinical establishments, charges and fees are not displayed) and the appropriateness of
treatment provided. This has led to many patients becoming impoverished to meet healthcare
costs. The list is long and it could be longer! Only the most dire, tragic, and sensational
experiences are reported in the media. The fact is most of the healthcare providers lie under a
thick fog and the public knows very little about the way they are run, except by way of first-hand
encounters. There is a lack of information on the outcomes of treatment by the healthcare
providers available to the consumers or the government. Private medicine has flourished in India
because of a weak regulatory climate with no standards to monitor quality or ethics (Jain et al.
2014).
One of the major reasons for a list like this, and the litany of negative experiences, is due to
the unregulated, unaccountable, and non-transparent functioning of private health establishments
in India, which are a dominant and growing segment of healthcare services in this country in
terms of provision, financing, and utilization. The private health sector has remained largely
unplanned, fragmented, and unregulated. This has taken place in the context of public policies
providing tacit support and encouragement, whether in the form of encouraging growth of
private medical education, delivery of ancillary industries, various concessions in the name of
public-private partnerships, purchasing of care through state-sponsored insurance, and duty
waivers to ‘charitable’ hospitals among others. At the time of independence, only about 8 per
cent of all qualified modern medical care was provided by the private health sector. But over the
years the share of the private sector in the provision, utilization, and financing of healthcare has
kept rising, and now provides nearly 75 per cent of outpatient and over 60 per cent of
hospitalization/inpatient services (National Sample Survey Office 2014). Healthcare costs have
been rising due to medical consumerism led by its rapid corporatization.
The general perception is that the regulatory and accountability mechanisms in terms of
policies, legislations and process for health providers in India is inadequate and not responsive to
ensure healthcare services of acceptable quality or to prevent malpractice, negligence, and
corrupt practices that are plaguing India’s healthcare system. One is not assured of redress or any
kind of justice in a timely manner for the various forms of malpractice in the medical sector. It is
a well-known fact that there are a plethora of legislations in India that affect one’s personal and
professional life. However, unlike most other business establishments such as shops, beauty
parlours, and dance bars that need a licence to operate, healthcare establishments providing care
such as hospitals, nursing homes, diagnostic and pathological laboratories in many states are not
mandated to register or acquire a licence to operate. This state of affairs has been going on since
independence.
Concerns about how to regulate private healthcare establishments so that they are accountable
and transparent, and the need to improve healthcare quality continue to be frequently raised by
the general public and a wide variety of stakeholders, including the government, professional
associations, private providers, agencies financing healthcare, the Human Rights Commission,
and the judiciary.

Regulations of Healthcare Providers

Regulation can be thought of as occurring when a government/state exerts control over the
activities of individuals and firms (Roemer 1993). More specifically, regulation has been defined
as government action to manipulate prices, quantities (and distribution), and quality of products.
In India there are several actors involved in the regulatory process namely, healthcare
professionals, managers, the ministry of health at the central and state levels, commercial
interests, NGOs, and community and consumer groups.
Regulation seeks to ensure quality and accountability, protect consumers, and control costs as
well as the distortions created by market forces. Regulations are required to ensure that quality
standards are met, that financial fraud and other abuses do not take place that those entitled to
care are not denied services, and the confidentiality of medical information is respected (World
Bank 1993). A review of global experiences show that regulatory frameworks assume a variety
of forms. The foremost amongst these is legislation or imposition of legal restrictions or controls
where participants must conform to legislated requirements. In addition to these formal rules,
more informal codes of conduct, standards, guidelines, or recommendations may exist. Countries
are also increasingly using other mechanisms such as the introduction of incentives and
encouraging competition as part of their regulatory framework. Another approach which is
gaining momentum is that of peer review, self-regulation, and certification. Essentially, the
elements of any regulatory process includes, establishment of rules, its application to specific
cases, detection or monitoring violations, and imposition of penalties on violators.
The central and state governments in India have promulgated several legislations to regulate
provision and utilization of healthcare and safeguard the health of the population; a compilation
of the existing legislations at the central level identified around 250. They cover legislation for
health facilities and services, disease control and medical care, medical professionals, human
power (education, licensing and professional responsibility), quality of care, medical procedures,
ethics and patients’ rights, pharmaceuticals and medical devices, radiation protection,
occupational health and accident prevention, elderly, disabled and rehabilitation family, women
and child health, mental health, smoking, tobacco control, social security and health insurance,
environmental protection, nutrition and food safety, health information, and statistics and
consumer protection.
In spite of legislation covering the aspects mentioned above, there is a near absence of laws to
regulate many key areas such as medical devices or introduction of new medical technologies,
reproductive technologies despite the emergence of a considerable number of specialized
hospitals and infertility clinics in India. One of the important areas is legislation for registering
private providers, hospitals, nursing homes, laboratories, diagnostic centres, various types of
clinics and centres (including from the Indian systems of medicine and homoeopathy). Major
providers are individual practitioners (formal and informal), hospitals, laboratories, and
diagnostic centres in the private and government sectors.

The Clinical Establishments (Registration & Regulation) Act, 2010

The parliament, on 3 May 2010, passed the Clinical Establishments (Registration and
Regulation) Act (CEA), 2010. It was notified by the Government of India on 19 August 2010.2
The central government was compelled to enact the CEA, 2010 as in a majority of the states
in India, healthcare establishments were not regulated or monitored and the states had failed in
their obligation to enact appropriate legislation for regulating, or for that matter, even registering
private healthcare providers.3 Out of 29 states in the country, Assam, Arunachal Pradesh, Bihar,
Chhattisgarh, Goa, Haryana, Himachal Pradesh, Jharkhand, Kerala, Mizoram, Meghalaya,
Rajasthan, Tripura, Uttarakhand, and Uttar Pradesh did not have any legislation that made it
mandatory for private clinical establishments to have a license to function. That such a dominant
section of healthcare delivery, which concerns life functions without any accountability after 64
years of independence, is a matter of grave concern.
A review of the state’s legislations regarding regulation of clinical establishments such as
Andhra Pradesh, Delhi, Jammu & Kashmir, Karnataka, Madhya Pradesh, Maharashtra, Manipur,
Nagaland, Orissa, and West Bengal clearly bring out that they are not being adequately enforced
and implemented (see Table 26.1). Many of the legislations are outdated, inadequate in content
and coverage, with no formulation of rules and byelaws, and no prescribed standards. For
instance, the Bombay Nursing Home Registration Act, 1949, was applicable only in the cities of
Mumbai, Nagpur, Solapur, and Pune, but it wasn’t being properly implemented in these cities. A
public interest litigation in 1991 by the Medico Friend Circle filed in the Bombay High Court
forced the Maharashtra government and the Bombay Municipal Corporation to implement the
act. In their order, the judges observed, ‘The writ petition has served the purpose of activising the
concerned authorities, who seem to have woken up and taken certain steps in the direction of
implementation of the various provisions of the law’ (Nandraj 1994). However, not much has
changed after 20 years, as the implementation remains questionable in spite of advocacy for
changes in the Act and rules by civil society groups. Similarly, it is seen that out of the few states
that had legislations, such as Andhra Pradesh, Karnataka, Punjab, and Tamil Nadu, they are not
being enforced and implemented effectively. In Andhra Pradesh, which had the Andhra Pradesh
Private Medical Care Establishments (Registration and Regulation) Act, 2002, along with rules,
is not implemented adequately due to the influence of the Indian Medical Association (IMA).4 In
Tamil Nadu, the Tamil Nadu Private Clinical Establishment Act, was passed in the assembly in
April 1997, but the Act was never enforced as the state did not notify and frame rules. The high
court pulled up the government and asked it to enact suitable legislations (Arul 2016). In
Karnataka, the government has made amendments to the Karnataka Private Medical
Establishments (KPME) Act, 2007 and passed the KPME (Amendment) Act, 2017.

TABLE 26.1 Regulation of Clinical Establishments in the States and Union Territories as of 22 June 2017
States and UTs where the CEA, 2010 is applicable: Arunachal Pradesh, Himachal Pradesh, Sikkim, Mizoram and
(UTs) Andaman & Nicobar Islands, Daman, Diu, Dadar & Nagar Haveli, Lakshwadeep, Chandigarh, Puducherry
States which adopted the CEA, 2010: Bihar, Jharkhand, Rajasthan, Uttar Pradesh, Uttrakhand, Assam
States which do not have legislations: Goa, Gujarat, Kerala, Nagaland, Punjab, Tamil Nadu
States having their own legislations
AP Private Medical Care Establishments (Regulation and Registration) Act 2002 (AP Allopathic Private Medical
Care Establishment (Registration & Regulation) Rules, 2005 and 2007
Chhattisgarh State Upcharyagriha Tatha Rogopchar Sambandhi Sthpanaye Anugyapan Adhiniyam, 2010
The Delhi Nursing Home Registration Act, 1951:
Presently drafting a new legislation—Delhi Health Bill on the lines of the CEA, 2010
Haryana has notified its own Act, Haryana Clinical Establishment Registration and Regulations Act, 2014 on 28
March 2014
The Jammu & Kashmir Nursing Homes & Clinical Establishments (Registration and Licensing) Act, 1963
Karnataka Private Medical Establishment (Amendment) Act, 2017
Madhya Pradesh Upcharya Griha Tatha Rujopchar Sambandi Sthampamaue (Ragistrikaran Tatha Anugyapan)
Adhniyam, 1973 The rules in 1997
Bombay Nursing Home Registration Act, 1949; Amended in 2005
Manipur Nursing Home & Clinics Registration Act, 1992
Odisha Clinical Establishment (Control & Regulation) Act, 1990 [OCE (C&R) Act, 1990. Amendment in 2016
The Tripura Clinical Establishment Act, 1976 (Act 12 of 1976)
Telangana follows the AP Private Medical Care Establishments (Regulation and Registration) Act, 2002 (AP
Allopathic Private Medical Care Establishment (Registration & Regulation) Rules, 2005 and 2007
Tamil Nadu Private Clinical Establishments Regulation Act, 1997
West Bengal Clinical Establishments (Registration, Regulation and Transparency) Act, 2017

As mentioned earlier, several of the existing legislations were outdated, inherited from the
pre-independence period as part of the British legacy. They were cumbersome and irrelevant to
the concerns of present healthcare service delivery. The Bombay Nursing Home Registration Act
of 1949, West Bengal Clinical Establishment Act of 1950 and Delhi Nursing Homes Registration
Act of 1953 are prime examples. In the above Acts the clauses, rules, and bye-laws were not
updated taking into consideration the growing and changing profile in terms of size, scale of
complex operations, and meeting the public health needs and have therefore lost their relevance.
Further to compound the issue, the CEA promulgated by states such as Jammu & Kashmir,
Manipur, Nagaland, Orissa, and Punjab, to a large extent, draw their the content and coverage
from the outdated Nursing Home acts of Maharashtra and Delhi. These are not necessarily
adapted to the needs of the particular states.
One of the major lacunae in the existing legislations is that the coverage is restricted to only
the registration of hospitals and nursing homes providing allopathy care. Laboratories, diagnostic
centres, clinics run by single doctors and dentists, clinical establishments from other recognized
systems of medicine, namely Ayurveda, Unani, Siddha, homeopathy, and government
establishments, are not included. Thus, large sections of the healthcare delivery system that
provide care are not included despite the growth of such facilities in India. Moreover, minimum
standards related to infrastructure, human resources, patient safety, display of information have
not been developed, nor have issues relating to accountability of quality and price been
addressed in the states having these legislations.
In many of the acts, the penalties for non-registration or for deficiencies are quite ridiculous
and do not provide for a deterrent effect. Under the Delhi Nursing Home Registration Act, 1953,
whoever contravenes any of the provision of the act will be punished with a fine which may extend to Rs. 100 and
in case of continuing offence to a further fine of Rs. 25 in respect of each day on which the offence continue after
such. In Maharashtra the amount is Rs. 5000 and in case of continuing offence to a further fine of Rs. 50 in respect
of each day on which the offence continues after such conviction.

One of the reasons for non-implementation has been the limited capacity and provision of
sufficient resources and enforcement machinery at the state level to enact and effectively
implement the existing regulations. The grievance redressal and organizational structure for
enforcement is weak.
Furthermore, there was a need felt for ensuring minimum uniform standards of facilities and
services by the clinical establishments across the country. One of the major aspects relates to the
absence of health information and data from private providers. A systematic collection of
information from private health establishments in the country is near absent or inadequate.
Whatever data is collected and used is mainly from government establishments, which are
utilized by only 30 per cent of the population. The entire planning of the health sector is based on
government data. It needs to be noted that many states are involved with private healthcare
establishments under various state-sponsored health-insurance schemes and undertaking private-
public partnerships under the National Health Mission without sufficient information or data
regarding private healthcare providers.

The Clinical Establishment: Purpose, Coverage, and Applicability

The purpose of the CEA, 2010 is to provide for the registration and regulation of clinical
establishments with a view to prescribe minimum standards of facilities and services which may
be provided by them so that the mandate of Article 47 of the constitution for improvement in
public health may be achieved. The act is applicable to Arunachal Pradesh, Sikkim, Mizoram,
Himachal Pradesh, and all union territories (Andaman & Nicobar Islands, Chandigarh, NCT of
Delhi, Dadra & Nagar Haveli, Daman & Diu, Lakshadweep, and Puducherry). The states of
Uttar Pradesh, Rajasthan, Bihar, Jharkhand, Uttarakhand, and Assam have adopted the Act by
passing a resolution under Clause (1) of Article 252 of the constitution in their respective state
assemblies.
The Act covers all public and private facilities and services, clinics, all types of laboratories
and diagnostic centres, and therapy centres (including single doctor and dental clinics) by all
recognized systems of medicine including allopathy and Indian systems of Ayurveda, yoga,
Unani, Siddha, and homeopathy (AYUSH) (except the Armed Forces hospitals). The coverage
and definition in the Act are quite all-encompassing to include the majority of the providers of
healthcare services. A clinical establishment has been defined as ‘a hospital, maternity home,
nursing home, dispensary, clinic, sanatorium or an institution by whatever name called that
offers services, facilities requiring diagnosis, treatment or care for illness, injury, deformity,
abnormality or pregnancy in any recognized system of medicine established and administered or
maintained by any person or body of persons, whether incorporated or not’; or a place
established as an independent entity or part of an establishment referred to in sub-clause (i), in
connection with the diagnosis or treatment of diseases where pathological, bacteriological,
genetic, radiological, chemical, biological investigations or other diagnostic or investigative
services with the aid of laboratory or other medical equipment, are usually carried on, established
and administered or maintained by any person or body of persons, whether incorporated or not.
The central government has brought government clinical establishments under the purview of the
Act. There is a need for strengthening them with regard to infrastructure, human resources,
availability of medicines and equipment including their maintenance for the improvement in the
quality of care provided in the provision of healthcare services to the people.

Salient Features of the CEA, 2010

The scope of the Act has made the entire process of registration, as well as the availability of
data of clinical establishments a web-based system at the district level. It is based on self-
declaration of the services and facilities available, which would be in the public domain. The
application for registration is in a time-bound manner. If there is no response from the
registration authority in the prescribed time, the establishments would be deemed to be
registered. The registration is through a process of self declaration, without any inspection. The
strength of this legislation is with regard to its transparency through an online system of
registration and empowering of the people, as it places the entire process of registration and
details of facilities and services, equipment, staff, space and other details, which the clinical
establishment claims to have in the public domain. People can come to know about the facilities
and services being provided. If the information provided is contrary to the ground reality, then
recourse is available to proceed against the clinical establishment. It ensures use of effective
regulation with limited resources, prosecuting only those violating the law. The establishments
need to meet the prescribed minimum standards of facilities and personnel, maintain records, and
report the same to authorities in a timely manner, and provide staff and facilities as may be
required in order to stabilize an accident emergency medical condition to any individual. Further,
the Act empowers the government to obtain information that may be required for public health
purposes with regard to getting data and statistics from clinical establishments for emergency
medical management in cases of an outbreak of diseases and the need for interventions, which is
presently unavailable from the private sector. The Act specifies clearly that the details of charges
and available facilities need to be prominently displayed at each establishment. The registration
authority has the power to inspect a registered clinical establishment with prior intimation.
Cancellation of registration can occur at any time if conditions for registration are not compiled
with. Any person aggrieved by an order of the registering authority shall refer an appeal to the
state council. No person shall run a clinic unless it has been duly registered in accordance with
the provisions of this Act.
For the implementation of the Act in a time-bound manner, timelines have also been
specified. The categorization and classification of different types of clinical establishments and
the first set of uniform minimum standards need to be developed within two years from the date
of notification of the Act. Adherence to minimum standards would ensure that proper protocols
are followed, including standard treatment guidelines to be followed by clinical establishments.
Further, the establishment of a digital National Register of Clinical Establishments in a digital
format would aid in policy formulation and resource allocation, assist in the generation of a
reliable database of all types of clinical establishments at the national, state, and district levels,
assist the government in obtaining information and data required for public health interventions
including outbreak and disaster management.
The National Council, which is a multi-stakeholder body, must meet at least once in four
months. It is responsible for categorizing clinical establishments and for developing the
minimum standards for different specialities/levels of the clinics, in consultation with the
experts. The Act also allows for setting up of a multi-member state-level council of clinical
establishments, which would be responsible for the compilation and updating the register of
clinical establishments in states and union territories, sending the monthly returns in a digital
format to the national register, and acting as an appellate body.
The district registration authority is a multi-member registering authority at the district level.
It will have the power to grant, renew, enforce, or cancel the registration of any clinical
establishment in accordance with the provisions and rules of this Act.
Representatives from the various councils (doctors, dentists, nurses, pharmacy, Indian
systems of medicine, homeopathy), medical associations, paramedical, regional representation,
and consumer organizations have been provided representation in the three bodies.
In case of non-compliance, the CEA, 2010 provides for stiffer penalties which include a fine
which may extend up to Rs 10,000 for the first offence, Rs 50,000 for the second offence and
any subsequent offence with a fine which may extend to Rs 500,000 for contravention of any
provisions of the act. The Act also specifies separate penalties for carrying out a clinical
establishment without registration, whoever knowingly serves in a clinical establishment which
is not duly registered under this Act and whoever wilfully disobeys any direction lawfully given
by any person or authority empowered under this Act.

Present Status and Limitations

The Ministry of Health and Family Welfare has notified Clinical Establishments (Central
Government) Rules, 2012 (Ministry of Health & Family Welfare 2010). The National Council
for Clinical Establishments has been notified vide Gazette notifications dated 19 March 2012. In
the majority of the states and UTs where the CEA, 2010 is applicable, the state councils, district
registration authorities, and rules have been notified. A dedicated website
(www.clinicalestablishments.nic.in) has been made operational. Presently, there are around
16,221 clinical establishments registered online as on 21 February 2018. A secretariat for the
national council has been set up for coordinating the work of national council. Financial
provisions for implementation at the state level are provided through the National Health
Mission. Operational guidelines for implementation of the CEA are available on the website of
the Act. Advocacy-cum-training workshops are regularly being conducted regarding
implementation of the Act and rules. Categorization of clinical establishments has been finalized
and minimum standards of major general categories of clinical establishments, namely clinics,
polyclinics, mobile clinics, hospitals, physiotherapy centres, health check-up centres, dental
laboratories, physiotherapy and dietetics units, and integrated counseling centres has been
completed. Minimum standards for 35 speciality/super-speciality departments/clinical
establishments has been finalized and approved by the national council. Minimum standards for
all systems of medicine under AYUSH have been finalized and approved by national council.
Formats for collection of information and statistics from OPD, IPD, and laboratory and imaging
centres have been finalized. The national council has approved a list of medical treatment
procedures and a standard template for the costing of procedures and services. State/UT
governments have been advised to use these for determining the standard cost of any procedure
taking into consideration all pertinent factors. The process of registration for permanent
registration is in process.
There are various limitations of the CEA, 2010. Foremost, is the lack of provision for a
grievance redressal mechanism for patients and consumers. Secondly, there is no provision for
articulation of patients’ rights. Thirdly, it does not address the issues related to cut practices,
forcing patients to purchase from specific vendors, and clinical and social audits to be
undertaken. Further, it does not address issues of corrupt practices of irrational and differential
rates and charges, overcharging and excessive billing, demanding money before operation
procedures, inappropriate treatment, unnecessary surgeries, investigations and over-
prescriptions, and harassing patients and their relatives.

Challenges and the Way Forward

The implementation of the CEA, 2010 has been slow, many of the states have not framed the
rules required under the Act, and registration has not begun. In Bihar, due to a PIL (public
interest litigation), the judiciary directed the government to enact the rules and implement them.
In Rajasthan and UP, due to the opposition of the IMA, the states have been slow in enacting the
rules and implementing the Act. The bureaucracy, especially the directorate, at the state and
district levels, has been slow, since many of members of the medical bureaucracy own or are
associated with private clinical establishments. Additionally, in many states there is limited
capacity for online registration at the district level.
One of the major challenges has been the opposition by private providers, including medical
associations, as there is resistance for accountability and transparency of functioning of hospitals
and laboratories. The concerns raised with regard to the CEA, 2010 are that it is leading to
‘license and inspector raj’, curtails freedom of medical practice, and penalties are harsh. The Act
provides for provisional registration through an online system of self-declaration, with no
inspection by authorities and grant of registration is time-bound. There are only monetary
penalties and no provision for imprisonment, as the intention is compliance rather than punitive
action. The mandate in the Act that a clinical establishment should provide basic emergency care
is opposed by private players, because it is well known that private hospitals do not admit
accident victims requiring care since it can lead to medico-legal cases, or the patient may be
unable to pay for treatment costs. As this malaise is widely prevalent, the Supreme Court in 1989
passed a ruling in the case of Parmanand Katara v. Union of India,5 making it obligatory for
practitioners and establishments to provide medical care for those requiring emergency
treatment. The CEA reemphasizes the judgement that clinical establishments shall provide
medical care ‘within the staff and facilities available’ as may be required to stabilize the
emergency medical condition of the patient. Practitioners’ not treating patient seeking services
during emergency situations is against the Hippocratic Oath.
Another concern is that standards prescribed are rigid and would lead to closure of smaller
establishments and thus increase the costs of medical treatment. Presently, the national council, a
multi-stakeholder body is in the process of framing minimum standards for different categories
of clinical establishments. The IMA is represented at the national and state councils and is an
active participant and has been engaged to survey existing standards in clinical establishments
where the Act is applicable. There is no evidence that minimum standards would lead to a
closure of clinical establishments and increase costs. Their reservation that multiple bodies
govern the medical profession is baseless as in many states, no registration is required to run a
hospital or a laboratory. The Act was passed on the request of governments that did not have
appropriate legislation. The apprehensions by private providers are not based on clear reading of
the provisions of the Act. The CEA is comprehensive, far-reaching, and progressive and is the
need of the hour. Doctors need to play a constructive role by supporting it as it would contribute
to improve the quality and availability of services for the people.
What the CEA, 2010 has done is it has highlighted way the private clinical establishments
function. It has sowed the seeds for long-term changes in the manner which private healthcare
establishments function. The central Act has generated awareness and put pressure to take
necessary action to enact suitable legislations. The states of Kerala, Goa, Chhattisgarh, and
Haryana, which did not have a legislation have enacted, or in the process of, enacting it.
Maharashtra, Karnataka, West Bengal, Tamil Nadu, Delhi, Punjab, and Odisha have amended or
are in the process of amending their existing legislation.
There is a need to disseminate information regarding the CEA, 2010 to various stakeholders
and dispel fears and misconceptions that they have. Additionally, it is important that consumers
and patients are involved in the implementation of the Act and rules, which would make it more
effective.

References
Arul, P., 2016, ‘Madras High Court has “Hair-raising” Queries for Tamil Nadu Government’,
Deccan Chronicle, 14 September.
Jain, Anita, Samiran Nundy, and Kamran Abbasi, 2014, ‘Corruption: Medicine’s Dirty Open
Secret’, BMJ, 348.
Ministry of Health & Family Welfare, 2010, Annual Report to the People on Health,
Government of India, September, available at http://mohfw.nic.in/showfile.php?lid=121
Nandraj, S., 1994, ‘Beyond the Law and the Lord, Quality of Private Health Care’, Economic
and Political Weekly, XXIX(27).
National Sample Survey Office, 2014, ‘Social Consumption: Health’, NSS 71st Round: January–
June, New Delhi, Ministry of Statistics & Programme Implementation, Government of India.
Roemer, J.E., 1993, ‘Evolution and the Theory of Games; Can There Be Socialism after
Communism?’ Politics and Society, 20: 261–76.
World Bank, 1993, World Development Report 1993: Investing in Health, New York: Oxford
University Press.
 CHAPTER TWENTY SEVEN
Can Digital Technology Help Curb Healthcare Corruption?
Surajit Nundy

According to Transparency International, ‘Corruption is the abuse of entrusted power for private
gain’.1 The editors appear to have, prima facie, used the power entrusted in them by Oxford
University Press for potential gain (some or all of the massive expected royalties of this
academic book). However, was it abuse? Was there a kickback of said royalties to the editors?
Has the editors’ nepotistic choice of having this author on board let you, the reader, down? These
questions, and proving corruption, are hard to answer without more information. The same
problems of proving corruption under imperfect information exist in healthcare. If you have
better things to do than these silly internet searches and would like to check to see if the editors’
choice was indeed abuse, I hope to use the next pages to explain how technology might help
solve some of these information problems in healthcare.

The Problem Today

Imagine going to the store to buy dal (Indian lentils) for your loved ones. Imagine that the dal
seller told you that variety ‘A’ was for Rs 100/kg, variety ‘B’ for Rs 110/kg, and variety
‘Special, Incredible’ was for Rs 100,000/kg. Along with that, he also told you that eating it might
save your or, more importantly, your loved one’s, life. You would peruse the dal, examine it for
stones, and try to decide whether what the dal-seller said about the third variety was, indeed,
correct. Most of the time, and we know this because of the absence of 1,000x variations in dal
prices in stores, you would choose varieties A or B.
Now imagine going to the hospital to buy services for a loved one who is dying. Given the
same choice, and we know this because of the high variation in healthcare prices, you would
often choose to buy the Special, Incredible variety of service and the reservation about the
1,000x price differential would be overcome by the fear of your loved one’s death and the guilt
that would provoke.
Healthcare, like dal-selling, functions in a regulated market. Only some agents in such a
market can have entrusted power, for if they all did, it would not function efficiently. Therefore,
we impose higher standards of truth on some agents than others based on the level to which the
counter-agent is empowered. For example, we generally think it is okay for a dal-seller to make
outlandish claims about their extravagant dal affecting mortality in order to improve sales, for a
used-car salesperson to sell us a ‘lemon’ (Akerlof 1970), but for a doctor to do the same thing to
induce demand (Evans 1974) is morally suspect and, therefore, corrupt.
This distinction between doctors and dal-sellers (or, for that matter, used-car agents) is thus
fairly arbitrary and hard to grapple with when posed as a moral problem. However, it can be
fairly well understood and addressed when posed as an information problem.
Healthcare has always been a service where the provider caters to a sick, thus less able and
wary, consumer. The providers knows much more about healthcare than the consumer and this
resulting information asymmetry has always meant that there is a strong, almost natural,
incentive for entrepreneurial providers to induce demand in the consumer to benefit themselves
(McGuire 1991). This asymmetry that makes the healthcare market inefficient is also worsened
by opacity—for example, providers complicate the tools of their trade (anatomical parts and
prescriptions in Latin, handwriting in scrawl, training in decades) to make consumers unable to
understand what providers do. The main effect of asymmetry is to hide from the consumer what
is an effective and indicated intervention (there is ‘opacity of coverage’) and to thus also hide the
true cost of that intervention (there is ‘opacity of cost’). These opacities lead to high variations in
cost and coverage for the consumer. In countries with a lot of bundled payments like the US, a
six-time variation in price is found to be dramatic (Cooper 2015), but in India, where 70 per cent
of all healthcare payments are out of pocket, the ratio between outpatient visits can be 23 times!
(Chatterjee 2013).
This asymmetry in information is fundamental to the market (Arrow 1963) and, as a result,
consumers find it hard to safeguard their own interests. The constraints on providers have
traditionally been applied by regulation of the provision of healthcare services by the state.
Regulation, especially in poor countries like India, is blunt, slow to adapt, and dependent on the
strong presence of the rule of law. The state is also susceptible to provider takeover and, as the
Indian economy has allowed provider payments to increase, has tilted further towards provider
interests and away from safeguarding consumers. The effect has been to increase the perception
that there is corruption in the healthcare system.

Digital Healthcare
If this arms race between providers and consumers is inherent in healthcare, and the balance has
tilted towards providers, what does the future hold? To understand this, we would have to view a
typical healthcare encounter slightly differently.
A patient comes to a practitioner and gives him some information (a history). The practitioner
elicits more information from the patient (a physical examination) and uses the information they
have internalized in training to infer a list of possible problems that might be afflicting that
patient, a differential diagnosis. The practitioner recommends the eliciting of further information
from others in their network (diagnostics) to narrow that list and, at the end, prescribes some
information (a treatment plan) intended to help that patient.
Viewed by this lens, the healthcare system is a series of encounters between agents in a
network which is repeatedly eliciting, storing, sharing, filtering, operating on, and transforming
information. Humans have traditionally carried out this information work but computers in
networks can do it far better. Already, personal assistants, industrial production, even the act of
driving are being made unrecognizable by very similar processes. Healthcare is poised to follow
and be changed by this information revolution. There are two important ways in which
computers in networks will change healthcare: one, by more efficiently matching patients to
providers and two, by using Big Data and computation to support provider decisions.

Efficient Matching
It is said that Pierre Omidyar, the founder of eBay, understood an online marketplace’s value
when he found a collector of broken laser printers online to whom he could sell his broken
printer for USD 14.83. This idea, that an online system can serve as an efficient connector of
consumers and providers applies to healthcare as well.
Patients choose healthcare providers on the basis of reputations that are largely opaque. These
reputations are based on ‘soft’ factors and not value (it is thought that the ABCs of a doctor’s
reputation are availability, bedside manner, and competence, in that order). These reputations are
distributed inefficiently by word of mouth, and have little accountability built into them. In
contrast, there has now been two decades of experience during which networked reputations of
other types of service providers, such as sellers on Amazon and eBay, have been used effectively
by consumers to make informed buying decisions (Resnick 2002). There are limits, however;
healthcare reputation engines, in contrast, have been hard to develop because of the limits
imposed by patient privacy and because of the large information asymmetry which make it hard
for consumers to fruitfully compare providers by crowdsourcing. These frictions are actually
fundamental to the internet and its marketplaces, for example, in rental markets like Airbnb
(Fradkin 2015). However, it is hard to imagine that reputation algorithms in healthcare won’t use
this prior learning to scale those asymmetries as more and more information is digitized,
computed on, and networked.
The internet has brought transparency to the cost of goods and services. Networked agents are
now able to buy and sell their goods and services on platforms like TripAdvisor (vacations) and
Alibaba (goods suppliers), where information about cost is made transparent to consumers—
information that informs their buying decisions (Resnick 2002). The cost of healthcare services
has traditionally been opaque, not because the inherent cost of an individual service is hard to
estimate,2 but because, under fee-for-service models, the bundle of services required to treat an
individual patient for a given condition has a high degree of uncertainty. This uncertainty is
exploited by providers in their favour and consumers do not have the information to respond
appropriately (Nimdet 2015). A patient can be induced towards the unnecessary and sometimes
harmful Special, Incredible service by a provider in a manner that increases the amount of money
that the provider earns with the patient being none the wiser.
When a patient sees a doctor, she is sick and is not in a position to understand whether her
treatment is worthwhile. While many people now consult the internet to self-diagnose their
symptoms, these queries are hard to perform effectively, especially when compared with the
decade(s) of training that providers must go through. Providers are trained to assert that they are
acting in the best interests (are thus fiduciaries) of the consumer and patients, in their uninformed
and un-empowered state, often just accept what the provider tells them is the quality of the
service. While this is a historical necessity due to the information asymmetries between provider
and consumer, technology now supports consumer decision-making. Services like Uber are able
to close the loop on service-quality estimation by combining data generated while the service is
being provided, with more human factors like customer ratings, thus reducing the average
number of complaints about ride-sharing (Wallsten 2015).
Healthcare markets are different from low-cost consumer services, because curing morbidity
and saving mortality is much more valuable to consumers than having a good taxi ride. In places
like India, people are willing to sell their land, fall into poverty, and go into debt paid off over
generations in order to pay for a loved one’s health. This makes efficient matching a little
tougher, but it is still estimable. The cost of a year of life (usually a ‘quality adjusted life year’ or
QALY [quality-adjusted life year]) from the health system’s perspective, the cost threshold per
QALY can be applied across populations (about USD 50,000 for the US). For individuals,
however, it is a function of their ability and willingness to pay, and in India, the comparable
number for most is far, far lower and far more variable (Nimdet 2015).
What effect will this coming digital revolution have on variation in healthcare costs? The
experience of large, distributed systems such as ad-auction systems (for example, Facebook,
Google) and goods-selling systems (for example, Amazon) for the past decades is that they (1)
have brought down costs by removing the number of intermediaries in a transaction, thus
efficiently allocating resources (Cohen 2016), (2) have reduced variation in costs presented to the
individual by providing buyers and sellers with more information, and (3) are providing a service
that is more valuable to the consumer (Wallsten 2015).

Big Data and Computation

Healthcare, viewed in this manner, is information science, one where masses of empirical data
can be brought to bear towards treating the problems of a single patient.
Traditionally, that data has been collated and curated so that it can be learnt by medical
students in training. This training is long and arduous and involves branching points, called
specializations, that ensure that the nascent provider, once autonomous, adds value and is not
dangerous. Once trained, these providers elicit further information from their patients in order to
cure them. Over time, providers, by internalizing the data gained from their own experience with
their patients as well as data from their colleagues, become better and better at their vocation.
This model of agent-based delivery ensures better care with data over the working lifetime of an
agent.
Computers in networks learn differently. They, too, take in learning by storing algorithms
(programmes) as well as data from sensors that they use to improve. However, the important
difference between them and human agent-based delivery is that they are not multiple agents but,
in effect, one aggregated agent. This agent has no limitations on storage and can quickly
integrate data from, effectively, unlimited sources and sensors (Big Data) in order to do
computations. For example, Google Search can quickly compute unlimited (effectively) bids in a
distributed manner in order to come up with a price for its ads.
Computers can also now do things that humans could never do. They can play games like
chess and Go better than any known human. They can now translate text from one language into
another that they have never heard before (Schuster 2016).
Imagine if, when a patient went to see their healthcare provider, the provider already knew the
whole history of the patient. Not the whole history as related by the patient or elicited by
questions, but, for example, the whole history of how the patient’s blood pressure had varied, the
history of their DNA and epigenetic profile, what their food intake had been, what places they
had visited, how many steps they had taken, who they had talked to, and how much stress they
had endured. And imagine if the computation on this history had already been compared with the
history of billions of other humans in order to create a personalized estimate of what was wrong
with the patient. And now imagine that the patient doesn’t have to go to see a provider when they
are feeling unwell. That the computation will flag when a patient is about to do something that is
likely to make them sick as well as flag when a patient can do something that is likely to improve
their health.
The cost of such computation is large initially but, once created, it is small to provide to more
and more consumers. This cost is likely to fall below the cost of providing similar services with
human agents, in the manner that has already affected the travel industry. The promise of the Big
Data on healthcare is that it will inform providers and consumers with information that they
could never have possibly accessed with traditional human agent-based delivery, improving
healthcare to levels previously never imagined.

The Future
There are things we should be concerned about. Having large platforms intermediate large
marketplaces means that the platforms become very strong and, sometimes, the incentives of the
platforms do not align with those of the consumers or providers (Armstrong 2011). When a
technology becomes sufficiently advanced that humans can’t understand it anymore, we humans
(I am presuming that most of the readers who are still reading are humans) are likely to become
very wary of it and its actual goals, especially if it is engaged in the life-and-death situations of
human healthcare. These concerns will have to be watched carefully, as we prepare for the
inevitable digitized future.
Someone recently took a taxi ride and had the following experience. They could have taken a
pre-paid taxi and paid Rs 200 but there were no taxis available. Nearby, an online radio-cab was
willing to transport him for Rs 950 under ‘surge pricing’. Now irate, he went back to pre-paid
service where he was asked for a bribe of Rs 700 by the pre-paid cab driver and, upon paying it,
a cab magically appeared.
When the fundamental problem afflicting the healthcare system is viewed as an information
problem, the idea of corruption, as elaborated in this book, dissipates. That moral idea is
replaced by the idea of information, that is, what the real price of the healthcare service actually
is. The future of digital healthcare will make us, as individuals and as a society, focus more on
the information flows in the system and forget about the idea of corruption.

References
Akerlof, G., 1970, ‘The Market for Lemons: Qualitative Uncertainty and the Market
Mechanism’, Quarterly Journal of Economics, 84: 488–500.
Armstrong, M.A., 2011, ‘Paying for Prominence’, Economic Journal, 121: F368–F395.
Arrow, K.J., 1963, ‘Uncertainty and the Welfare Economics of Medical Care’, The American
Economic Review, 53: 941–73.
Chatterjee, Sushimita, 2013, ‘Unit Cost of Medical Services at Different Hospitals in India’,
PLoS ONE, 8(7): e69728.
Cohen, Peter, 2016, ‘Using Big Data to Estimate Consumer Surplus’, 30 August, available at
https://cbpp.georgetown.edu/sites/cbpp.georgetown.edu/files/ConsumersurplusatUber_PR.PDF
accessed on 1 January 2017.
Cooper, Zack, 2015, ‘The Price Ain’t Right? Hospital Prices and Health Spending on the
Privately Insured’, National Bureau of Economic Research, December, available at
http://www.nber.org/papers/w21815, accessed on 1 January 2017.
Evans, R., 1974, ‘Supplier-induced Demand: Some Empirical Evidence and Implications’, in M.
Perlman, The Economics of Health and Medical Care, London: Macmillan, pp. 162–73.
Fradkin, A., 2015, ‘Search Frictions and the Design of Online Marketplaces’, MIT, 30
September.
Hsiao, W., 1988, ‘Results, Potential Effects, and Implementation Issues of the Resource-Based
 Relative Value Scale’, Journal of the American Medical Association, 260(16): 2429–38.
McGuire, T., 2000, ‘Physician Agency’, in A.J. Culyer, The Handbook of Health Economics,
Vol. 1, Amsterdam: Elsevier, pp. 462–536.
McGuire, T.A., 1991, ‘Physician Response to Fee Changes with Multiple Payers’, Journal of
Health Economics, 10: 385–410.
Nimdet, K, 2015. ‘A Systematic Review of Studies Eliciting Willingness-to-Pay per Quality-
Adjusted Life Year: Does It Justify CE Threshold?’ PLoS ONE, 10(4): e0122760.
Resnick, P.R., 2002, ‘Reputation Systems: Facilitating Trust in Internet Interactions’,
Communication of the ACM, 43(12): 45–48.
Schuster, Mike, 2016, ‘Zero-Shot Translation with Google’s Multilingual Neural Machine
Translation System’, 22 November, available at
https://research.googleblog.com/2016/11/zero-shot-translation-with-googles.html, retrieved
from Google Research Blog.
Wallsten, S., 2015, ‘The Competitive Effects of the Sharing Economy: How is Uber Changing
Taxis?’ T.P. Institute, Producer, available at
https://www.ftc.gov/system/files/documents/public_comments/2015/06/01912-96334.pdf,
accessed on 1 January 2017.
 CHAPTER TWENTY EIGHT
Healthcare Corruption: Responses from People’s Health Movements
Abhay Shukla

Dard ka had se guzar jaana hai, dava ban jaana

(When the pain crosses all limits, it becomes the treatment)

—Ghalib

The evolving response of citizens and health movements to medical malpractices in India needs
to be located in the broader context of growing commercialisation of healthcare in the neo-liberal
era. The trajectory of the private medical sector in India, from the 1980s to the second decade of
the twenty-first century, is the story of transformation of a once noble profession into an
increasingly profit-seeking business, now in danger of being transformed into a corporate racket.
Medical practice, once regarded as an honorable profession with firm roots in society,
increasingly became detached from its social anchoring, and got sucked into the ruthless world
of commerce. Doctors who were traditionally disciples of Saraswati (the goddess of knowledge),
were lured by Lakshmi (the goddess of wealth) to such an extent that an increasing proportion
began to indulge in gross malpractices, with systematic deviation from the norms of rational
therapy.
Swept by the winds of commercialization penetrating all spheres of society, and encouraged
by a ‘leave it to the market’ policy that took hold from the 1990s, medical care became a
booming business. Starting with doctor-run smaller private hospitals and ‘nursing homes’ in the
1980s and 1990s, as the new millennium progressed, larger multi-speciality hospitals and
corporate hospitals began to dot the landscape of Indian cities. In these commercial enterprises,
business houses and ‘medical entrepreneurs’ began to call the shots. Ordinary doctors were
persuaded to trade their consciences for cash and become accomplices, or were threatened with
being relegated to the sidelines of the lucrative game. While public hospitals languished due to
stagnant funding and political neglect, the increasingly consumerist middle class began to flock
to ‘medical malls’. Even the poor were often forced to take heavy loans and sell scarce assets to
seek treatment in private hospitals. However, by the second decade of the new century, society’s
romance with the glittering private medical sector has begun to receive rude jolts, as the ugly
side of commercialization begins to surface. Unnecessary and irrational procedures, medical
malpractices, and gross overcharging have become common experiences, while doctor-patient
communication is breaking down. Ordinary patients have no effective mechanisms to ensure
redressal, except for prolonged, adversarial litigation in the limited proportion of cases which
deal with medical negligence, and this, too, often turns out in favour of the doctors.
This is the troubled context in which now slowly but surely, sections of society have begun to
move towards making private healthcare accountable, and asserting patients’ rights to care free
from malpractices, violations, or exploitation. It has long been recognized across the world that
delivery of healthcare and the practice of medicine should not be organized as a purely
commercial activity dictated by the market. This sector, more than perhaps any other sphere of
human activity, is notorious for ‘market failure’, yet policymakers in India have conveniently
turned a blind eye to this lesson over the last several decades. Now, with popular discontent
related to private healthcare reaching massive proportions, society is learning its lesson the hard
way. Interestingly, it is often sections of the same middle class which was enamoured with
commercial private hospitals, that is now beginning to speak up against malpractices, though this
is still fragmented. What was until now widespread but individual grumbling, is becoming
crystallized into the rumblings of demands for change. In this chapter we will discuss how this
long-neglected lesson is being painfully learned by society, in the context of India. This appears
as a painfully slow process, encountering major obstacles and resistance from organized vested
interests in the healthcare sector. Much of it appears like the story of Sisyphus, a saga of
continued efforts which have been repeatedly stymied. To understand why it has been so, yet to
also gain an insight into how we might move beyond this situation, let us first have a look at the
barriers the health movement has been up against when dealing with the private medical sector.

Barriers to Popular Mobilization and Policy Change Regarding the

Private Medical Sector
Special interests tend to control particular areas of policy, unless public interests are organised.
The role of public interest groups…is to intervene in politics to redress the balance of power, to
the benefit of the public.
—Andrew McFarland1

A complex combination of factors has retarded popular resistance to medical malpractices in

India, despite these becoming increasingly widespread and serious. Firstly, unlike many other
social issues which have some ‘core constituency’ based on directly affected groups (for
example, displaced populations against land acquisition, adivasis for forest rights, trade unions
for workers rights, etc.), despite its universality, the issue of healthcare is peculiar in lacking a
clear supportive constituency. Two directly concerned groups—doctors and patients—are, for
differing reasons, often not well suited as entire sections, to lead a sustained struggle against
medical malpractices. The former because large parts of the medical profession are themselves
deeply embroiled in the creation and perpetuation of the problem, and the latter because of their
major vulnerability, frequent infirmity, and scattered nature. This, of course, does not minimize
the fact that small sections of doctors, as well as particular affected groups such as people living
with HIV/AIDS, have significantly contributed to such struggles (we will revisit this point later).
Yet overall, the issue of malpractices and corruption in healthcare, which actually concerns
everyone, paradoxically might appear to be ‘nobody’s baby’.
Further, it is often asserted that healthcare is a ‘low priority’ for ordinary people. While there
is an element of truth in this assertion, it would be more accurate to say that healthcare is an ‘off
–on’ priority for most. This means that most of the time, when in the family there is no morbidity
or occasion to seek healthcare, it is an ‘off’ priority; yet when serious illness strikes, it becomes a
significant priority, maybe even top priority, for some period of time. However, this often
episodic nature of healthcare seeking, which tends to shift across individuals and families over
time (with the exception of chronic illness) makes the development of sustained solidarity and
mobilization difficult.
Also, there is no doubt that doctors are by and large still placed on a pedestal by society
(despite all the misdemeanours of the medical profession!) and an ordinary person would be
reluctant to confront his or her doctor for the provision of substandard service, compared to our
attitude towards say, a shopkeeper, clerk, or taxi driver. Compounding the well-known, massive
‘knowledge asymmetry’ between doctor and patient are major hierarchies of power and prestige,
which often prevent people from directly challenging medical malpractices.
Perhaps the most daunting barriers in this context relate to enforcing public accountability of
private actors—which is how privately owned hospitals are generally viewed. Of course most
private healthcare providers conveniently claim ‘private legal status’ as well as ‘publicly
supported privileges’ in different settings as it suits them. It is fascinating to observe how the
growth of the private medical sector in India over the decades, through massive direct and
indirect public subsidies—such as subsidized land and lakhs of doctors educated at substantial
public cost—has been accompanied by a complete refusal of this sector to accept public
accountability and related regulation. This situation makes it difficult for people to make even
basic claims in private hospitals (such as demand for patient information, standard rates of
services, or medical records) compared to public hospitals.
As noted by McFarland in the opening quote for this section, when private interest groups,
even though small, are well organized and resourced, they can override decades-long
unorganized public interest. In India, the well-known influence of the private medical lobby on
politicians and the state is testimony to this fact. Needless to add, the only way to move forward
in this situation is for public interests to become far more organized, of which we will present a
few examples later.
Finally, it needs to be recognized that the struggle against medical corruption and
malpractices in India becomes particularly complex because it is not just a contention between
two adversaries (for example, civil society vs the state) as in case of many social struggles, rather
it is a triangular tussle involving citizens, the healthcare industry, and state. This leads to a
situation where social organizations need to simultaneously tackle two large and powerful actors
—the private medical sector and the government—in an unfolding struggle with often shifting
alliances and terrain.
Though this range of challenges is definitely daunting, they are not insurmountable, and social
mobilization around the distortions of market-driven healthcare has been gradually developing in
India despite all these barriers, as we will see in the further sections.

Initial Efforts in Maharashtra to Promote Patients’ Rights and the

Regulation of the Private Medical Sector2
‘The arc of the moral universe is long, but it bends towards justice.’
—Theodore Parker, US abolitionist

For various reasons, Maharashtra is one state where citizens’ efforts around checking medical
malpractices and ensuring regulation of private hospitals have been pioneered in the Indian
context. Initiatives such as a PIL (public interest litigation) by the Bombay chapter of Medico
Friend Circle (MFC) to press for regulation of private hospitals in the late 1980s and early 1990s,
and activities of the Forum for Medical Ethics Society, including the publication of the Indian
Journal for Medical Ethics3 from 1993 onwards, have formed an important basis for further
efforts. One of the pioneering documentations of medical malpractice in India was led by
Mumbai-based activists, leading to publication of the book, Medicine, Market and Malpractice
(Jesani at al. 2004) in 2004. From the mid-2000s onwards, led by the Jan Arogya Abhiyan (JAA)
or Jan Swasthya Abhiyan (JSA)—Maharashtra, systematic efforts were initiated towards making
private healthcare services more accountable, with a twin focus on promotion of patients’ rights
and ensuring people-oriented regulation of the private medical sector.

Campaign to Protect Patients’ Rights through Bombay Nursing Home

Registration Act (BNHRA), 2005–2009
Right from its inception, JAA had been advocating the protection of patients’ rights by making
suitable changes in the Bombay Nursing Home Registration Act (BNHRA) of 1949. When an
official process was underway in 2005 to make modifications in the rather obsolete and
minimalistic BNHRA, JAA mobilized public opinion towards including in the amended Act,
provisions for protection of patients’ rights. The Maharashtra state legislature amended BNHRA
in December 2005, but unfortunately, the modifications were minimal in nature. Responding to
JAA’s criticism that the amended Act did not address patients’ rights, the directorate of health
services promised to consider this issue while formulating the rules under this amended Act.
Given this background of advocacy by JAA, the directorate of health services offered that the
preparation of draft rules could be facilitated by CEHAT (Centre for Enquiry into Health and
Allied Themes), a health-sector civil-society organization with a recognized track record of work
in health rights, which was associated with JAA. During the consultations facilitated by CEHAT,
key stakeholders including representatives of medical associations, concerned health officials,
health activists, and socially oriented lawyers discussed the draft rules which could be adopted to
accompany the amended BNHR Act. The JAA activists played a crucial role in this process, and
succeeded in ensuring inclusion in these draft rules, several provisions to promote patients’ rights
and accountability of private hospitals. These amended rules were displayed by the director of
health services on the official website in July 2006, for feedback and suggestions from the public
at large, and it was expected that these amended rules would soon be published in the Gazette,
following the health minister’s formal consent.
However, providing testimony to the powerful influence of the private medical lobby, the
government of Maharashtra never got around to adopting these draft rules, which had been
developed through consensus among various stakeholders. Jan Arogya Abhiyan conducted a
signature campaign in 2006, demanding approval to the draft BNHRA rules, including the
protection of patients’ rights, which attracted a few thousand signatures from across the state. A
web-based petition in mid-20094,5 addressed to the health minister with similar demands also
attracted significant public support, but apparently these popular efforts were not sufficient to
convince the government to stand up to resistance by the private medical sector, which has so far
refused to accept even moderate reforms towards its accountability.

Patients’ Rights Forum and Charter of Patients’ Rights: 2009–10

In the meanwhile, a parallel front of action was opened in Pune, the second-largest city of
Maharashtra, whose citizens are known for historically supporting various progressive causes. In
mid-2009, the idea of forming ‘Rugna Hakka Samiti’ or the ‘Patients’ Rights Forum’ was
floated. This city-level body for promoting popular awareness and dialogue around patients’
rights was launched by organizing a ‘Patient’s Rights Convention’ in July 2009.6 In this
convention, which was presided over by Dr Narendra Dabholkar, around 150 citizens and social
organizations participated. This included well- known social figures and activists as speakers, as
well as the Pune-based representatives of the Indian Medical Association (IMA) and Hospital
Owners’ Association. The latter publicly supported patients’ rights in principle, but they were
wary of related legal provisions, which they felt might be used by official inspectors to harass
them.
Based on the positions emerging from the convention, and the willingness of the IMA to
engage with proposals for patients’ rights, members of the newly formed Patient’s Rights Forum
and JAA organized a series of discussions with representatives of medical professional
associations in Pune in the second half of 2009 and early 2010. The core agenda was the
development of a patient-friendly but realistic charter of patients’ rights and responsibilities in
the context of private hospitals. The JAA, Patient’s Rights Forum, Pune branch of the IMA, and
the national president of the Federation of Obstetricians and Gynecologists (FOGSI) drafted a
joint Charter of Patients’ Rights and Responsibilities.7 This charter was publicized through a
media conference in February 2010, which was addressed by representatives of all these
organizations. This was followed by publication of booklets and posters to publicize the charter,
and a dialogue with various doctors, suggesting that they might display this in their clinics or
hospitals. The charter became a significant consensus document which informed further
advocacy and policy processes, yet given the absence of legal support at that time, it could not be
implemented widely.

Advocacy for Amended Clinical Establishments Act in Maharashtra:

2012–14
By the end of the first decade of the twenty-first century, an important national development took
place in the form of the central government adopting the Clinical Establishments Act, 2010. This
was followed by issuing associated rules in 2012. The rules contain important positive provisions
such as standard treatment guidelines and regulation of rates to be observed by private hospitals.
However, the Act and rules have no provisions requiring clinical establishments to protect
patients’ rights and also lack mechanisms for grievance redressal and involvement of citizen’s
organizations at the district level. Keeping in view both strengths and weaknesses of this set of
national legislations, the JAA adopted a strategy of asking for an improved state-specific
Maharashtra Clinical Establishments Act (CEA). Key additional provisions proposed have been
the need to ensure ‘social regulation’ through district-level multi-stakeholder bodies, including
civil society groups, and explicit provisions for the protection of a range of patient’s rights.
As part of the campaign for such regulation, JAA organized a mass demonstration focused on
the demand for an improved state CEA including patients’ rights, during the winter session of the
Maharashtra state assembly (which is held at Nagpur) in December 2012. Around 200 activists
from a dozen districts across Maharashtra marched to the assembly, bearing bandages (as
symbolic ‘patients’) and masks, chanting slogans like ‘Stop cheating by private hospitals’,
‘Adopt the Act for regulation of private hospitals in Maharashtra’, and ‘Protect patients’ rights’.
This was followed up in 2013, by persistent advocacy for an improved Maharashtra CEA,
including lobbying with the health minister through a socially oriented member of parliament
from Maharashtra, who belonged to the ruling party.
These efforts resulted in a broad-based meeting in December 2013, involving the state health
minister, JAA activists, and representatives of the Maharashtra Medical Council and IMA.
During this meeting, the decision was taken to draft a Maharashtra State Clinical Establishments
Act, which would be based on the national CEA, but would include modifications to address the
concerns of both patients and doctors. A 19-member committee was set up to prepare the draft,
convened by the chairperson of Maharashtra Medical Council (also a long-standing leader of
IMA in Maharashtra). Most members were state health officials and representatives of doctors’
associations, while two members were doctors associated with the health movement. After nearly
six months of deliberations and rounds of drafts, the modified CEA for Maharashtra was
prepared in June 2014.
This draft was an improvement over the national CEA, due to explicit inclusion of a charter of
patients’ rights, district-level grievance redressal bodies, and certain other improvements.
However, the critical provision for regulation of rates was dropped in the state draft bill, due to
resistance from medical associations. The draft bill was endorsed by the directorate of health
services and the law department, and was accepted by the health minister. Shortly after this,
though, state assembly elections were held in Maharashtra in October 2014, leading to the
incumbent Congress–NCP alliance being swept out of power, which was replaced by a victorious
BJP–Shiv Sena coalition. Once again, with the change in political leadership at the state level,
the draft Maharashtra CEA went into suspension, and the long-standing vision of patient-
oriented regulation of private hospitals began to appear like a mirage.

Sowing Seeds Nationally for Civil Society Action on the Private

Medical Sector
‘There may be times when we are powerless to prevent injustice, but there must never be a time
when we fail to protest.’
—Elie Wiesel

While action on patients’ rights and regulation of the private medical sector was pioneered in
Maharashtra, from 2013, organized efforts across various states also emerged to promote
awareness on this theme. This was accompanied by advocacy by Jan Swasthya Abhiyan (JSA) to
influence from a pro-patients’ viewpoint, the development of standards for the national CEA,
2013–15. Subsequently, some JSA state units initiated the documentation of the violation of
patients’ rights for public hearings, to be organized by the National Human Rights Commission
(NHRC) in collaboration with JSA (2015–16).
A health-sector civil-society organization SATHI (Support fro Advocacy and Training to
Health Initiatives), working with a rights-based approach in Maharashtra, had played an active
role in supporting several activities described above. Taking this agenda forward, SATHI, in
collaboration with JSA units and civil society groups in various states, conducted a series of
regional workshops across India in 2013–14. The theme for these regional workshops was
‘Promoting Patients’ Rights And Ensuring Social Accountability Of The Private Medical
Sector’, and were organized8 in Bengaluru (southern region), Ahmedabad (western region),
Raipur (eastern region), and Delhi and Lucknow (northern region). In case of many states, this
was the first time that issues like patients’ rights in private hospitals, and status of regulation of
the private medical sector at the state level were discussed in detail. These topics generated
considerable interest among civil society activists, and subsequently, health activists begin to
raise patients’ rights issues in a systematic manner in certain states. Notable was the ‘Mariz Haq
Abhiyan’ (‘Patients’ Rights Campaign)9 coordinated by the Healthwatch network in UP, which
documented cases of serious violation of patients’ rights across the state, and presented these at a
well- attended state-level public hearing. In Chhattisgarh, the JSA network initiated a state-level
campaign to build popular awareness and promote implementation of patients’ rights, provisions
for which were included in the State CEAs, but had not been implemented until then.
Along with civil society mobilization within states, from 2013 onwards, JSA conducted
advocacy related to the national CEA, focused on ensuring inclusion of patients’ rights in the
national standards which were being developed to enable the implementation of the Act and
rules. Following a meeting of a JSA delegation with the secretary of the Union Health Ministry
in August 2013, JSA submitted a set of suggestions regarding implementation of CEA, including
a proposed Charter of Patients’ Rights. Representatives from the JSA also participated in some
of the sub-committees involved in developing various aspects of the standards for clinical
establishments. The outcomes of this engagement were positive but limited, leading to inclusion
of some of the patients’ rights-related provisions in the standards for hospitals at various levels.
In hospital standards10 (sections 10.2/10.3), it is mentioned that in all hospitals, ‘Patient shall be
guided and informed regarding Patients’ rights & responsibilities’. However, for some reason,
the actual charter has so far been included only in standards for Level-1 hospitals (annexure-8). It
is notable that this charter is almost entirely based on the submissions made by JSA, and the
mentioned joint charter that had been developed in Pune in 2010.
Another front for action, which has helped to develop awareness and documentation, though it
could not achieve its primary objective, emerged with the decision taken by NHRC in mid-2015,
to conduct regional public hearings on the right to healthcare across the country, in collaboration
with JSA.11 That the scope of hearings would allow presentation of violations related to both,
public and private health sectors, was spelled out in the agreement signed between NHRC and
JSA. Based on this, JSA mobilized and organized over 30 preparatory workshops and meetings
in all regions of the country during the second half of 2015. Health activists across the country
were oriented regarding documentation of the denial of patients’ rights in private hospitals, along
with recording instances of health rights violations related to the public health system. In the
western region alone (Maharashtra, Gujarat, Rajasthan), around 25 cases of patients who had
suffered serious rights violations in private hospitals were documented.
After considerable such groundwork and preparation, the first in the series of NHRC-JSA
hearings on right to healthcare, covering the western region of the country, was organized at
Mumbai in January 2016,12 attracting an overwhelming response with around 650 participants
from across the region. While cases of denial related to public health services were given a
hearing, when patients who had suffered violations in private hospitals—and had been duly
registered by NHRC—attempted to speak, they were refused a hearing by the NHRC on the
grounds that such cases were beyond the commission’s mandate.13 Needless to say, this was a
major setback to dozens of ordinary patients and civil society activists especially from
Maharashtra, who had undergone months of preparation for this public hearing. However, even
this bitter lesson was later to provide certain fruits for furthering the health movement, as we
shall see below.
New Alliances, New Forms of Movement
‘Either we invent, or we are making an error.’
—Simon Rodriguez

This essay so far might appear like a ‘chronicle of blocked efforts’, which is testimony to
massive resistance of the private medical sector to accept any form of accountability, along with
extreme sluggishness of the state in regulating this sector, which together often stalled the
people’s health movement on this front. Even relatively straightforward provisions, like
protection of basic patients’ rights, have taken over a decade to be recognized officially in any
form. However, this otherwise rather depressing story seems to now be taking a more hopeful
turn. While it is too early to predict outcomes, a series of promising developments from 2016
onwards offer hope that the struggle to establish patients’ rights, and to check malpractices in the
private medical sector, may finally be moving towards achieving society-wide visibility and
impact.

Dissenting Doctors Begin to Find Their Voice

Many might agree that an important watershed regarding bringing malpractices in the private
medical sector into the public discourse in India was the publication of the popular book,
Dissenting Diagnosis (Gadre and Shukla 2016). To begin with, leading a study by SATHI, Arun
Gadre interviewed 78 doctors across the country about their experiences related to malpractices
in private medicine. Most of these purposefully selected doctors were whistleblowers, who
revealed striking instances of commercially dictated unethical practices by their colleagues in
private hospitals. This study was converted into the Marathi bestselling book Kaifiyat, authored
by Arun Gadre in May 2015. Encouraged by the popular response, Arun Gadre and the author of
this essay then jointly authored a significantly expanded version in English, which was published
in May 2016 under Dissenting Diagnosis. This book has evoked widespread popular response,
been reviewed in nearly two dozen periodicals and websites, and covered by television
programmes, with videos circulated on innumerable WhatsApp groups. Finally, widely felt
popular dissatisfaction regarding medical practices, which had hitherto been confined to closed-
door gossip and personal anecdotes, was now formally placed in the public domain, substantiated
by powerful testimonies from a sizeable section of the medical profession itself.
It is not surprising that this joint articulation of ‘voices of conscience’ by a section of doctors
was accompanied by formation of a related organization. A national network of doctors
supportive of ethical and rational healthcare emerged in 2015–16, in form of the Alliance of
Doctors for Ethical Healthcare (ADEH).14 Senior practising doctors from Punjab, Kerala,
Maharashtra, West Bengal, Delhi, and other states signed on to a declaration of the network,
which began to take public stands on key policy issues concerning the medical profession.
Notable interventions by ADEH so far have been demands for major reorganization and reform
of the Medical Council of India (publicized through a national programme in May 2016),
submission of a range of suggestions to Niti Aayog regarding the draft National Medical
Commission Bill (October 2016), and intervention in the cardiac stents pricing issue by
participating in consultations by the National Pharmaceutical Pricing Authority (NPPA), all of
which have been covered by the media. Given the inward-looking and largely ‘doctors’ lobby’-
oriented nature of the mainstream medical associations, ADEH is seeking to provide an
alternative voice from within the medical profession and is working for major reforms in the
healthcare sector. This effort is gaining support from numerically small but socially significant
sections of doctors, who are seeking change.

Dialogue, Demystification, Direction for Care—Emerging Citizen–Doctor

Forums
What can be regarded as another spin-off from Dissenting Diagnosis has been the recent
formation of novel social platforms in a few major cities, all of which have adopted the rubric of
Citizen–Doctor Forum (CDF). These emerging forums mostly led by the urban middle class fed
up with gross commercialization of private healthcare and all its negative impacts. Mostly active
citizens and some rational, ethical doctors are coming together on a common platform to
organize feedback and information systems, which would raise awareness and enable people to
access more rational care. In some cases, there is also an attempt to raise policy issues related to
regulation of the private medical sector. So far in Maharashtra, such forums have been developed
in Mumbai and Pune, while incipient forums have been launched in Chennai and Jaipur. Here,
we will briefly describe the forums in Maharashtra.
The Mumbai Citizen Doctor Forum emerged from a series of events in 2016, of which two
are notable. The first was the western region public hearing on right to healthcare organized by
NHRC and JSA in January 2016 (mentioned above). From Maharashtra, around 20 patients and
families who had major grievances, among which some had suffered serious bodily loss related
to mismanaged care in various private hospitals, approached this hearing with the expectation of
redressal. Several of them had extremely negative experiences of existing redressal mechanisms
such as the state medical council. Unfortunately, NHRC failed to provide them even with a
hearing, on procedural grounds. However, since many of them were from Mumbai, after the
hearing, on the suggestion of JAA, they began to meet and discuss—as ‘medical victims’—how
to take forward their quest for justice, and the idea of a forum was floated.
Subsequently, a few months later that year, a public programme was organized by SATHI in
collaboration with the Times of India group and other like-minded organizations, on Doctors
Day (1 July) in Mumbai.15 Due to the media publicity and given popular relevance of the issue,
despite the pouring Mumbai monsoon, the meeting hall was packed to capacity by busy
Mumbaikars. Certain prominent, senior doctors from Mumbai strongly critiqued the growing
unethical practices in their profession, while active citizens also voiced the need for effective
redressal of problems faced by patients. There was general agreement on the need for a regular
forum including both ethical doctors and active citizens, to address this critical situation. These
events helped to concretize the Mumbai Citizen Doctor Forum, which expanded and has
continued to meet on a monthly basis, discussing key problems being faced by patients and
citizens concerned with healthcare. The forum has voiced popular opinion in the media and has
begun to campaign on key issues like the need for the reorganization of the Maharashtra Medical
Council,16 especially its ethics committee meant to deal with complaints of unethical practices by
doctors; regulation of rates of services in private hospitals and ambulance services;
standardization of dialysis centres in the city; and the demand for the enactment of a CEA with
protection of patients’ rights.
The Pune Citizen–Doctor Forum has taken a somewhat different trajectory, focusing on the
development of a web-based system enabling ordinary people to both suggest doctors with
whom they have positive experiences, and to give feedback about various doctors. The emphasis
is on rating doctors based on their transparency and willingness to provide information to
patients. On World Health Day (7 April 2017) Pune CDF was formally launched, along with
inaugurating the website medimitra.org, during a well-attended public programme where a
significant cross-section of Pune’s middle class, known for its social awareness, participated. A
small but significant set of doctors who seek to promote rational, ethical healthcare is also
actively participating in this process.
It is important to note that through these emerging forums, a vocal and active constituency of
concerned middle-class people is getting crystallized around their serious concerns related to
medical care. In addition, a small section of doctors is also searching for means to resist
commercial pressures to engage in unethical practices, and would like to support a system which
promotes rational healthcare. Such citizen-doctor forums are promising platforms which bring
together these two key constituencies, with the hope that in the coming period, they will act
together synergistically to raise social awareness and develop alternatives to current malpractice-
driven healthcare.

Organizing Public Interest to Regulate Private Profiteering—From

Crisis to Change
‘First they ignore you, then they ridicule you, then they fight you, then you win.’
—Mahatma Gandhi

As outlined in the earlier sections, citizens’ mobilization to challenge and address medical
malpractices has so far faced serious barriers, including resistance from the medical industry and
apathy from governments. Nevertheless, efforts have gradually moved forward, and a few key
lessons that emerge from experiences until now include:

• Building on people’s experiences of serious problems faced in private hospitals linked with
lack of regulation, campaigning for patients’ rights can become an important basis for
citizens groups and civil-society organizations to work for patient-oriented regulation of the
private medical sector. Linked to this, any demand for a regulatory framework regarding the
private medical sector must include asking for provisions on patients’ rights, which expands
the scope for ensuring citizen-oriented accountability of healthcare providers.
• Standard models for regulation of the private medical sector are highly prone to ‘expert
capture’ and ‘elite capture’, with domination by the private medical lobby and technocratic
officials, while excluding ordinary people and patients. Hence there is need to propose multi-
stakeholder participatory bodies to oversee regulatory processes. Such ‘social regulation’
based on wider accountability of regulators is an emerging framework, which needs to be
discussed and developed through appropriate legal and operational mechanisms.
• Given the lack of ‘core constituency’ on health issues, it is necessary to innovatively develop
social coalitions to promote patients rights. Active citizens need to be sensitized and
brought together, along with identifying and involving numerically few but socially impactful
doctors who are seeking alternatives to the current situation of gross commercialization of
healthcare. Such platforms need to be widely publicized through the media, especially
through social media networks.

Overall, despite limited success in ensuring policy-level changes related to patients’ rights
until now, it appears that the tide might be turning in favour of patients and ordinary people. The
recent legal process culminating in the decision by National Pharmaceutical Pricing Authority
(NPPA) to regulate prices of cardiac stents (February 2017) is a fascinating case study. Based on
a PIL filed by Delhi-based lawyer Birender Sangwan,17 and persistently supported by research
and media advocacy, led by civil-society networks such as the All India Drug Action Network
(AIDAN),18 and with inputs from the recently formed ADEH,19 the Department of
Pharmaceuticals and NPPA was moved to take a decision for such price regulation.20 This
demonstrates how a reluctant state, operating under the shadow of a powerful and largely
unaccountable medical industry, was pushed by citizens’ action into enforcing price controls in
an area marked by huge profiteering. It has been estimated that the stent scam involved
overcharging of patients in India to the tune of Rs 3,500 crore per year in recent years.
Imposition of a ceiling on the prices of stents and bringing down their costs for the consumer on
an average by over 70 per cent should be regarded as an important victory. Firstly, this opens the
way for campaigns to demand regulation of prices of other implants and devices, as well as key
medical items like anti-cancer drugs, where huge ‘cost–MRP difference’ has been allowed until
now, an area involving massive overcharging of patients. Secondly, the stents’ pricing decision
has been followed by widespread positive publicity and some evidence of political support for
the decision, suggesting that such demands might be coming more strongly on the socio-political
agenda. These kind of positive openings portend that a combination of public actors—public
authorities like NPPA, courts, legal activists, civil society groups and coalitions of ethical
doctors—might be able to make further inroads into the empire of profit-driven healthcare.
Until now, challenging medical corruption by people’s health movements—primarily civil
society coalitions and citizens’ groups, but also emerging networks of ethical doctors—has been
an uphill journey, with few overt successes despite significant efforts. This might be because the
social mobilization around these issues has so far been sub-critical to achieve policy impacts in
the face of major resistance by private lobbies and historical apathy of the state. However, it
seems that now with new formations such as citizen–doctor forums, and deployment of a
combination of strategies as seen in the stents’ pricing issue, building a critical social mass
around issues like patients’ rights and regulation of the private medical sector might be incipient.
Undoubtedly, many further struggles and campaigns would be required to ensure that in the
health sector, ‘social logic’ would prevail over the dominant ‘profit logic’. In Seamus Heaney’s
words:
History says, don’t hope
On this side of the grave.
But then, once in a lifetime
The longed-for tidal wave
Of justice can rise up
And hope and history rhyme.

References
Gadre, Arun and Abhay Shukla, 2016, Dissenting Diagnosis, Delhi: Penguin Random House
India.
Jesani, Amar, P.C. Singhi, and Padma Prakash, 2004, Medicine, Market and Malpractice,
CEHAT: Mumbai.
McCubbin, M., R. Labonte, and B. Dallaire, 2001, ‘Advocacy for Healthy Public Policy as a
 Health Promotion Technology’, Centre for Health Promotion.
Phadke, A., A. More, A. Shukla, and A. Gadre, 2013, ‘Developing an Approach Towards Social
Accountability of Private Healthcare Services’ SATHI, India, and COPASAH, available at
www.copasah.net/uploads/1/2/6/4/12642634/developing_an_approach_towards_social_accountability_of_priv
_sathi.pdf
 CHAPTER TWENTY NINE
Evidence-Based Interventions for Healthcare Corruption
Rakhal Gaitonde

In general, corruption is seen as the use of a position of power for personal gain. However, there
are numerous forms of corruption and these occur in even more diverse settings. It is important
to take into account this diversity while setting out to assess interventions to reduce corruption in
the healthcare sector. Just one example of this diversity is the recognition of what is known as
survival corruption (Vian and Norberg 2006), which talks about forms of corruption in situations
where public servants have to work under circumstances of extreme resource scarcity.
Increasingly, the literature on corruption also recognizes that various structural/macro-level
issues determine the existence and form of corruption in a given society (Rose-Ackerman 2004).
Given these diverse forms of corruption, it is important to note that any intervention to reduce
its prevalence would depend on the way the situation is problematized. A lot depends on how
one perceives corruption. One can see it as aberrant behaviour purely within the confines of an
isolated person-to-person interaction. Each person then is seen as attempting solely to maximize
her or his benefit. In such an approach, one would choose stricter regulation and changing
individual motivations. However, one can also see corruption (or indeed any human behaviour)
as being influenced at multiple levels. It is then seen as embedded in complex systems of
reinforcements and motivations. This suggests the need to take a more nuanced view. It is thus
imperative that one comes up with interventions that see the problem from multiple levels, are
iterative in nature, and evolve from experience in each situation (Gaitonde 2014).
This diversity of perspectives and views on corruption is reflected partly in the diversity of
definitions that abound in the literature on corruption. In a recently published Cochrane review
of the interventions to reduce corruption in the healthcare sector, it was pointed out that one of
the characteristic features of the literature on corruption was the diversity of definitions. That
review came up with the following definition of corruption: ‘The abuse or complicity in abuse,
of public or private position, power or authority to benefit oneself, a group, an organization or
others close to oneself; where the benefits may be financial, material or non-material; and where
the abuse violates the rights of other individuals or groups’ (Gaitonde et al. 2016).
The key points that this definition drew from the others in the literature was the recognition
that abuse may either be direct or may be complicit, and importantly, that the effects of such
abuse of position and power were to be considered not only at the individual but also at the group
level. For example, higher-level corruption that affected the funds allocated to the health system,
in turn affected its accessibility to marginalized communities. This, therefore, has also come
under the definition of corruption, in addition to the more visible direct forms that occurred at the
interface between the health worker and the patient.
Corruption in the Health Sector: An Approach
The specific characteristics of corruption occurring in the healthcare sector arise due to a number
of factors. One is the extreme disparity in the knowledge levels between the healthcare providers
and the patients. Second, the actual interaction usually happens at a time of distress, when the
patient is sick and thus particularly vulnerable. Third, and probably increasingly pertinently, the
rising influence of the medico-industrial complex that covers the pharma and diagnostics sectors
means that motives for prescribing and the approach to various diseases are increasingly defined
by these commercial interests rather than the best interests of the patient and/or society. Also
pertinent to the study of corruption and its reduction is the fact that we are in an era where public
systems are being systematically undermined by a lack of funding/investment, especially under
the structural adjustment policies of the international financial institutions like the International
Monetary Fund and the World Bank (Pal and Ghosh 2007). Thus, increasingly, marginalized and
vulnerable communities are being left to the mercy of the markets. In a nutshell, these macro-
and micro-level factors play a key role in the actual form and extent of corruption in the
healthcare sector and, in theory, should be the basis for the formation/evolution of approaches to
the reduction of corruption in this sector.
Broadly, if one sees the various practices in the healthcare system that are usually classified as
corrupt, one can divide them into three broad categories:

• Those that arise in settings of systemic shortages of various kinds of resources—these include
shortages of human resources, drugs, and diagnostics (especially in rural areas and poor urban
areas). This also includes settings in which front-line health workers have not got their
salaries for months (and/or situations in which a part of their salary is routines deducted as a
‘contribution’ to higher officials).
• The way in which medical technology itself has developed has led to the emergence of highly
advanced technology—therefore leading to restricted access and thus situations of potential
rent-seeking. Alternatively, such costly technology—especially in the private sector means
that huge costs need to be recovered—and again, this comes from the patients.
• The third broad category is the issue of individual greed, especially for those in positions of
power.

These are discussed in more detail below:

Systemic shortages: The systemic shortages of personnel, drugs, diagnostics, and basic
infrastructure are itself the result of a complex situation. In developing countries like India that
have embarked on the structural adjustment policies—broadly following the vision of new public
management and new institutionalism as defined by the neo-liberal framework—such shortages
may be a combination of systematic underfunding or slashing of funds to the social sector, as
well as increasing corruption within the healthcare sector, thus not allowing the allocated funds
to reach the point of expenditure (Saxena 2006).
Under the new economic policies adopted by the government there was a cutback in social-
sector spending and a move towards the private sector and market mechanisms to provide
services that fell under the aegis of the government in the past. This cut in social-sector spending
meant that the health sector was affected with the resultant lack of investment in either its
expansion or increasing its quality. These trends were reversed (if partially) only in 2005 with
the National Rural Health Mission (NRHM). The germane point to this chapter is that these
strategies led to a situation of gross neglect of the public health system. It is probable that this
situation of underfunding which also affected the working conditions of the health workers (with
an increasing reliance on contractual staff, for example) led to situations in which various forms
of corruption were justified by front-line workers (Lerberghe and Coeceic 2002). Similarly,
specialists are known to bring their own equipment to government hospitals—or refer patients in
government hospitals to their private practices due to the lack of adequate resources. Such
situations, fuelled by this systemic underfunding, may be invoked to justify corrupt behaviour in
the name of providing the best-quality care to the patient (Lerberghe and Coeceic 2002).
Another key aspect of the reforms were the change in institutional arrangements. Thus under
the new policy, funding is increasingly routed through the non-treasury root directly to
autonomous societies (in the name of efficiency). It has been suggested that such institutional
arrangements may in fact have facilitated gross corruption at the higher levels in the health sector
as noticed by the sudden number of scams unearthed around the funds of the NRHM over the
years (Saxena 2006).
In such a context, no amount of regulation at the individual level will lead to a reduction in
corruption in a context that actually encourages it, unless the underlying systemic issues are
addressed.
The role of medico-industrial complex in the encouragement of corruption: In my
opinion, the issue of technology development and the way in which it influences the medical
field—leading to corruption of various kinds—is not fully explored, nor engaged with. Some key
features of medical technology and the way it is marketed, and especially the discourse built
around it make it a facilitator of corruption.
One is that medical technology, including both drugs, diagnostics, and therapeutic equipment
are extremely complex and sophisticated. This means that both the production and the
deployment are only possible in limited situations by public sectors with limited funds. In such
situations—especially when the production as well as deployment is completely in the hands of
private players (Mahal et al. 2006) and increasingly, so is the delivery of care—cost-recovery
considerations become overriding concerns. In such cases, issues like the right of the patient (and
her / his family and community etc.) are not discussed at all.
Further, given the logic of the industry (and free market), we find that compared to the actual
need, there is a surfeit of the latest equipment, especially in unregulated markets like in India
(Mahal et al. 2006). Thus various diagnostic centres have to resort to various forms of ‘cut
practice’ to doctors (who refer patients to them) in order to make profits. Of course, one of the
issues is of regulation of the number of MRI scan machines or other such sophisticated
technology, and where they are allowed to be placed. Equally relevant is the fact that such
technology exists, that it benefits society, but more importantly, it is seen as a valid way of
making private profit. The combination of systemic underfunding and persistent lack of
regulation in the private sector lead to a situation in which such MRI machines (for example) are
invariably in the private sector, and thus private profit-making.
The discourse created by such state-of-the-art equipment then means that society is used to
expecting miracles and the almost unending extension of life; this mirage is further used in the
justification of their use. More critically, the situation is such that today, these norms have been
internalized by society to such an extent that patients have begun demanding these practices. One
can thus see how a particular paradigm of biomedical technology, when embedded in an
unregulated private market with a weak public health system, is a fertile area for corruption.
The role of individual greed: Of course, there is no denying the importance of the individual
greed component of corruption. This is probably the most important type. It is basically about an
individual or group in positions of power who systematically use this power for personal benefit.
Personal benefit may include both the individual as well as the group to which one belongs. In
this, I think, it is important to make a clear distinction between those who are the bottom of the
ladder in a system (yet are in positions of power relative to the patient in need of medical
attention), and is likely to be underpaid, overworked etc., from those occupying positions at the
top of the hierarchy. A person in such a position is in direct contact with decision-making
pertaining to a huge amounts of funds (that are usually spent in any public system) and is thus in
a position of potential rent-seeking. Furthermore, and more importantly, such a person is out of
the public gaze, and given the technical, complicated, and non-transparent nature of most such
high-level decision-making, it is likely that such corruption—probably accounting for the largest
in terms of quantum as well as impact—is hardly discussed.
It is important to recall that corruption in such differing situations will have very different
incentive structures and rationalizations, and thus, different interventions to reduce it will have
quite different outcomes in both, the short and the long term. It is with such a framework in mind
and in such a health-system setting that one needs to assess the evidence for various approaches
to the reduction of corruption in the healthcare system.

Evidence-based Approaches to Reduce Corruption in the Health

Sector
Peters and Muraleedharan (2008) talk about the various approaches to regulating the health
system in India and conclude:
We argue that poor regulation is a symptom of poor governance and that simply creating and enforcing the rules
will continue to have limited effects. Rather than advocate for better implementation and expansion of the current
bureaucratic approach, where Ministries of Health focus on their roles as inspectorate and provider, we propose
that India’s future health system is more likely to achieve its goals through greater attention to consumer and other
market oriented approaches, and through collaborative mechanisms that enhance accountability. Civil society
organizations, the media, and provider organizations can play more active parts in disclosing and using
information on the use of health resources and the performance of public and private providers.

In their paper, they posit the likelihood of success for a more hybrid approach where the
community in actively involved in governance, thus leading to what is called the co-creation
model of regulation and indeed control of corruption.
The Cochrane review identified the following as the possible types of interventions based on
an initial screening of the literature (Gaitonde et al. 2016).

• Information campaigns aimed at changing knowledge, attitudes, or beliefs about corruption; or

developing skills to address corruption.
• Reducing monopolies so as to increase the ability to choose from different providers of a
service or product.
• Removing or reducing incentives or factors that motivate corrupt behaviour.
• Increasing transparency and accountability in decision-making processes.
• Decreasing discretion of those who have power.
• Improving detection and punishment of corruption.
• Establishing an anti-corruption agency to coordinate anti-corruption activities.
 The Cochrane review concluded that overall, there was very little evidence in the published
literature on what were the best interventions to reduce corruption in the healthcare sector. As
noted above, however, they did identify reports of interventions that were promising and at least
one of them had a good amount of evidence favoring it. These four broad categories of
interventions identified by the review are as follows: ‘The review identified published case
studies assessing / attempting to assess four categories of interventions – dissemination of
information; improved detection and enforcement; establishing an independent agency with
improved detection and enforcement; and increased transparency and accountability.’ (Gaitonde
et al. 2016).
It is pertinent to note that all these studies were mainly performed in developed countries,
with only two studies from so-called developing countries—Kyrgystan and India. While the
interventions from the former, such as the US, Germany, and South Korea included developing
elaborate systems to check for various forms of corruption, and the dissemination of guidelines
etc., those from Kyrgystan attempted to strengthen the system by both increasing transparency as
well as ensuring better working conditions and salaries for health workers (Falkingham et al.
2010). In India, the case study was that of the Lok Ayukta system in the state of Karnataka,
which appointed a special vigilance officer for the health system (Huss et al. 2010).
The example of dissemination of guidelines refers to a study done in Germany which showed
that a hospital which had explicit guidelines with regards to acceptance of gifts from pharma
companies had a much lower proportion of doctors who identified these gifts as acceptable, thus
showing the importance and possible efficacy of such explicit guidelines (Gundermann et al.
2010).
Another example from the US describes the efforts of the Department of Health and Human
Services and the Department of Justice to reduce fraud in the various billing processes in the
country’s complex insurance system. Using the backing of the US Health Insurance Portability
and Accountability Act of 1996 (HIPAA), the Office of the Inspector General was empowered to
coordinate federal, state, and local enforcement efforts against healthcare fraud. These included
improper coding and billing of medicare payments and the power to investigate and prosecute
offenders. They used a slew of interventions including sophisticated computer-based analysis
and modelling to identify and investigate and eventually recover a huge amount of fraud.1
The examples of improved detection and enforcement come from South Korea and the US.
Both talk both about the importance of the perception of the health institution (South Korea), of
it being investigated, as well as the expenditure (US) on anti-fraud activities (as a proxy for
actual such activities). They showed that both these features resulted in a reduction in the
corruption in terms of overcharging, wrong billing etc.2
The examples from Kyrgyzstan were a complex set of reforms that sought not only to reduce
the motivation for corruption (through increased salaries and regular payments), but linked this
with a proactive and transparent dissemination of the various co-payment charges being
introduced. This, in theory, addressed both the supply- and demand-related determinants of
corruption. The proportion of people who reported they made other payments in connection with
a consultation decreased from 55 per cent in 1994 to 20 per cent in 2007. There should have been
no other charges after 2004 when the reform was expanded from two provinces to the whole
country. The proportion of people who reported making any payment at a family general
practitioner decreased from 17 per cent in 2004 to 13 per cent in 2007, and the proportion of
patients paying at a polyclinic/family medical centre decreased from 45 per cent in 2004 to 23
per cent in 2007 (and no one in 2007 reported making a payment for maternity care)
(Falkingham et al. 2010; Kutzin 2001; Baschieri and Falkingham 2006).
The experience of the Lok Ayukta in the state of Karnataka provided a promising intervention
from India. However, while the complaints and cases of potential corruption increased hugely
under the proactive and charismatic team of the Lok Ayukta and the vigilance officer for health,
the study itself shows that the translation of these complaints into actual prosecutions were
stalled by the vested interests and a judicial system that was not up to the task. Thus showing that
mere detection of corruption is not enough in settings like in India where the other general
systems of governance including the judiciary are overworked, overburdened, and at risk for
political interference (Huss et al. 2010).
The review also points out that while there is a need to monitor and evaluate the impacts of all
interventions to reduce corruption, including their potential adverse effects. None of the papers
that we included examined potential adverse effects or impacts on equity, and there was no
reliable data for impacts on healthcare or health (Gaitonde et al. 2016).

Discussing the Evidence in the Indian Context

While the above is a summary of the evidence for international-level interventions of corruption,
it is important to place them in the context of the Indian situation. Some of the key aspects of the
healthcare system in general and the India specifically that need to be kept in mind while
assessing the interventions are listed below:

• Corruption that is most obvious and visible is only one of the many forms of corruption, and a
large part of the corruption that is happening is beyond the visibility of the community.
• Importantly, the doctor-patient and indeed the healthcare professional-patient relationship in
general is fraught with huge power inequalities and knowledge gaps. In a situation when the
patient is sick, she / he and their caregivers are particularly vulnerable, creating a situation
ripe for corruption.
• Powerful forces create a context in which such corruption is normalized—one such force is
the power of the medical and diagnostics industries—by creating (and overproducing) costly
technology with limited or even questionable real benefit to the individual and community.
They create a pressure to sell (and make a profit) and then pass this on to the buyers of these
technologies to recover their costs (and make a profit). This invariably leads to corrupt
practices.
• The other significant contextual feature is the underfunding of public systems. Systematic
underfunding has been reported from the late 1980s in India—especially after the opening up
of the economy and the acceptance of the structural adjustment packages post 1991. In such a
situation it becomes more and more frustrating working in systems that are being
systematically eroded, again leading to a situation ripe for corrupt practices.
• Given the systematic underfunding and underdevelopment of the public health system, various
basic public health functions like health information systems, national health accounts,
research on the appropriateness or quality of care, and formal and informal expenditures,
which would typically form the basis of any intervention to reduce corruption in India are
completely lacking.
• Regulation of the healthcare system has been weak, with the private sector having almost no
regulation whatsoever. In fact, health policies over the years have seen the private sector as a
valued ally in the provision of healthcare without questioning their underlying profit motive.
 This has led to massive growth of the private sector at the same time that the public sector in
India has been falling apart.

Keeping this situation in mind, we see that intervention like dissemination of information and
guidelines as well as agency-based detection and enforcement are not going to give very good
results. First of all, given a weak public health system, an unregulated private sector, and the
present huge knowledge gap between the community and the healthcare system workers, self-
regulation and the enforcement of any guidelines seems a distant dream. This contention follows
the conclusions of Peters and Muraleedharan (2008).
While agency-based detection using computer-based analytics is very appealing, two issues
from the Indian situation work against it. First, there is a complete lack of baseline information
or even real-time information that can be used to track expenditures, bills etc., that form the
bedrock of any such interventions.
What seems to be more promising are the examples of more systemic interventions like those
tried out in Kyrgyzstan (Falkingham et al. 2010; Baschieri and Falkingham 2006) as well as the
‘hybrid’ interventions suggested by Peters and Muraleedharan (2008). But there are no published
studies support them.
Consider the commitment of the Kyrgyzstan government’s initiatives to tackle corruption, by
ensuring adequate funds to health centres and increased salaries to healthcare providers to reduce
the demand for informal payments from their side. This is a very important approach in a setting
in which more and more health workers are employed on a contractual basis and in many states
salaries have not been paid for months at a stretch. This highlights the importance of ensuring
that the front-line workers get assured and timely release of their salaries. However, while this is
a promising approach, whether this will be possible in the present vested structures is
questionable.
Similarly, the Lok Ayukta approach—while promising, energizing, and newsworthy—suffers
in its dependence on the very same corrupt and underfunded regulatory and law enforcement
authorities to translate the complaints into actual investigation and prosecution. In terms of
appointing ombudsmen, in the present situation of governance and the populist, paternalistic
form of state that we have, there is a huge risk of political interference. As a very poignant
example the number of deaths of activists using the Right to Information Act is a good example
of the power of the vested interests and the utter impotence of the Indian regulatory and law
enforcement agencies (Dhawani 2016). In such a situation, expecting this form of intervention to
work is unrealistic
In India, some recent, promising examples of reducing corruption include the community-
based monitoring and planning of the NRHM (aimed primarily at strengthening the health
system and not at reducing corruption) (Kakde 2010), which is described in an earlier chapter,
and the Social Audit Cell of the Andhra Government.3
While the community-based efforts (backed by social movements/community groups) have
managed to reduce corruption and even led to the return of the money collected in some
instances, these have been sporadic and depend completely on the local situation. The experience
of the SSAAT (Society for Social Audit Accountability and Transparency), on the other hand,
has been more promising, with the identification of crores of rupees as having been diverted due
to potential corruption and a large proportion of that being recovered by the law enforcement
bodies.
The Community-Based Monitoring and Planning programme is now called the Community
Action for Health of the NRHM. In these programmes, especially during the monitoring of
primary health centres, the corruption at the centres in terms of collecting illegal fees, or asking
patients to buy medicines from outside etc., came up prominently. Action, including the demand
for stopping such practices, were the cornerstones of many of the initiatives. It has been reported
from at least two states that in a significant number of such institutions, the practices
significantly reduced after the monitoring. In Maharashtra, the process was strengthened by the
presence of social movements which not only exposed and demanded a stop to such corruption,
but in fact made sure that such money as was collected was in fact returned to those who paid out
(Kakde 2010).
The SSAAT which was formed by an act of the Andhra Pradesh state, is an example of the
newly emerging spaces for governance. While being formed by an act of the assembly, it is
situated in an autonomous space. It is assured of a constant funding, and is thus fully independent
in its working. The SSAAT works through teams of core staff and volunteers that follow a set
process in each village to ensure that all relevant data regarding the MGNREGA (Mahatma
Gandhi National Rural Employment Guarantee Act) is collected and presented transparently. As
described in their website, ‘The social audit process as it is being implemented by the Society for
Social Audit, Accountability and Transparency in the State of Andhra Pradesh, includes public
vigilance and verification of the various stages of implementation. This is followed by ‘Social
Audit Public Hearings’ where information gathered is read out publicly, and people are given an
opportunity to question officials, seek and obtain information, verify financial expenditure,
examine the provision of entitlements, and critically evaluate the quality of works as well as the
functioning of the programme staff’.4
In another remarkable experiment, the formation of patients groups in urban settings and a
joint effort with doctors who are willing to join such alliances are creating an interesting
dynamics.5 Similarly, linked to this are forums for doctors who are willing to join such
initiatives. It is important to wait and see the results of this endeavours.
However, international literature on this type of community involvement actually questions
the automatic assumption that community involvement or monitoring is key to the reduction of
corruption. In a number of studies (not necessarily in the health sector) it was shown that, (1)
while community monitoring was able to curb ‘visible’ corruption, it was not able to touch high-
level and invisible corruption, and thus was overall quite ineffective in making a large impact;
(2) on the other hand central / departmental efforts, like putting in anti-corruption mechanisms
within the department (when backed up with adequate commitment), seemed to work quite
effectively in controlling and reducing corruption.
It is in the light of such evidence that the examples of SSAAT and the community, monitoring
under the NRHM (both examples of what may be called hybrid / co-governance interventions)
are particularly promising.
Despite this field-level experience and evidence, the government of India has persisted in
pursuing the digitization, e-governance route of administration as a promising intervention
specifically aimed at reduction of corruption (Vittal 2001). There have been a number of
initiatives like the process of changing cheque and cash payments into internet-based bank
transfers. Apart from reducing delays, this was also supposed to reduce the opportunity for any
corruption. This may have reduced corruption (indeed while there is no formal study, anecdotally
things have improved, if marginally) that occurs directly; however, the fact that the essential
power relationship and the various other contextual factors have not changed means simply that
the corruption has changed in form. While in the earlier situation the front-line worker would
demand a proportion of the amount received as a cutback, nowadays, she charges ‘processing
fees’, claiming that she spends a lot of time and energy accessing the internet etc., to fill in the
forms and get approval, and that the community must be ready to support her in this way. What
this and other examples show is that merely blocking the most obvious expression of corruption
is not a guarantee to its control and ultimate eradication. In the absence of tackling the
underlying determinants, the form, explanation, and justification merely change, doing little to
reduce the actual quantum of corruption.
***
While the formal verdict in terms of a Cochrane review reveals a paucity of evidence, apart from
a few promising case studies, experience from the field, where a number of more hybrid
interventions have been tried out in India have been more optimistic. But any intervention cannot
be separated or divorced from a commitment to systemic reform that must ensure, at a minimum,
secure and satisfying working conditions, a strengthening of the public health system, and a
commitment to the principal of political non-interference in terms of law and enforcement
activities. In my opinion, all these can come about only if there is a massive public outcry,
mobilization, and demand. The recent India Against Corruption movement was a promising start
and was potentially a move towards building up such energy; however, subsequent developments
have belied such hope.
While there is some guidance from the literature as to the type of interventions that are
successful (in their local settings), unless these are embedded among a whole host of both
systemic and specific interventions, backed by massive popular mobilization and organization of
demand, no intervention is going to be successful and sustained.

References
Baschieri, A. and J. Falkingham, 2006, ‘Formalizing Informal Payments: The Progress of Health
Reform’, Centr Asian Surv., 25(4): 441–60.
Dhawani, H., 2016, ‘Death Toll of RTI Activists Goes up to 56’, The Times of India, 20 October,
available at http://timesofindia.indiatimes.com/india/Death-toll-of-RTI-activists-goes-up-to-
56/articleshow/54947268.cms
Falkingham, J., B. Akkazieva, and A. Baschieri, 2010, ‘Trends in Out-of-Pocket Payments for
Healthcare in Kyrgyzstan, 2001–2007’, Health Policy Plan, 25 March, pp. 427–36.
Gaitonde, R., 2014, ‘We Need to Dig Deeper to Root Out Corruption’, Curr. Med. Res. Pract., 4
June, pp. 141–47.
Gaitonde, R., A.D. Oxman, P.O. Okebukola, and G. Rada, 2016, ‘Interventions to Reduce
Corruption in the Health Sector’, Cochrane Database System Review, Art. No. C (6).
Gundermann, C., A. Meir-Hellmann, M. Bauer, and M. Hartmann, 2010, ‘Der Einfluss Einer
Krankenhausinternen Richtlinie Auf Die Einstellung Von Ärzten Zur Pharmazeutischen
Industrie’, Deutsch Med. Wochenschr, 135: 67–70.
Huss, R., A. Green, H. Sudarshan, et al., 2010, ‘Good Governance and Corruption in the Health
Sector: Lessons from the Karnataka Experience’, Health Policy, New York.
Kakde, D., 2010, ‘Community-based Monitoring of Health Services in Maharashtra, India’,
Pune.
Kang, H., J. Hong, K. Lee, and S. Kim, 2010, ‘The Effects of the Fraud and Abuse Enforcement
Program Under the National Health Insurance Program in Korea’, Health Policy: New York,
 95(1): 41–49.
Kutzin, J., 2001, ‘Addressing Informal Payments in Kyrgyz Hospitals: A Preliminary
Assessment’, Eurohealth: London, 7(3): 90–96.
Lerberghe, W. Van and C. Coeceic, 2002. ‘When Staff is Underpaid: Dealing with the Individual
Coping Strategies of Health Personnel’, Bull. World Health Organ, 80(7): 581–84.
Mahal, A., A. Varshney, and S. Taman, 2006, ‘Diffusion of Diagnostic Medical Devices and
Policy Implications for India’, Int. J. Technol. Assess. Health Care, 22(2): 184–90.
Pal, P. and J. Ghosh, 2007, ‘Inequality in India : A Survey of Recent Trends’, New York: Report
No. 45.
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What Future?’ Soc. Sci. Med., 66(10): 2133–44.
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http://www.copenhagenconsensus.com/sites/default/files/cp-corruptionfinished.pdf
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Securing Health for All: Dimensions and Challenges, New Delhi: Institute for Human
Development, pp. 163–222.
Vian, Taryn and Carin Norberg, 2006, ‘Corruption in the Health Sector’, Bergen: Chr.
Mischelsen Institute, U4 Issue 2008:10.
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2017.
 VI

PERSONAL VIEWS
 CHAPTER THIRTY
My Battle with Medical Corruption
Kunal Saha

The glaring flaws seen in the Indian healthcare and medical education system today have a root
that could be traced back to several decades ago. Although the fundamental principles for
establishing an equitable system for good medical education and regulation of medical practice
in post-Independence India were established through legislations under the Indian Medical
Council (IMC) Act in 1956, general awareness about medical ethics and patients’ rights was
virtually non-existent in Indian society until very recently. Unfortunately, with the increasing
decay of moral values in almost every aspect of public service in recent times throughout India,
greed and corruption have also started to infiltrate the healthcare system. Some of the most
dishonest members of the Indian medical fraternity who have no interest in promoting
standardized medical education or ethical practices of medicine have gradually taken control of
the entire healthcare system including Medical Council of India (MCI), the highest authority for
regulation of medical education and practice by doctors. These mendacious medical leaders were
also generally backed by equally immoral political parties with vested interests, making them
virtually impervious to objections raised by other members of the medical community. And with
these unprincipled medicos occupying the helm of medical regulation for the past several
decades in India, even the ordinary doctors too have started to feel that it may not be necessary to
maintain even the minimal standard of treatment or ethical medical practice.
It is no wonder then that the growing number of doctors in India have started to get involved
with overtly immoral activities such as issuing of false medical certificates or accepting financial
kickbacks (‘commission’) from drug companies or diagnostic laboratories making these once
unimaginable activities as ‘normal’ for members of the noble profession of medicine. The
concept of ethical medical practice started to appear as a worthless idea for many Indian doctors.
When I graduated from a premier government medical college in Kolkata (NRS Medical
College) before migrating to the US in 1985, there was hardly even any discussion on medical
ethics during our five-year long MBBS curriculum. And with the ever-increasing corrosion of
the healthcare regulatory system and no opposition from the righteous medicos who were afraid
of being caught in the quagmire of sullied politics in a decaying medical system, it was no
surprise that only a handful of truly dishonourable members of the medical community took total
control of medical education and healthcare as corruption ripped through the entire medical
system over more than two decades. The widespread corruption in Indian healthcare is
responsible not only for the substandard medical education and skyrocketing medical expenses,
but it is also the root cause for the plummeting public trust on doctors and ever-increasing
number of deaths from alleged ‘medical negligence’ in hospitals and nursing homes across India
today.

My Personal Tragic Story

As mentioned earlier, I migrated to the US soon after graduating from medical school in Kolkata
in 1985 and ever since, I have been settled there, involved with the study of HIV/AIDS. My
battle against medical corruption in India started from an incomprehensible personal tragedy, as
my wife and US-based child psychologist, Anuradha Saha, died during a social visit to India in
1998, falling prey to gross medical negligence by Dr Sukumar Mukherjee, a senior, so-called
‘eminent’ medicine specialist in Kolkata. My wife was only 36 when she died. As young
migrants from India, we were just about ready to live out the American Dream after a long and
hard struggle to obtain advanced education in the country. But destiny willed otherwise.
Anuradha, who developed an acute skin rash/drug allergy, eventually died from septicaemia
due to severe immunosuppression after she was injected with an astronomical amount of a long-
acting corticosteroid (‘depomedrol’). Long-acting corticosteroids like depomedrol are generally
recommended in treating chronic medical conditions like asthma and arthritis at long intervals
for their slow and protracted release in the body. My wife was given this medicine as treatment
of her acute drug allergy at a dose of 80 mg twice every day, 20 to 50 times its maximal
recommended dose. A potentially lethal drug (depomedrol) was chosen for my wife without an
iota of scientific rationale and that too, administered in a dose unheard of in the annals of
medical science. This unthinkable use of depomedrol was primarily responsible for the untimely
death of my wife as categorically held by two separate benches of the Supreme Court of India in
2009 (2009 SCC 9, 221) and again for awarding compensation in 2013 (2014 SCC 1, 84). In
fact, the apex Indian court imposed a compensation amounting to almost Rs 11.5 crore including
interest (equivalent to about USD 1.7 million) against Dr Mukherjee (plus two other doctors) and
AMRI Hospital in Kolkata. This was by far the highest ever compensation in Indian medico-
legal history for unethical medical practice and causing the wrongful death of a patient. The
Supreme Court not only severely criticized my wife’s reckless treatment, it also held Dr
Mukherjee’s personal conduct as ‘unbecoming of a doctor’ as the doctor attempted to shirk his
personal responsibility and deflect it to other doctors during the trial through gross
misrepresentations and lies.

Medical Justice and Doctors’ Code of Silence

It took almost 15 years and an untold amount of personal, professional, and financial sacrifice for
me to establish medical negligence’ by the senior Kolkata doctors and to find justice in the court
of law for the wrongful death of my wife. But what about medical justice, that is, justice by the
one’s peers in the medical profession? Disciplinary action taken by the peer groups in the
medical council is perhaps most important as a deterrent to stop incidents of medical negligence
or ethical violation by doctors. While investigating the complaint against Dr Mukherjee, doctor-
members of the West Bengal Medical Council (WBMC) acted in the most blatant fashion in
order to shield him as the council refused to accept that there was anything wrong in Dr
Mukherjee’s treatment even after the highest court in the country held him guilty for gross
medical as well as ethical violations. Hardly any Indian doctors (except a senior pharmacology
professor, late Dr Salil Bhattercharya and well-known dermatologist Dr J.S. Pasricha) including
more than 150 of my medical school classmates (except one) were willing to step forward and
testify truthfully even about the most basic and non-controversial scientific medical facts. I was
successful in proving my case before the apex court that gross medical negligence was actually
responsible for the untimely demise of my wife primarily because I was settled in a top medical
centre in the US and was able to obtain opinions from numerous medical experts from that
country and Europe.
Being a doctor with direct knowledge about practice of medicine, both in India and the US, I
have first-hand experience about why the medical justice system functions so very differently in
these two countries. Being a doctor as well as a victim of medical negligence in India, I also had
the unique opportunity of analyzing the inherent problems responsible for collapse of the
medical justice in my native country. Unlike in the West, members of the medical community in
India (and perhaps in other developing nations) have historically remained above and beyond
any laws that regulate medical practice. Until the turn of this century, hardly any doctor in India
was found guilty even by the court of law for wrongful treatment causing injury or death of a
patient—thanks to a long tradition of the strict ‘code of silence’ followed by our healers in India.
The Hippocratic Oath is considered simply as an apologue by most doctors in modern India.
Instead, just like the 11th Commandment as popularized by former US president Ronald Reagan
—which is routinely followed by the US Republican party—members of the Indian medical
fraternity have maintained their ‘untouchable’ status by adhering to their own mandate—‘Thou
shalt not speak ill of any fellow doctor’.

Shocking Revelations about Medical Councils and Healthcare

Corruption
As mentioned earlier, new laws framed more than 60 years ago under IMC Act, 1956 were
aimed at proper regulation of medical education and ethical practice by doctors in post-
independent India. Under the Act, the MCI was given exclusive authority to regulate the standard
of medical education across the country. New laws were also framed under the same Act for the
establishment of a medical council in every state and union territory for the purpose of
investigating complaints against doctors and to take disciplinary action against reckless medicos
in order to protect the lives of innocent patients. In the long course of my search for medical
justice, I moved a public interest litigation (PIL) in Supreme Court of India in 2000 (Writ
Petition Civil No. 316/2000) after WBMC endlessly delayed investigation of my complaint of
medical negligence against Dr Mukherjee.
Through this PIL, it was revealed in 2002 that even after the lapse of almost five decades
since the enactment of the IMC Act, 1956, there was no medical council in several states and
union territories in India. And even in the states that did have medical council, virtually no
doctor was ever found guilty for medical negligence or unethical medical practice. The few
complaints lodged against doctors were routinely kept pending for years and decades without
any investigation by the state medical council. The picture was painfully apparent to the hapless
patients of India as there were no checks and balances for doctors. It is ironic that a platform
built with the primary purpose of protecting the vulnerable patients had turned into nothing but a
stout shield to protect the errant medicos. Unlike in the West, medical councils in India are
formed exclusively with doctor-members, creating an obvious environment for conflicts of
interest. Little wonder then that nobody was eager to bring any changes in the medical councils
or enforce accountability for our healers. Unfortunately, the ultimate price for this inherently
flawed medical regulatory system is paid by both sides—while ordinary people continue to
suffer at the hands of the delinquent medicos, honest doctors also suffer from the growing
ignominy of the medical profession and plummeting public trust in doctors.

Corruption in MCI and Dr Ketan Desai

The issue that perhaps has affected the entire healthcare system in India most profoundly is the
presence of deep-rooted corruption inside the MCI. Shocking reports of private medical colleges
admitting poor-quality students from wealthy families in exchange for large financial donations
(‘capitation fees’) or unqualified MCI inspectors being bribed to grant approval to substandard
medical colleges appear frequently in the news these days. This pervasive corruption inside the
MCI was publicly admitted by the last central health minister, Mr Harsh Vardhan. Even the
multi-party Parliamentary Standing Committee on Health, in its 92nd Report in 2016, has
unequivocally held that corruption has infiltrated deeply into the fabric of MCI.
In fact, corruption has a long history in the MCI and the name associated most prominently in
this regard is Dr Ketan Desai, a disgraced ex-MCI president who maintained a firm grip on the
Indian medical fraternity over the past several decades. In 2001, the Delhi High Court found Dr
Desai, then MCI president, guilty on serious charges of corruption and ordered to remove him
from his post with scathing observations, holding the MCI as being a ‘den of corruption’. It is
noteworthy that when Delhi High Court ordered to remove Dr Desai from the MCI in 2001, he
was also holding top positions in other major medical regulatory authorities including the post of
president of Indian Medical Association (IMA) and Gujarat Medical Council as well as being
board member of the Dental Medical Council, All India Institute of Medical Sciences (AIIMS),
and several other health universities across India—all providing irrefutable evidence in support
of his immense influence over the entire medical system in India. But even after Dr Desai’s
unprecedented indictment for corruption and ouster from the MCI by Delhi High Court in 2001,
he was able to make an incredible return to the helm of Indian medicine as he was elected
‘unopposed’ to be MCI president again in 2009. Using explicit and implicit support from
unscrupulous political leaders and medical cronies who maintained firm grips over various
medical groups including Indian Medical Association (IMA), Dr Desai regained the most
powerful position in Indian healthcare as head of the MCI once again in 2009. But the
widespread corruption inside the MCI was shockingly exposed once again in 2010 when Dr
Desai was caught red-handed by the Central Bureau of Investigation (CBI) highest law-enforcing
agency in India, through a sting operation for taking bribe from a private medical college
allegedly in exchange of granting MCI recognition to admit medical students. The agency’s
arrest of Dr Desai while he was still MCI president created a huge public outcry across India as
the health ministry was compelled to dissolve the organization and discharged 100-plus MCI
members who unanimously chose Dr Desai as their president only few months earlier. Can there
be any doubt about the reign of corruption inside the MCI headed by Dr. Desai and his medical
cronies until 2010, many of whom are still occupying top positions in Indian medicine?
This long-drawn-out sordid episode of corruption in MCI has brought great ignominy for all
doctors of Indian origin. It has also caused a further deterioration of the already fragile doctor-
patient relationship and a deep erosion of public trust in doctors in India. The ignoble evidence
of healthcare corruption is palpable not only in medical education or treatment in hospitals,
flagrant violation of medical ethics, such as doctors accepting financial kickbacks
(‘commissions’) from diagnostic laboratories or dead patients kept on ventilator for days only to
hike up hospital bills has also become common knowledge these days. Unfortunately, there is no
sign that the rot in our healthcare is to end anytime soon because it appears that Indian
government is only happy to remain in an endless and deep slumber. Although Dr Desai was
arrested by the CBI in 2010 on serious charges of alleged bribery and corruption, more than
seven years later, he remains free on bail. While still awaiting the beginning of the criminal trial,
Dr Desai continues to play a key role in Indian medicine as many of his medical cronies have
already managed to retake prominent positions in important regulatory bodies including MCI and
IMA. In fact, despite having a suspended medical registration (in response to our complaint
against him for professional misconduct) and facing serious criminal charges, Dr Desai was
elevated to the coveted post of president of the World Medical Association (WMA) in 2016 by
virtue of a false claim made by the IMA that all charges against Dr Desai have been dropped by
the Indian government.

Our Responsibility for a Better Future

For more than a decade, People for Better Treatment (PBT), a charitable organization that I
established in India with the aim of promoting a corruption-free medical education and
healthcare delivery system in the country, has been involved with numerous PILs in the Supreme
Court and High courts against medical corruption involving MCI, IMA, and Dr Desai. Some of
these PILs have brought important changes in our flawed medical education and healthcare
delivery system. But in order to restore the dwindling public trust on healers and to rebuild the
severely ravaged doctor-patient relationship in India today, the overarching issue of medical
corruption must be resolved first. But it cannot start to happen until the truly honest and
compassionate Indian doctors—who have hitherto remained on the sideline as silent majority
allowing a small number of devious medicos to plunder the entire healthcare system—step
forward and raise their voices to bring an end to medical corruption that will not only save
countless innocent human lives but it will also help to restore the dignity of the noble profession
of medicine.
 CHAPTER THIRTY ONE
What Should We Do?
Farokh Erach Udwadia

Corruption is a canker, a festering sore that eats into the vitals of a nation. Transparency
International has defined corruption as the abuse of unlimited power for private gain and has
estimated that 10–25 per cent of global spending in public procurement of health is lost in
corruption.1 No country is free from corruption but in some countries such as India, corruption is
rampant.2 Corruption in healthcare besides its unfortunate economic ramifications is a source of
jeopardy to health and life. David Berger’s experience in the Indian health system illustrates the
corrupt practices prevailing in this country (Berger 2014).
There are many aspects to healthcare in India. All of these, in varying degrees, are riddled
with corruption. However, the final delivery of healthcare to the patient in any country is through
the practising physician, whether he or she be a general practitioner, or a consultant in any one of
the many specialities in medicine. It is the corruption and the malpractice at this level and my
views on how this can, to some extent be combated, that constitute the subject of this chapter.
It is indeed a paradox that though medicine has achieved so much in this day and age, there is
a rising disillusionment, distrust, and even hostility against medicine and the medical profession.
The paradox is doubly striking because around the middle of the last century when medicine had
comparatively achieved much less, the profession was held in the highest regard and the doctor’s
image outshone that of any other profession (Udwadia 2009). How and why has this happened?
It is because the trust between the doctor and the patient has been lost. The doctor-patient bond, a
mutually trusting relationship, an unwritten covenant hallowed by time, which lies at the very
heart of medicine, now stands eroded. The patient is aware that many doctors are uncaring and
more concerned with money. This uncaring attitude, the lack of humanity, and the greed for
money are witnessed by the kickbacks offered by consultants to general practitioners. The public
is also aware that patients are often shunted from doctor to doctor not for the benefit of the
patient, but for the doctors concerned. Prescribing expensive tests and medications when basic
tests and cheaper medications would suffice is also a form of corruption. Corruption is also often
institutionalized in hospitals when patients are fed as fodder to machines so that the expensive
cost of these machines is defrayed. This is just a part of the sordid state of affairs that exists in
our country.
How can we restore the doctor-patient relationship, which is the very core of medicine? The
answer to my mind is simple, though difficult to implement. It lies in producing doctors who
truly care, who can be the beacons of light and hope that could extinguish corrupt practices, at
least to a certain extent. In my experience of over 50 years as a practising consultant and a
teacher of medicine, I have observed that a doctor who genuinely cares for a patient is usually
not corrupt. Also, a doctor who is both caring and competent is not likely to be either corrupt or
negligent.
How does one produce caring doctors? Ideally, it is in the premedical years—at home, school,
and college—that caring, ethical altitudes should be cultivated. This can only be realized through
good education given by dedicated teachers. Education does not lie in churning out graduates
and postgraduates in large numbers, but devoid of quality. Stress on good education is one of the
key factors that could stifle corruption at all levels in our society.
The system of education in medical schools needs to be overhauled (Kay 2013). This can help
counter corruption in medical practice. Entrance to medical schools should be above board. The
curriculum in medical schools should include ethics, not just as a two-month course but all
through undergraduate and postgraduate years. Ethics in general, ethical professional conduct
(Kay 2013), ethical problems, and ethical quandaries in relation to actual case histories should
form important subjects of discussion. There should be a department of medical ethics in every
teaching hospital in the country, headed by teachers of integrity who respected by the student
community. An introduction to the history of medicine and to the exemplary lives of great
physicians who have blazed a glorious trail in their various fields of endeavour would surely
influence young would-be doctors on the threshold of their professional careers.
Responsibility and accountability should be observed at all levels during medical school and
should also be organized and insisted upon in medical practice. Admission to postgraduate
courses should be stringent and devoid of any corrupt practice. Postgraduate entry today is
dependent almost solely on the marks scored in multiple-choice question papers. After
graduation, students spend more than a year doing nothing other than memorizing answers to
these questions. Successful students commence postgraduate studies devoid of clinical
experience, and to start with, make pathetic doctors. Everyone concerned with medical education
seems to forget the fact that medicine is learnt at the bedside of patients, not by reading books,
least of all by memorizing answers to multiple-choice questions.
The purpose of medical education is to provide caring, competent practitioners and
consultants in medicine. In this country, a consultant should never rely on general practitioners
for referred patients. The medical system in this country allows a patient to directly visit a
consultant and if the consultant is caring and competent, the patient, happy at having recovered,
brings new patients to the consultant. This can snowball into a thriving practice. There is always
a waiting period, but that is the case in every profession.
I do not propose to write an autobiography of my professional life. Though at the start, I
earned a paltry sum of Rs 700 per month or less, the early years were, perhaps, the happiest in
my life. Happiness consisted in looking after a medical ward at the J.J. Hospital in Mumbai and
teaching students medicine during my ward rounds. Happiness, of course, also lay in my home
and my growing family. There were, and still are, honest general practitioners in this city. Honest
practitioners recognized honest competent consultants and would request help for difficult
problems. But referrals to start with were few and far between—it was typically patients who
brought patients. Once a consultant has made a name, patients will seek his advice even against
the direction of the general practitioner. The nexus breeding corruption between consultants and
general practitioners is thereby broken.
Public health is necessarily a mix of public and private spending. However, today India has
the most privatized healthcare system in the world; the out-of-pocket expenditures in healthcare
are more than 70 per cent, even higher than the US (Dutta 2012). This should be reversed. Many
medical colleges (with few notable examples) run by the private sector consider the delivery of
health to patients a business, a proposition, which in turn, leads to corrupt, nefarious practices.
Seats are sold at some of these private colleges at astronomical prices.3 They pass inspections
through bribery and corrupt, fraudulent practices.4 Corrupt medical schools can only produce
corrupt medical practitioners and corrupt consultants of questionable medical competence.
Unless strongest reforms are imposed, the objective of producing caring, competent doctors will
be defeated.
It is important that large public teaching hospitals become the standard bearers of excellent
healthcare and fruitful medical research. Many qualified consultants would prefer to join such
institutes if given respectable salaries and job satisfaction, rather than join the rat race of corrupt
practice.
Perhaps the underlying explanation for the decline in the ethics of contemporary medicine is a
change in the sense of values in many countries of the world. A burning desire for material gain
and wealth at any cost dominates life today. We have, therefore, a ‘consumer society’ which
resorts to corrupt practices. Doctors are a part of this consumer society. It is difficult for a
profession to remain an island of high-mindedness and virtue when surrounded by a sea of filth
and corruption. The island is first eroded and then may well be swamped. This is no excuse for
the sorry state of affairs in the medical profession; it is the pathogenesis of what exists today.
The medical profession has an ancient heritage to cherish and maintain. An awareness of the
magnitude of the problem and the way in which these corrupt practices operate is the first step
towards a solution.
There are, however, beacons of light and hope in this besieged island. I can vouch for the
integrity of many of my colleagues and the many practising doctors who I have taught over 50
years of practice. These beacons of hope should multiply and light a fire that destroys the
corrupt.
To reduce corruption in the healthcare system on a large scale necessitates a less corrupt
society. Good values, economic prosperity, good education, good governance, and the lessening
of social inequity are the pillars that determine the health of a society. It is these pillars which
need to be strengthened in our country for this to come about.

References
Berger, D., 2014, ‘Corruption Ruins the Doctor-Patient Relationship in India’, BMJ, 348:g3169.
Dutta, N., 2012, ‘What Ails India’s Healthcare System’, Health Site, 18 August, available at
http://health.india.com/diseases-conditions/what-ails-indias-healthcare-system/.
Kay, M., 2013, ‘Indian Medical Curriculum is to Get “Long Overdue” Ethics Training’, BMJ,
346: f2794.
Nundy, Samirun, 2014, ‘Corruption: Medicine’s Dirty Open Secret’, BMJ, 348.
Udwadia, F.E., 2009, The Forgotten Art of Healing and Other Essays, New Delhi: Oxford
University Press, pp. 3–18.
 CHAPTER THIRTY TWO
Means and Ends
Ratna Magotra

Legacy and Challenges

Ethics essentially is an evolving process shaped by experience, observation, and finally
realization. Foundations, however, are laid much earlier and these in turn influence the choices
one makes.
Belonging to the proverbial generation of children of independence has been a distinct
advantage. We saw India through difficult times but lived in a largely corruption-free social
milieu. It is not that corruption was non-existent. It had started with the dawn of independence
but it was largely frowned upon (Jain 2011). The corrupt did not enjoy much social respectability
even if they were famously wealthy. Most parents had modest means and desired, first and
foremost, a good education for their children. Simple living and high thinking were not mere
clichés. For role models, I had an uncle with a bar-at-law from London not wanting to build his
practice based on telling lies; a professor of physics taking a detour in liberal arts while teaching
students about the passage of light through prisms or of currents through galvanometers; and
finally, the teachers at medical school imparting knowledge with empathy and respect for
patients. These near-contiguous exposures had left subtle impressions in the subconscious that
the means should always be kept ahead of the ends.
Idealism and hard work were allowed to thrive in educational and professional institutes.
Merit was the sole criterion for admission to the medical college. I graduated as an MBBS doctor
from Delhi, and was a postgraduate student and then a young faculty at the Topiwala National
Medical College and Nair Hospital, Mumbai (then Bombay). Later, I worked as a professor and
head of the department (HOD) of cardiothoracic surgery at the G.S. Medical College and King
Edward Memorial (KEM) hospital. All three institutions had a great legacy—an inheritance of
the past built on solid national goals inspired to go beyond physical limitations.
I grew up wanting to become a surgeon and drifted into cardiac surgery inspired by the
pioneers who had scaled the transition from general to cardiac surgery with nothing more than
raw courage and great passion. Although India was struggling to provide primary healthcare to
the masses, a few bold men had dared to dream of doing open-heart surgery against heavy odds
even as cardiac surgery was in its infancy the world over (Magotra 2010).
It was always a formidable task to handle the overwhelming patient load at Nair and KEM
hospitals. Most were poor and had come from remote areas from all over—including
neighbouring countries—coming to the maximum city seeking treatment when they were at their
most vulnerable stage. It was only natural to adopt the patient-first strategy with honest and open
communication at all times, especially when things went wrong. Trust reposed by the patients in
turn gave faith to challenge the status quo when required. The subordinate staff, though an
important interface with the patients, probably fell short of the expected standards at times only
because they lacked the opportunities to upgrade their social skills. Resentment becomes a
defence mechanism for those who are not in the power hierarchy. The institutional strengths
were harnessed to overcome the gap by co-opting nurses and senior ward boys into the theatre
committee meetings. They, in turn, as informed decision-makers, increased the possibility and
probability of implementing simple practices like washing one’s hands as an ethical practice
rather than a fiat from top!

Box of Sweets
The influence of the medical industry with the inbuilt mechanisms of marketing, lobbying, and
media projections is a trap for doctors working in high-tech speciality. Those working in
teaching hospitals have an additional obligation to train young doctors keeping up with the latest
technological advances. Though cardiac care remains disproportionate and diverse worldwide the
gap is wide between public and private hospitals in India (Ghosh and Magotra 2004).
The major source of corruption is perhaps while buying costly medical equipment even when
a strict process exists on paper with many tiers of approvals for purchase. I was still new as head
of the department when a medical company representative was ushered into my sparsely
furnished office. He placed a largish box on the examination table as he himself occupied one of
the two chairs in front. He politely informed me that the purpose of his visit was to remind me of
a tender meeting the following day. I had no idea about this meeting until then. As he prepared to
leave I noticed that the box was still lying there and when reminded, he said it was a small gift
since this was our first meeting. A friend, a successful head of large public sector unit, had once
mentioned that it would be respectful to accept a box of sweets around Diwali for example, but
anything more should cause indigestion. The lesson, however, had not prepared me to react when
confronted with neatly packed silverware in that box. I was temporarily immobilized before
asking him to leave. I reported the matter to the committee the next day and, still seething with
rage, did not take part in the proceedings. In hindsight, my response that day was clearly
inadequate. We learnt to have team meetings for closer technical scrutiny to select the best offers
as per our needs and not go for every vestigial technical advance that came with a price tag.
At other times, bribes and allurements came in tragicomic forms, wrapped in the innocence of
the poor, like the time when a few crisp hundred rupee notes slipped onto my lap through the
case file of a patient awaiting admission for open-heart surgery. It seems the poor man was
convinced that his wait for surgery would end only after greasing some palms, including that of
the chief! Were some ward boys and menial staff making quick buck in the name of doctors?

Commissions and Kickbacks

Funds are scarce in public hospitals. Cardiac surgery departments, however, are considered rich
and are even envied. High volume of disposables, catheters, costly medical devices like heart
valves, pacemakers etc., add a halo of plenty. Many young residents used to vie for a rotation in
the department even though the duty hours were long and led to food and sleep deprivation.
Since it was not possible to do more than a dozen surgeries with the allocated budget, only way
of handling the patient load was to make patients pay for the consumables. A well-oiled and
efficient system had been put in place. A printed list of required items was given on admission
with the name and address of the vendor. The patients or relatives would deposit the money and
equipment was delivered directly. The same pattern was followed where the money was
deposited in the poor box fund and payments were made against the name of the patient. The
patients and their families, especially those coming from far- off places, were grateful for the
convenience. On the face of it, this appeared to be a perfect arrangement—the patients were
happy and no one was complaining, though a clear nexus existed between the vendors and the
hospital staff. It is difficult to disrupt the long-entrenched and seemingly innocuous practices but
we slowly managed to get the open-heart surgery kits organized and purchased through a
tendering process.

Perks on the Sly

Teaching hospitals in Mumbai those days had honorary doctors who dedicated four hours or so
to teaching and treating patients in medical college hospitals while also practising privately. The
best names in medicine gave honorary services; the poor patients thereby could access the best in
the medical field. They also made excellent teachers. As the full-time system came into being,
the discrepancy in incomes caused a lot of heartburn. Some full-time doctors started indulging in
private practice on the sly while some honorary doctors, too, indulged in corruption by bringing
their private patients to public hospital as ‘note cases’. Resident doctors were asked by both to
assist them in private surgery; nascent minds were thus introduced early to the illegality
(Magotra 1998). Unfortunately, sly private practice by full-time doctors in the municipal
hospitals was legitimized in 2005.
Sponsorships for attending conferences and meetings at home and abroad by the medical and
pharmaceutical companies have remained a controversy. Many justify the academic exchanges—
even if sponsored—as crucial to keep abreast with the technical advances being made. The
conference allowances, available only to senior faculty, were meagre and involved a lot of paper
work. Medical companies filled the gap by sponsoring travel and hospitality and often extended
the perks to the family as well. This has now come to attention of the regulators and several
medical companies have adopted internal codes. Attending the annual meetings of our
professional associations, in my opinion, is a member’s obligation, to engender the sense of
fraternity among colleagues and for the purpose of exchanging and enhancing knowledge
(Magotra 1997). I discouraged sponsorships though senior colleagues were free to take
individual calls as long as there was no quid pro quo or conflict of interest. I have, in the course
of my career, enjoyed good relationships with medical companies, and they, in turn, learned to
accept and respect my decision. The good part was that many stopped asking.

Children of a Lesser God

Intellectual corruption is less talked about unless it involves major academic fraud. Favouritism
and nepotism, like special clinics, disproportionate surgical work, and discreet help in exams are
taken in stride. The students deserve fair and just evaluation after a long and hard training
programme. Several internal and external pressures are sometimes brought on examiners.
Bombay had a peculiar problem, with four medical colleges with legendary rivalries among the
hospitals and sometimes within the hospital, which unwittingly affected the otherwise
meritorious students. I learned not to interfere with assessments when my students were being
evaluated, earning themselves a moniker of ‘children of a lesser god’. Obviously, my students
were not amused!
***
It was not easy to select episodes from an over 40-year-long career to squeeze into a 1,500-word
chapter. Only a few aspects that I thought fit the mandate given by the editors of the book have
been touched upon.
The attitude of service, which comes with cultivated spirituality, gives one the capacity to
accept the chances and opportunities that life offers. A good deal of courage is necessary while
handling life-and-death situations in a typical day of cardiac surgery. Ethics evolve from the
cumulative experiences of life. I have faltered and stumbled but was always fortunate to have
helping hands from both within and outside the profession. I wish to express my deep gratitude
to all of them. It is a humbling experience to share the writing space with some of them.

References
Ghosh, Probal and Ratna Magotra, 2004, ‘Adequate Cardiac Care? Conundrum for Non-affluent
Countries’, 27 May, available at http://www.ctsnet.org/sections/imo
Jain, L.C., 2011, Civil Disobedience, The Book Review Literary Trust.
Magotra. R., 1997, ‘Sponsorships for Medical Specialists’, Ind. J. Med. Ethics, 5(4).
———, 1998, ‘Public Hospitals and Private Practice’, Indian Journal of Medical Ethics, 6(4).
———, 2010, ‘Tribute to Kersi Dastur, a Pioneer in Open Heart Surgery in India’, Indian
Journal of Thoracic Cardiovascular Surgery, 26: 228–32.
 VII

MAJOR SCANDALS
 CHAPTER THIRTY THREE
The Justice Lentin Commission of Enquiry: A Case Study
Laying Bare the Malaise and Corruption in Our Health System
Rupa Chinai

In January–February 1986, 14 patients well on the road to recovery in Mumbai’s government-run

JJ Hospital suddenly died, showing identical symptoms after consuming a routine medicine
glycerine (or glycerol), an anti-oedema drug used to combat swelling. The glycerine was laced
with industrial glycol, a chemical which attacks the kidneys and kills quickly. These deaths may
not have come to public notice but for the Maharashtra Times story on it, broken by journalist
Jagan Phadnis. The public furore that followed compelled the Maharashtra government to
announce the institution of an enquiry commission, led by a sitting judge of the Bombay High
Court, Justice B. Lentin, and presumed that the matter would blow over. It did not, and for
several years thereafter, the Justice Lentin Commission of Inquiry remained the focus of intense
and unprecedented public and media interest.
In the introduction to the report of the commission, Justice Lentin wrote, ‘Little did the 14
persons who died in the JJ Hospital tragedy know that they would arouse an outcry of public
indignation which would lay bare lack of probity in public life, malaise and corruption in high
places indulged in contempt of the laws of God and man. All is over bar the shouting. It is time
to pause and forage into the murky waters of lies, deceit, intrigue, ineptitude and corruption to
salvage the truth which led to this ghastly and tragic episode.’
This report, made public in March 1988, after much prevarication by the state government, is
the first official document of its kind providing a rare and detailed insight into the state of our
public health system. Its pages describe the ‘ugly facets of the human mind and human nature,
projecting errors of judgement, misuse of ministerial power and authority, apathy towards human
life, corruption, nexus and quid pro quo between unscrupulous licence holders, analytical
laboratories, elements in the Industries Department controlling the awards of rate contracts;
manufacturers, traders, merchants, suppliers, Food and Drugs Administration (FDA) and persons
holding ministerial rank. None of this will be palatable in the affected quarters. But that cannot
be helped’.
The commission’s sittings, which ran on for one-and-a-half years, initially focused on the JJ
Hospital staff. Inertia, lack of accountability, and total absence of communication were the
hallmark of their functioning. It exposed the gross negligence of the top administration in
withdrawing the killer drug, which continued to do the rounds in the wards for four days, even
after some alert hospital doctors had sounded the ‘red alert’ on 25 January 1986 and identified
the suspect drugs. The hearings revealed the archaic method of communication within the
sprawling hospital, where even on a matter as vital as stopping a killer drug, the information was
conveyed through a single, roving, handwritten circular. With record keeping in shambles the
system of drug recall needed remodelling on an emergency footing, the commission noted.
Dwelling at length on the qualities and duties of top hospital administrators who had utterly
failed in acting to stop the killer drug even after being informed about it in writing, Justice Lentin
observed, ‘The success of any system must ultimately depend on the integrity and efficiency of
those manning it, and if these attributes are found at the top, they must percolate downwards. It is
here where the system has utterly failed, resulting in the kind of tragedy which struck the JJ
Hospital.’
The commission provided an important understanding of the drug purchase system followed
in our public hospitals. Kept deliberately obtuse and secretive, its rules left to individual caprice,
it facilitated racketeering and money making right down the line, at huge public cost. The JJ
Hospital tragedy took place because the FDA (Food and Drug Administration) granted an illegal
licence to Alpana Pharma, supplier of the killer drug glycerol, without ensuring that basic
regulations were complied with. During the course of the hearings and even thereafter, one found
that the name of Ramanlal Karwa and his brothers, the owners of Alpana Pharma worked like a
‘magic wand’—as Justice Lentin put it—in the corridors of power. (Even after the JJ Hospital
tragedy and despite the commission’s strong indictment, the Karwa brothers continued to find
favour as drug suppliers to public hospitals, using the simple expedient of starting a company
with a new name.)
Meanwhile, the members of the hospital’s drug purchase committee, which included hospital
doctors and government departments, went out of their way to place the hospital’s drug supply
order with Alpana Pharma, far exceeding the proportion allotted to them by the industries
department in their rate contract. The quid pro quo was evident with the discovery of money
placed by the drug supplier in the private bank account of committee members, as in the case of
the hospital’s then head of pharmacology department.
The absence of checks to ensure that quality drugs reached the public was revealed with
painful clarity during the commission’s investigations. At that time there were only four
government-owned drug-testing laboratories in the country and in order to cope with the huge
workload the government appointed ‘government approved’ private laboratories that certified the
purity of drugs. One such was Chem Med Laboratory that certified Alpana Pharma’s killer
glycerol as being of standard quality. This company enjoyed special protection of FDA officials
who had been wined and dined by the owners. Even after its role in the JJ Hospital tragedy was
known to them, the FDA indulged in a massive cover up to shield this company by raising ‘red
herrings’ and leading investigators up the wrong path.
In the case of yet another firm, Apex Laboratory, 14 assistant chemist employees had
complained to the FDA about the firm writing ‘false, incomplete, misleading and imaginary
reports’ related to drug analysis tests, but the organization did not take action.
An issue intensely debated at that time, as an outcome of the commission’s hearings, was
whether public hospitals as also drug manufacturers should set up in-house drug-testing
laboratories to ensure drug purity. Although a mandatory precondition for issuing of a drug
manufacturing license, the FDA did not insist on its implementation. Small drug manufacturers
insisted that they could not afford it. The trouble, however, was that even large drug companies
—including multinationals that had in-house drug-testing laboratories—produced substandard
drugs and could not be trusted to voluntarily withdraw them from the market unless caught by
the FDA and severely penalized, which the latter was not inclined to do.
The fact that even ‘reputed’ drug companies were repeat offenders was discovered by Justice
Lentin when he visited the FDA headquarters during the commission’s investigations and
examined the FDA’s Register of Sub-Standard Drugs, which he dubbed ‘The Murder Book’. It
revealed the FDA’s failure in prosecuting 582 grossly erring drug manufacturing concerns,
whose drugs were found to be substandard, misbranded, or sub-therapeutic, the majority of
which were termed as ‘life saving drugs’. Many of these ‘merchants of death’ were habitual
offenders, having committed as many as 41 offences during the span of five months in 1986, but
the FDA turned a blind eye. When questioned, FDA joint commissioner S. Dolas told the
commission that ‘someone has to die first’, before the FDA could issue prohibitory orders
against a firm.
This pointed to the enormous scale on which the public health system had been reduced to a
captive market for profit spinning, where human life was of least concern. An examination of
this register or ‘murder book’, if monitored today, would clearly provide the clues we need to
explain why—despite the JJ Hospital tragedy—no lessons have been learnt and killer drugs
continue to stalk patients in both public and private hospitals.
This and a multitude of such incidents uncovered by the commission revealed how the system
of drug purchase and licensing was vulnerable to the pressures of vested interests. In
consequence, the commission underlined that the cheapest-priced drug was not a criterion to
guarantee quality drugs. It recommended scrapping of drug procurement through the rate
contract system and reservation for backward areas. It instead suggested that government
hospitals directly purchase their quota from reputed manufacturers and conduct their own tests to
ensure standard-quality drugs, amongst other measures.
Looking beyond the specific JJ Hospital episode, the commission then expanded its scope to a
thorough probe into the state of the public health system in Maharashtra. Over 10 politicians,
which included health ministers past and present, MPs, and MLAs, were forced to reveal—after
much prevarication and loss of memory and when confronted with documentary evidence—how
their interference in the workings of the FDA had harmed public interest by the protection they
gave to manufacturers of substandard drugs and destroyed the moral fibre of the FDA, reducing
it to a ‘lapdog body’, according to the judge.
The Lentin report strongly indicted then health minister Bhai Sawant who was charged with
gross ministerial interference, favouritism for extraneous considerations, and misuse of power,
while irresistible inference of corruption was also drawn against him. It recommended an Anti-
Corruption Bureau investigation against him as also former health minister Baliram Hiray, who
was similarly indicted.
The commission found that the ‘government machinery was utilised by these politicians to
extort money from the drugs industry to inflate the coffers of private trusts with which the
ministers were associated.’ Dr Hiray was hard-pressed to explain to the commission how the
Bhau Saheb Hiray Smarnika Samiti Trust had received a large number of donations from beer
bars, distilleries, and liquor vendors from all over Maharashtra as well as several hundred
pharma concerns, including multinationals, which fell within his jurisdiction as minister. He had
also assisted the trust in acquiring government-allotted land in Bandra, measuring 1,927 square
metres at a throwaway price of Rs 3.49 lakh.
The findings of the Lentin Commission are important not just for Maharashtra’s public health
system but also for other states, as the majority of the drugs produced in India are manufactured
in Maharashtra and patients from across the country come here for tertiary treatment. The
commission found that far from regulating and imposing standards on the drug industry, the
FDA had wilfully allowed substandard drugs to be sold in the market. The commission
undertook a detailed investigation into the manner in which the FDA functioned, both in terms of
licensing and controlling the standard of drugs produced. The licensing of the then Rs 2,000
crore drugs industry in Maharashtra was solely handled by the FDA joint commissioner and
licensing authority, who was answerable to none but the health minister. This official handled all
applications for licences and had the power to refuse or grant them. He was also responsible for
launching prosecutions against offenders amongst drug manufacturers. These untrammelled
powers that he enjoyed could only be challenged in an appeal to the health minister.
‘In the hands of unscrupulous Joint Commissioners and Licensing Authority, it could be an
instrument of harassment and a device to make vast sums of money. This added to the
inducements of the manufacturer of sub standard, spurious and misbranded drugs and total lack
of fear of the consequences provided by the Act and Rules.’ the judge stated.
Dividends came to those FDA officials who said ‘Yes Minister’ promptly enough. Their
talent lay in wresting donations from the profit-spinning pharma companies which swelled the
coffers of the private trusts controlled by ministers. It was this talent that enabled officers like
S.M. Dolas, the FDA joint commissioner and sole licensing authority in the state to thwart every
transfer order, supported as he was by a galaxy of politicians, thereby enabling an uninterrupted
20-year posting in Mumbai. Politicians stepped in to cancel every transfer made on Dolas since
1978 and overruled adverse reports made against him by successive FDA commissioners.
India’s hard-earned reputation as one of the top-ranking global producers of medicines
continues to take a beating for its inability to tackle this nexus of corruption as highlighted by the
Lentin Commission. While the government has moved to decentralize the powers of the
licensing authority, the FDA is still unable to perform its role as a watchdog. A policy brief
published by The Foundation for Research in Community Health on ‘Accessing Medicines in
Africa and South Asia’ (July 2013) states: ‘Its (Indian government) failure to establish a strong
drug regulatory mechanism is casting doubt on the safety and quality of Indian drugs. With
complaints of sub-standard drugs coming from major international buyers the US, Uganda, South
Africa, there is deep concern within the Indian pharmaceutical industry that the ‘black sheep’ can
tar the credibility of the entire industry.’ The country’s pharmaceutical industry today valued at
Rs 1,00,000 crore, is seeing a rapid growth at approximately 10 per cent per year. It meets 95 per
cent of domestic needs, and has a 10 per cent share by volume in the global market.
The Lentin Commission of Inquiry had highlighted how the safety and quality of drugs
produced in Maharashtra, where 29 per cent of the country’s manufacturing and sales units are
based, must urgently undergo scrutiny and reform. The state commands a 38 per cent share
(2008–9) of India’s Rs 42,000 crore export market in medicines.
Some key thinking emerging from the debates of that time is that the government will not be
able to stem such tragedies unless it addresses itself to two tasks. To begin with in the short term,
given Indian conditions—where we contend with an irresponsible pharmaceutical industry and
an inadequate vigilance machinery—there is need for stiff penal action against errant
manufacturers (which includes FDA confiscation of machinery and property in extreme cases)
and prevention of cases from languishing in the courts. Evidence shows that even these measures
come to nought in the absence of strong political commitment to weed out corruption and
disallow the shielding of politician cronies.
In the long term, many see that the only solution lies in curbing the number of drugs, reducing
them to the 270 basic drugs recommended by the WHO (World Health Organization). This was
also endorsed by the Hathi Committee and former FDA commissioners who agree saying there is
a definite advantage in this. Several consumer and medical bodies have asserted the need to start
by weeding out drugs banned the world over, but continue to be manufactured and sold in India,
in some cases even in defiance of the ban order of the Drug Controller of India, under the shield
of court-granted stay orders. Also highlighted is the need to use drugs by their generic rather than
brand names, which would curb their proliferation and bring down prices. They have also
stressed the uselessness of cough mixtures, tonics—major money spinners for the industry—
which can be effectively and cheaply substituted by a balanced food diet. Such measures would
enable the medical and pharmaceutical industries to get back to their role of creating health
rather than merely selling drugs.
As a cub reporter then working The Indian Express in Mumbai, I chose to cover the daily
hearings of the Lentin Commission through its entire duration of one-and-a-half years. It turned
out to be a rare exposure and education on how the public health system works in our country
and where one needs to look to find irregularities. This exposure enabled me to subsequently
conduct my own investigations into the public health system, leading to the uncovering of some
more contaminated drug-related tragedies at two leading private hospitals in Mumbai—the Tata
Memorial Hospital (‘The cure that killed’, 8 May 1988, The Indian Express) and Bombay
Hospital (‘Sub-standard drug kills six in Bombay Hospital’ 2 and 16 June 1991, The Sunday
Observer). One also found that those indicted by the Lentin Commission continued to flourish
and wield favour in the corridors of power while political parties closed ranks to protect their
spheres of vested interest. Despite the work of the Lentin Commission and several other reports
of official expert committees, nothing has changed. The nexus of corruption and negligence in
our healthcare system is intact but is rarely exposed in the absence of a vigilant media, strong
public pressure, and government commitment.
 CHAPTER THIRTY FOUR
Vyapam
Sandhya Srinivasan

Described as the biggest admission-cum-recruitment scam in India, with some 2,500 arrests and
200 criminal cases filed, the Vyapam scam seems to have caught the public’s imagination for a
number of reasons. In sheer numbers, the scale of operations seemed to have been enormous—
about 1,000 students got admission through fraud between 2008 and 2013. And in addition to the
middlemen and their accomplices within the examination system, it implicated politicians,
government officials, and the police in the state of Madhya Pradesh. Naturally, the state
government resisted efforts to investigate the allegations, and then downplayed the findings. In
the course of the investigation, some 40 people linked with the enquiry died, often under
suspicious circumstances. All this makes for snappy newspaper headlines.
In fact, the Vyapam and similar scams belong in the category of ‘shocking but not surprising’.
As has been pointed out repeatedly over the years, such rackets are the inevitable consequences
of government policies in medical education and healthcare, and the governance of the sector. If
the promoters of private colleges view them as a profitable enterprise, many if not most aspiring
medical students also view medicine as a business. In both cases, the investment must bring
returns. The middlemen find a special opportunity in bringing the two together. As one analyst
puts it, Vyapam is not a cheating exam ‘gone too far’. It is organized cheating as a service
industry, which is run as a collaboration of multiple players (Krishna Kumar 2015).
The expansion of private medical colleges in India dates back to the 1980s but got a boost in
1991 with liberalization policies (Krishna Kumar 2015). The legitimacy of private medical
education—through so-called charitable trusts—was established in the case of the T.M.A Pai
Foundation vs the State of Karnataka judgement in 2002, where the Supreme Court accepted the
contention that the government alone was not able to meet the needs for higher education and the
private sector had an essential role as well. It also held that private institutions that did not
receive government money had a fundamental right to determine their own admission policies,
their governing bodies, faculty, and fees (Dhavan 2016).
The establishment of private medical colleges picked up speed post 1991, soon dominating
the medical education sector. In 1994, there were 143 medical colleges across India, of which 41
were private. In 2015–16, there were 222 private medical colleges with 29,995 seats, and 200
government medical colleges with 27,143 seats (Jain 2016).
The Medical Council of India (MCI) is the regulatory body for licensing new medical
colleges and ensuring their adequacy in infrastructure, staff strength, and curriculum. As a body
dominated by private doctors and their investors, the MCI lends itself to corruption of the highest
order. Commenting on the consequences, Rama Baru, a former member of the ethics committee
of the MCI, says:
‘What we are witnessing are the results of the criminalisation of medical education which begins with licensing of
colleges by the MCI. Besides the MCI, this criminal nexus includes promoters of private colleges, real estate
lobbies, local politicians, and serving or retired doctors from government colleges. Large amounts of money
changes [sic] hands at every stage of the medical education chain.’ (quoted in Sharma 2015)

While these private medical colleges are charitable enterprises in name, it is no secret that
their investors make crores of rupees in under-the-table deals selling admissions, with capitation
fees ranging from Rs 25 lakh for an MBBS seat to Rs 2 crore and more for a postgraduate seat in
a super-speciality. That investment has to give returns. Instead of considering stronger steps
against corruption, the Niti Aayog has taken this one step further by proposing the setting up of
‘for profit’ medical colleges.
It has been pointed out that along with this privatization of education, shifts in the
examination process and technologies enabled cheating of the Vyapam type. For example, the
use of multiple-choice questions simplified copying and changing answers. The coaching class
became an intrinsic part of the education system—those who attended one were promised
success, possibly even a seat in the college of their choice; for those who chose not to attend, or
could not afford them, there was the unspoken threat that they would fail. By advertising the
‘toppers’ among their students, the owners of these classes implied that they had access to the
system and could even manipulate marks to obtain admission (Krishna Kumar 2015).

Entrance to Medical Colleges

Aspiring doctors in India may sit for a number of exams in the hope of getting into medical
school. There are separate exams for admission into various state and national colleges as well as
private ones. To illustrate the type of competition students face, in 2014, over 617,000 students
competed for about 2,500 seats in the All India Pre-Medical Entrance Test (Chowdhury 2016).
So lakhs and lakhs of students attempt an exam for those 57,000 seats in the 422 private and
government medical colleges across the country.

Vyapam
The Madhya Pradesh Professional Examination Board (MPPEB) or Vyaysayik Pariksha Mandal
(Vyapam) started off in 1970 as a premedical test board. In 1982, it was merged with the board
for professional examinations for state medical colleges and for various state-government jobs.
In 2013, over 40,000 students appeared for the premedical test competing for 1,659 seats (Sethi
2015).
Cases of cheating in the Vyapam exams were being reported at least since the 1990s, but
cheating for most examinations is not news anywhere in India. Between 2000 and 2012, 55 cases
were filed in the state of impersonation of the registered candidate by a qualified doctor or a
senior student (Ghatwai 2015). The Vyapam scam showed that this could be done on a different
scale. It required involvement of staff at all levels as well as connivance of senior-most
government officials and politicians.
The most common method of cheating all over Indian college exams is to leak the question
paper in advance to those who are willing to pay for it; another is to have ‘jockeys’ who sit in a
nearby room and answer the questions which are then handed over to the paying candidate to
submit. A third is to have doctors or high-achieving senior students take the exam in place of the
candidate. This requires replacing the candidate’s photograph with the impersonator’s on the
admission cards and reversing the process once the paper is submitted. A fourth is the ‘engine
bogey’ system in which high-scoring candidates would be given seats that allowed candidates
who paid to copy their answers. And the fifth did away with matters of chance to simply
manipulate the marks in the system. For this, candidates were told to leave blank the questions
that they could not answer. The correct answers would be inserted, and the corrected answer
sheet entered in the computerized system.
The Vyapam scam was unearthed because of the persistence of three whistle- blowers—
Anand Rai, Ashish Chaturvedi, and Abhay Chopra, incidentally, all are members of the RSS
(Rashtriya Swayamsevak Sangh) or one of its organizations. They have been behind the many
petitions in the state high court and the Supreme Court calling for investigation and action
against the guilty. Interesting, because the Vyapam scam implicated top politicians of the BJP
government in MP.
Anand Rai was vice president of the Indore branch of Arogya Bharati, the medical wing of the
RSS, when, in an interview, he recounted his campaign of almost a decade. He said he suspected
a racket after his postgraduate exam results in 2005, when he saw rich but academically
mediocre students topping the exams. Among these were Deepak Yadav and Jagdish Sagar. A
couple of years down the line, Rai says, he had the opportunity to open Sagar’s briefcase, and he
did so, on a hunch. His doubts about Sagar were confirmed when, in that suitcase, he found
photographs and documents clearly meant for proxy examination candidates. But Rai apparently
felt he didn’t have enough to take any action (Ashraf 2015).
In 2009, Rai learned that students at a hostel at the Mahatma Gandhi Memorial Medical
College in Indore were being offered advance copies of the premed test paper. They were also
told to refer other buyers, for a referring fee of Rs 50,000. He filed a complaint with the deputy
superintendent of police on the basis of which 40 parents and 25 students were caught. But
instead of being arrested, they were made complainants in the case. Rai then lodged a complaint
with the principal secretary of the state’s department of medical education. He learned that a
department subcommittee had been formed to investigate the complaint, and at least 50 cases of
fraud had been recorded, but the reports of this investigation were not made public. He then filed
an application under the Right to Information Act on the number of candidates found to have
used fraudulent methods, but like most such applications, it was stonewalled. He twice persuaded
members of the state legislative assembly from opposition parties to file a question in theVidhan
Sabha but got no satisfactory response (Ashraf 2015).
It took more than two years after Rai’s initial complaint for the directorate of medical
education to announce the results of the enquiry. At least 114 medical students at six government
medical colleges had got in through fraudulent means; academically superior students and, in
some cases, qualified doctors wrote their exams for them, using forged identification—which
would have required the collusion of examiners. Middlemen had charged between Rs10 and 20
lakh per student for admission. The department quickly announced that biometric identification
would be used henceforth to prevent impersonation (Lalli 2011).
The biometric scheme, however, did not stop this very lucrative scheme. This became clear on
7 July 2013, when the Indore police conducted raids of hotels in the city and arrested 20 people
who, it was confirmed, were to impersonate registered candidates for the Vyapam exams.
Among those also arrested were the ‘kingpins’, Jagdish Sagar and Deepak Yadav, Vyapam
comptroller Pankaj Trivedi, and Nitin Mahendra, a systems analyst for Vyapam.
 Under the pressure of Rai’s repeated complaints at various levels, the state government set up
a special task force (STF) to take over the police probe into allegations of a syndicate of
systematic manipulation of the examination process and results. In October the same year, the
STF investigation led to cancelling results of 345 candidates in the July 2013 exam.
The progress of the enquiry shed doubt as to whether the investigating agencies were
functioning impartially or whether they were protecting guilty people in government. For
example, when Digvijay Singh of the Congress party produced electronic records listing the
candidates who paid for a seat, and the name of the person who recommended them (in many
cases the name was of the chief minister Shivraj Singh Chouhan), the government sent the
material to a government forensic laboratory which concluded that the records were forged—a
conclusion accepted by the STF. Convinced that the state government was blocking an impartial
enquiry, Anand Rai and others appealed to the Supreme Court. In July 2015, the Supreme Court
transferred the Vyapam case to the Central Bureau of Investigation (CBI).
By then, over 2,000 people had been arrested in the scam, and chargesheets under the
Prevention of Corruption Act and other laws had been filed against over 100 people. Among
those arrested in the course of the investigation was the former education minister of the state,
Laxmikant Sharma. The state’s governor, when threatened with arrest, went to court and argued
successfully that his post gave him constitutional immunity from incarceration.
Evidently, the stakes for those at the very top of the scheme were high, and the syndicate
fought back to block the investigation in a manner resembling a mafia film. Regular reports,
from 2013 onwards, of people close to the investigation dying in suspicious circumstances had
largely been ignored. For example, when shortly after the scam broke in 2013, Namrata Damor,
a medical student accused of paying for a medical seat, had been found dead on the railway
tracks, her death was ruled a suicide. Such deaths became news only after the death of an
investigative journalist. In June 2015, Akshay Singh interviewed Namrata’s father. Shortly after
the interview, Singh collapsed and died.
More than 40 people who were related in some way to the racket died. They were officials
who ran the scam, students alleged to have paid to clear the exams, and potential witnesses for
the prosecution who could expose others in the investigation. They died of road accidents, heart
attacks, brain haemorrhage, poisoning, and ‘suicide’. In one case, a college professor who had
investigated cases of cheating was set on fire on the lawn outside his house. Though the state’s
home minister insisted that there was nothing unnatural in the deaths (‘Everyone has to die,’ he
is quoted as saying), investigators reported that 23 of the reported 45 deaths of accused and
witnesses could be linked to the racket—thereby confirming that people were being killed off.
The whistle-blowers sought police protection but were refused this until they went to court.
In 2016, investigations for the period from 2008 to 2012 found conclusive proof that 634
students who obtained admission in those years had obtained admission by illegal means and
their admissions were annulled. Those who had graduated and obtained a degree were told their
degrees were cancelled. (The investigation was limited to these years, and there could have been
fraudulent admissions before 2004.)
The 634 students challenged the decision at the state high court and then the Supreme Court.
A division bench of the Supreme Court confirmed the high court’s decision. However, the
justices differed on the punishment. One of them was of the view that society should not be
denied the benefit of the knowledge that the students had gained in medical college. The students
should be allowed to retain medical college admission—and their degrees—in exchange for
doing a stint of social service. As a result of this difference of opinion, the decision on
punishment was taken to another bench of the Supreme Court.
In its February 2017 judgement dismissing the appeal of medical students against the
cancellation of their admission and their degrees, the Supreme Court judges noted that the
students had benefitted from a fraud that involved multiple falsification—from tampering with
the computer system, changing roll numbers, and fixing seating plans, to hiring impersonators
and providing false identification, something that ‘could only be effectuated, by a corrupted
administrative machinery’. Allowing these students to retain their degrees, they said, ‘would
seem like, allowing a thief to retain the stolen property’.
The investigation seems to have come to a halt after the Supreme Court judgement. A lawyer
involved in the Vyapam cases before the Supreme Court complained that the CBI, which was
expected to conduct a thorough and independent investigation, had not taken the enquiry further,
and senior government officers and politicians have thus managed to go scot-free. The CBI,
through leaks to the press, has indicated that ‘our probe has also revealed that the corruption
happened mostly at junior level, not the political level’ and ‘there is no conclusive evidence of
political conspiracy in the Vyapam scam or whether it was run like an organised crime’
(Srivastava 2017).
When asked what he thought of the Supreme Court decision, Anand Rai, whose persistent
campaign had been instrumental in keeping the investigation going, and transferring the case to
the CBI, pointed out that while students had been punished, the masterminds behind the scam,
who made all the money, were still free.
The Vyapam scam may not be an exceptional case; it may only be the tip of the iceberg. As
experts have noted,
‘…Vyapam is not restricted to Madhya Pradesh. The scam is pervasive and could well cover many other states
ruled by other political parties. Governments in other states are not above board in matters relating to the
recognition and licensing of medical colleges, conducting entrance tests, and collecting capitation fees and bribes
for admission and award of degrees. The extensive corruption in medical education represents both a political and
an institutional crisis.’ (Baru and Diwate 2015)

Indeed, the press is filled with reports of similar schemes. For example, in 2013, students
from Andhra Pradesh filed complaints of being duped after paying Rs3 crore for guaranteed
admission into private medical and dental colleges in Uttar Pradesh. And in July 2015, the
Supreme Court ruled that 6,00,000 students would have to repeat the All India Pre-Medical and
Pre-Dental Entrance Test conducted by the Central Board of Secondary Education (CBSE)
because of evidence of large-scale high-tech cheating that depended on communication through
micro sim cards, Bluetooth devices, wristwatch cameras, and WhatsApp.
In fact, in 2015, at the same time that the Supreme Court handed over the Vyapam
investigation to the CBI, it was reading another of Anand Rai’s petitions, on an inter-state racket
for the Dental and Medical Admission Test (DMAT).
Conducted by the Association of Private Dental and Medical Colleges (APDMC), the DMAT
was set up in 2006 for admission to management quota seats in undergraduate programmes in six
private medical and 16 private dental colleges in MP; the rest were filled by Vyapam (for the
government quota). The DMAT allocated about 1,500 seats every year, or over 13,000 seats up
to 2017. It is believed to have sold medical seats from its very inception in 2006, receiving
under-the-table payments of between Rs15 lakh and Rs1 crore for each those seats, totalling
Rs8,000–10,000 crore. Using techniques similar to Vyapam, DMAT is reported to have involved
politicians, judges, civil servants, and the police. Investigations have been repeatedly scuttled,
reportedly by politicians who were paid off by the medical college industry.
It has been suggested that the DMAT scam, which is of the rich buying seats, has not received
as much public interest as Vyapam, because there is no sustained campaign against corruption in
private medical colleges where the stakes are multiples of those in Vyapam. In 2015, DMAT’s
controller, Yogesh Uprit, was arrested for his part in the scam.
Uprit, who incidentally was a former Vyapam director, said that from the organization’s very
inception in 2006, every health minister of the state government had taken Rs10 crore from the
APDMC in exchange for not investigating and exposing the scam (Dixit 2015).
Which only confirms that as long as medical education is a business, and these businesses are
run by politicians, money will be made by subverting the very values that doctors are supposed
to uphold when they go out into the world to heal the sick. Vyapam and DMAT represent barely
3,000 out of more than 55,000 medical seats for which students compete each year. In such a
situation, even the most persistent of whistle-blowers is unlikely to make a difference to
corruption in medical education.

References
Ashraf, A., 2015, ‘Vyapam Whistleblower Explains How He Cracked the Scam and Why Modi
and Bhagwat Need To Speak Up’, Scroll.in, 11 August, available at
https://scroll.in/article/747539/vyapam-whistleblower-explains-how-he-cracked-the-scam-and-
why-modi-and-bhagwat-need-to-speak-up
Baru, R. and A. Diwate, 2015, ‘Vyapam is the Symptom, Criminalisation of Medical Education
is the Disease’, The Wire.in, 12 August, available at https://thewire.in/6170/vyapam-is-the-
symptom-criminalisation-of-medical-education-is-the-disease/
Chowdhury, P.K., 2016, ‘Role of Private Sector in Medical Education and Human Resource
Development for Health in India’, Economic and Political Weekly (EPW), 16 January, pp. 71–
9.
Dhavan, R., 2016, ‘Medical Council’s NEET: Unfair, Unjust, Arbitrary’, The Wire.in. 16 May,
available at https://thewire.in/36274/mcis-neet-unfair-unjust-arbitrary/
Dixit, Rakesh, 2015, ‘As Vyapam Goes to CBI, Hopes Rise that DMAT Scam will be Probed
Too’, The Wire.in, 14 July, available at https://thewire.in/6275/as-vyapam-goes-to-cbi-hopes-
rise-that-dmat-scam-will-be-probed-too/
Dixit, Rakesh, 2015, ‘Vyapam: How a Munnabhai Style Exam Scam Turned into a Macabre
Thriller’, The Wire.in, 1 July, available at https://thewire.in/5249/vyapam-how-a-munnabhai-
style-exam-scam-turned-into-a-macabre-thriller/
Editorial, 2015, ‘A Tale of Greed and Cynicism’, Economic and Political Weekly, 16 May, p. 8.
Editorial, 2017, ‘A Subversive Silence’, Economic and Political Weekly, 8 April, p. 8.
Ghatwai, M., 2015, ‘Timeline: Story of the Vyapam Scam’, The Indian Express, 8 July, available
at http://indianexpress.com/article/explained/across-the-board-vyapams-spread/
Jain, Abhishek, 2016, ‘India’s Medical Council Needs Urgent Reforms, but the Proposed Draft
Bill is Flawed’, The Wire.in, 12 October, available at https://thewire.in/74605/indias-medical-
council-needs-urgent-reforms-proposed-draft-bill-isnt-free-flaws/
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 MP-hit-by-Munnabhai-scam/articleshow/11285266.cms
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Exposed the Vyapam Scam’, Scroll.in, 31 May, available at
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517–18.
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The Wire.in, 21 February, available at https://thewire.in/110647/cbi-supreme-court-vyapam/
 VIII

BEACONS OF HOPE
 CHAPTER THIRTY FIVE
Developing a Health and Social Care System for Homeless People with
Mental Illness
The Banyan Experience in Tamil Nadu, India
Lakshmi Narasimhan, Nisha Vinayak, Kishore Kumar, and Vandana
Gopikumar

The Banyan, Tamil Nadu, was established in 1993 as a humanistic response to the untenable
reality of homeless women with mental illness, who remained invisible and excluded despite the
abjection, abuse, neglect, and vulnerability on the streets. Stripped of citizenship, and their very
identity as human beings, homeless people were at the receiving end of society’s systematic and
structured violence in the form of absolute apathy or criminalization of their poverty and
incarceration away from public sight under vagrancy and beggary laws. Our beginnings as a
small shelter, focused on the promotion of agency, independent living, and inclusion, were
marked by challenging circumstances with limited resources, in a mental health sector and
service environment that was dominated by large mental hospitals and few private or non-
governmental services for homeless people with mental illness.
The global burden of disease on account of mental disorders has grown dramatically since
1990, contributing to nearly 7.5 per cent of the total burden (Murray et al. 2013). In both high-
income and low-medium-income countries, there is an epidemiological transition from
communicable diseases to non-communicable diseases (NCD), with mental ill health predicted to
lead among all NCDs by 2030. Pervasive negative notions of capacities of people living with
mental illness perpetuate a hegemonic power structure in social transactions, which results in
loss of agency and consequent exclusion from active participation in everyday life. This further
contributes to the legacy of compromised rights. More importantly, there is a cyclical nexus
between mental ill health, poverty, and homelessness. Poverty increases the risks of developing
mental disorders (Hudson 2005).Conversely, those who develop mental illness experience a
downward social drift with an erosion of their economic and social assets (Lund et al. 2011).
Similarly, persons living in poverty with a mental illness face greater dangers of being rendered
homeless (Sullivan et al. 2000). In a survey of women from households with a mean per capita
income of Rs 2,000 per month accessing our outpatient clinics, 32 per cent reported being
homeless at least once in their lifetime. In this double helix between social causation and social
drift, justice is greatly compromised, and those at the margins are further distanced from their
legitimate claims to a reasonable quality of life.
For over 30 years, international commitments to offer mental healthcare in the community
through existing public health infrastructure have been expressed; this is articulated in the
National Mental Health Programme (NMHP) in India as well. More recently, India has also seen
the introduction of the Mental Health Bill (2013) and the Rights of Persons with Disabilities Act,
both in keeping with the United Nations Convention on the Rights of Persons with Disabilities.
Despite these progressive legislative reforms, less than 1 per cent of budgets in healthcare across
low-medium-income countries are dedicated to improving mental health (Saxena et al. 2007),
much of which is invested in large institutions that are vestiges of the colonial system of mental
healthcare, which are replete with practices inconsistent with the rights and dignity of service
users. A diverse range of effective pharmacological, psychological, and social interventions are
now available to address mental health issues. Yet the sad reality is that a majority of people who
need these interventions do not receive them at all (Raban et al. 2010); even when they do, these
are hindered by deficits in quality due to overburdened public health systems, lack of
convergence between health and non-health pathways to recovery and scarcity in appropriately
trained human resources (Jain and Jadhav 2009). Nearly half of the beds in acute care facilities
are occupied by people incarcerated for a year or more with no exit pathway into the community
(WHO Mental Health Atlas 2011). These dichotomies between intent and translation on the
ground remain undeterred by the growing crisis in mental health.

The Banyan: Values, Strategy, and Thrust Areas

The Banyan’s service expansion has strategically paralleled this transition in the mental health
landscape. We have grown from the 30-bedded home-like shelter to a mental health system that
offers comprehensive clinical- and social-care services in both community and institutional
settings. Two psychiatric nursing homes and a shelter facility service 210 persons each month
(over 2,000 have accessed services in 23 years), day care, employment, and rehabilitation
services, skills labs, group homes, and inclusive and independent living options service over 300
persons, after-care services are offered for 200 people across 10 states in India, and community
programmes service 1,500 on each month, with a registry of approximately 10,000 persons
across two districts in Tamil Nadu. The Banyan Academy of Leadership in Mental Health
(BALM) studies these innovations and partners with a diverse range of stakeholders such as civil
society organizations, government health departments, local rural governments, city
corporations, and so on to diffuse these approaches in other contexts and contribute to policy
change. The BALM is engaged in developing a new generation of mental health professionals
and leaders for the sector by transmuting values knowledge and skills gained from The Banyan’s
experience through immersive learning at the postgraduate level and diploma programmes in
mental health and development.
The capabilities approach, expounded by Amartya Sen and later by Martha Nussbaum,
considers assessments of individual well-being and justice based on effective opportunities that
people have to lead the lives they value. Poverty and mental disability, in isolation and
combination, have catastrophic effects on the opportunities that people have to make such valued
choices. Consistent with this theoretical framework, our goals are centred on addressing
inequities and other such complex issues at the cusp of mental ill health, homelessness, and
poverty. Individualized, nuanced, and robust approaches that mandate restoration of agency and
dignity and enthusiastic participation in social, economic, and cultural life are some of the
critical tenets that drive The Banyan’s approaches. Guided by these philosophical underpinnings,
values of user centricity, responsiveness, walking alongside a client in administering
interventions, infusing hope, celebrating small successes, and pursuing every collaborative goal
set by the service user and care team, are met with a sense of ardent passion and tenacity.
Humanism, creativity, and interdependence are embraced as keenly as adherence to methods
emerging from evidence-based practice or practice-based evidence. It is our belief that societal
apathy, social isolation, and abandonment are best tackled by being more than mental health
professionals and doing what a friend or family member would, while at the same time, being
mindful of uncompromising ethical boundaries. A relationship of this nature fosters a climate of
trust and safety and lends itself to therapeutic advantages.

Key Thrust Areas of the Banyan

Transit Care Center and the Shelter: Emergency and Therapeutic Services
for Homeless Persons with Mental Health Issues
‘I was fortunate to have my life turned around in a second, the day when I was approached on the
beach with my toddler son by The Banyan social worker. Had I not come to Adaikalam that day,
I would have lost my son and been eliminated myself, not standing here now as a confident and
self-reliant woman. Today, I am a mental health activist in my area. I take care of not just
myself, but my mother and my son, and the entire society is witness to this transformation in my
life.’—Bhavani, mental health activist
Homeless people with mental illness face a number of concurrent health, social, and economic
deficits due to prolonged exposure to violence and deprivation. History of significant trauma and
critical incidents such as the death of parents, child sexual abuse, hunger, and so on, coupled
with mental illness and multidimensional poverty (low educational outcomes, poor housing, and
lack of sanitation access) accompanies their mental health concerns. Therefore, their needs
stemming from such a background are complex and require multiple forms of biopsychosocial
approaches. The Transit Care Center (TCC) is a 160-bed acute-care facility that offers a safe and
therapeutic environment for homeless people with mental illness. It is a place meant to allow
them to recover, provide access, and help them pursue their capabilities and live a life that is
meaningful and satisfying. In 2012, pursuant to a Supreme Court order that mandated one shelter
for every 1 lakh population, we forayed into services for homeless men with psychosocial needs
through the Shelter, a 30-bed facility with street-engagement services, collaboratively run with
the Corporation of Chennai. TCC and Shelter focus on multiple domains of recovery and use
case management as a critical method in care coordination, assessing needs, strengths, assets,
challenges, and risks; gathering information on essential domains ranging from physical and
mental health status and care routines, social and rehabilitation needs, economic support,
housing, hygiene, co-morbidity, levels of socialization and nature of relationships, pursuit of
meaning, and so on. In doing so, it attempts to enhance functionality and use problem-solving
and person-centred therapy, interpersonal therapy, cognitive behaviour therapy, mindfulness,
open dialogue, as required to reduce distress and strengthen participation and feelings of safety
and belonging. Rogerian ideals from the psychological school of humanism that demonstrates
the need and urge for every individual to be one’s best self and Abraham Maslow’s hierarchy of
needs and motivations that influence thoughts, behaviour, and emotions, drive our care and
intervention-plan formulations. Motivational interviewing to encourage self-directed goal setting,
adaptive behaviour changes, and related positive outcomes; eco maps to improve support
networks, befriending to enhance human connection, besides Nussbaum’s 10 central capabilities
that prominently include bodily health, senses, imagination and thought, and affiliation shape our
care paradigms around personal recovery significantly. This also includes continuity of care and
features of assertive community treatment (ACT), such as the promotion of stability in
community living and normalizing daily activities including employment, housing, and so on.
Twenty-four-hour availability and development of individual tailored programmes are often a
part of our after-care design to prevent recurrent episodes of hospitalization and homelessness.
Reintegration services enable exit pathways to families of origin where inclination to support,
care, and normalize are high. For others, choices for reintegration include working women’s
hostels, independent living, and supportive housing in the community.
The TCC and Shelter adopt a collaborative, user-driven approach to care with systems such as
open wards, resident-led service audits, an externally constituted human rights cell, grievance
redressal bodies, and so on to ensure accountability and transparency. They hinge on an inclusive
architecture that accommodates micro enterprises of users, youth club activities, spaces for fun
and leisure, among many others and thereby challenge physical, social, and philosophical
barriers associated with conventional institutional services.
Currently, 2,160 homeless people with mental illness have accessed emergency and
therapeutic services offered by The Banyan; 40 per cent of people across these facilities are
engaged in internal or external paid employment and 75 per cent of homeless women with
mental illness have been reintegrated back to their families all over India.

Home Again and Clustered Group Homes: Inclusive Eco-systems for

People with Mental Health Issues Experiencing Long-term Needs
‘Now I feel like how I did in my younger years, before I became ill, at home, going to school,
coming back home, cooking...I feel very content and delighted. This is good, everyone will be
happy; they will feel peaceful that they are at home.’ Parvathy, currently pursuing a diploma in
mental health
Our Clustered Group Homes (CGH) facility is a thriving community of 48 women who live in
a group of cottages, located in the idyllic village of Thiruvidanthai off the East Coast Road in
Chennai. Coexisting within this community is The Banyan Academy of Leadership in Mental
Health (BALM) campus where diploma programmes in community mental health and
postgraduate programmes in psychology and social work are offered. In the mornings, women go
about their daily lives, working within the campus, engaging in basket weaving, listening to
songs over the radio, while students attend lectures in classrooms on the campus. Evenings at the
CGH are fun-filled. When the labours of the day are over, the area is filled with impromptu
dance competitions and games with students, while others can be found bonding over quiet
conversations.
Meanwhile, Home Again fosters choice-based inclusive living spaces through rented homes
in rural or urban neighbourhoods with a range of supportive services for people with persistent
mental health issues living over a long term in institutions. People come together to form affinity
groups and live together in homes in a community, creating a shared space of comfort, one that
mimics a family environment, with relationships, choices, responsibilities, and pursuits with
personal meaning. Along with housing, these approaches feature allied supportive services
including social-care support and facilitation (opportunities for a diverse range of work,
facilitation of government-welfare entitlements, problem solving, socialization support, leisure,
and recreation), access to healthcare, case management (detailed biopsychosocial assessments
and personalized care plans), and onsite personal assistance.
The placement of housing amidst an ordinary neighbourhood or the student community and
the consequent engagement of people with mental illness with the wider community offers the
opportunity to reframe personal evidence regarding mental health. Stigma and discrimination,
indicated by both attitudes and behaviours of three groups—the user, the onsite personal assistant
and the community—are influenced. Organic interactions, in and through these homes, influence
these attitudinal changes in contrast to the didactic messaging of awareness initiatives. These
approaches have the potential to transform institutional mental healthcare in the long run, by
offering the opportunity to incisively invest resources in acute care; and by reorienting mental
health services to focus on responsible transitions out of the institution through appropriate
community supports. Currently, 106 women use these various housing options.

NALAM: Comprehensive Well-being-oriented Packages of Care in the

Community
‘Being able to take up a task and see to finish, having a can-do attitude, instead of saying I am
unwell and cannot do, feeling well and saying that I can do.’ Kumar, NALAM clinic and day-
care user and block printer
‘Saraswathy (NALAM mobilizer) took my father-in-law to the clinic and helped us get
medicines for him. She also got us insurance, and the Aadhar and MGNREGS (Mahatma Gandhi
National Rural Employment Guarantee Scheme) cards. Then the bus fares to go the clinic and
come back. Besides this, 2 kg of rice. This money and rice are like security for us today. When
my husband died, circumstances at home tied me. But now I have shared my difficulty.’ Kavitha,
carer and daughter-in-law of a NALAM clinic user
The NALAM approach offers a multidimensional array of services and pre-emptive measures
delivered by grassroots mobilizers, to reach the underserved, mitigate social causation pathways,
arrest social drift, and prevent the spiral into homelessness. The development of NALAM stems
from our understanding that mental health cannot be separated from one’s socio-cultural identity
and that these domains play a key role in illness trajectories and well-being. The NALAM
programme covers nine wards in Chennai city and 91 panchayats in the Kanchipuram district to
a combined population of six lakh through 11 centres co-located with government and non-
government facilities. The programme offers a range of medical and psychosocial services to
mitigate distress and promote health and socio-economic outcomes. Besides mental health
professionals, NALAM engages community- based workers trained by The Banyan in basic
mental health and social care, who provide services towards poverty alleviation, awareness
creation, stigma reduction that complement the clinical services. Since the beginning of the
programme, 9,961 persons have received NALAM services.
***
Despite the complex and unyielding nature of the nexus of mental ill health and poverty, people
in whose interests we work have overcome these odds to achieve gains in personal recovery and
quality of life. What are the key messages that emerge from our two decades of working and
learning along with this unique constituency of homeless people with mental illness that can
inform aspirations for mental health and well-being of future generations?
 Convergence between health and social systems are vital to achieving a reduction in burdens
associated with non-communicable diseases, and mental health is no exception. Therefore, health
and welfare systems need to be able to discern mechanisms that sustain the mental ill-health-
poverty-homelessness trap and draw out concomitant processes that break this cycle. Care
systems must, therefore, be ingrained with dynamism so that they are adaptive and grow with
each service user’s journey, enabling them to cater at a population level while upholding
personal preferences. Global directions may represent intent. However, translations into actual
action are possible only by tuning into local contexts and constituencies. Individual narratives of
illness and recovery and socio-cultural contexts should be considered unequivocally in designing
any initiative, more so for marginalized populations.
Much of The Banyan’s success is owed to the people who drive our work—our constituency,
staff, and stakeholders. Human resources equipped with not just knowledge and skills, but the
will to effect change in the face of adversity are key to resolving persistent and complex issues.
Health systems must be embedded with processes that school a strong cadre, of peer advocates,
mental health managers, leaders, activists, and personal assistants, to advocate for their clients,
and persist with intractable problems until solutions can be gleaned. Engagement with diverse
stakeholders—users, carers, non-government organizations, donors, governments, corporates—
has been a key feature of The Banyan and BALM since inception. A strong coalition of diverse
stakeholders, who subscribe to the ethos of responsiveness, user-centricity, and personal
recovery, will contribute to public discourse on mental health and eventually propel a grass-roots
movement that promotes social justice and human rights, and has the potential to profoundly
alter the landscape of mental healthcare in the country.
In conclusion, a comprehensive and appropriate mental health system should account both for
social causation and social drift and thus arrive at approaches and designs that address the
multiplicity of factors which precipitate and perpetuate distress, disorders, exclusion, alienation,
and disability. In doing so, socio-culturally sensitive and relevant conceptualizations and
narratives of mental ill health, treatments, and rights have to be discussed, accounting for
diversity and heterogeneity of experience. It is now increasingly clear that the nature of
investments into mental health will, without a shadow of doubt, influence the achievement of, or
further distance from, our goals of ending poverty in all forms and enhancing quality of life
equitably.

References
Hudson, C.G., 2005, ‘Socioeconomic Status and Mental Illness: Tests of the Social Causation
and Selection Hypotheses’, American Journal of Orthopsychiatry, 75(1): 3.
Jain, S. and S. Jadhav, 2009, ‘Pills that Swallow Policy: Clinical Ethnography of a Community
Mental Health Program in Northern India’, Transcultural Psychiatry, 46(1): 60–85.
Lund, Crick, M. De Silva, S. Plagerson, et al., 2011, ‘Poverty and Mental Disorders: Breaking
the Cycle in Low-income and Middle-income Countries’, The Lancet, 378(9801): 1502–14.
Murray, Christopher, Theo Vos, Rafael Lozaon, et al. 2013. ‘Disability-adjusted Life Years
(DALYs) for 291 Diseases and Injuries in 21 regions, 1990–2010: A Systematic Analysis for
the Global Burden of Disease Study 2010’, The Lancet, 380(9859): 2197–2223.
Raban, Magdalena Z., Rakhi Dandona, G. Anil Kumar, and Lalit Dandona, 2010, ‘Inequitable
Coverage of Non-communicable Diseases and Injury Interventions in India’, National Medical
Journal of India, 23(5): 267.
Saxena, S., G. Thornicroft, M. Knapp, and H. Whiteford, 2007, ‘Resources for Mental Health:
Scarcity, Inequity, and Inefficiency’, The Lancet, 370(9590): 878–89.
Sullivan, G., A. Burnam, and P. Koegel, 2000, ‘Pathways to Homelessness among the Mentally
Ill’, Social Psychiatry and Psychiatric Epidemiology, 35(10): 444–50.
WHO Mental Health Atlas, 2011, available at
http://www.who.int/mental_health/publications/mental_health_atlas_2011/en/
 CHAPTER THIRTY SIX
Christian Medical College, Vellore
Sunil Chandy

Tucked away in the hinterlands of northern Tamil Nadu in a village called Tindivanam,
somewhere in the 1890s stood the lime and stone bungalow of an American missionary doctor.
His 21-year-old daughter, Ida Sophia Scudder, was reading a book late into the night when she
heard a knock on the front door. Unlatching it and holding a dimly lit kerosene lantern up, she
held the door ajar to view the visitor. There stood a man, a villager with folded hands who
explained the reason for this late-night call. His wife, a teenager, was in difficult labour and
wanted her to attend. He was desperate. Ida Sophia, however, not being a doctor herself, offered
her father’s help. But the man declined the offer as the prevailing taboos would not allow a man
to attend to a woman. As he lumbered down the steps in disappointment, his parting words were:
‘… then she must die’. Ida returned to her bed. An hour or so later, there was another knock.
Thinking that the gentleman had returned after changing his mind, she opened the door. But it
was another man, a Muslim, with the same request. He too received the same response from Ida
and left disappointed. Hardly had she settled back into her bed, came the third knock. There was
yet another man with the same request. He was given the same reply too, the situation being no
different from the other two. There was no sleep that night for young Ida. Three women in
childbirth and no one to attend? To hear later that all three women died without being attended to
was devastating.
What is the statistical probability that three men from three different homes in the same
village would have the same problem, come to the same person with the same appeal, get the
same response, and face the same outcome? One in a trillion? There are only two logical
conclusions. Either it is a fabricated well-crafted story meant to capture the reader’s attention, or
it is a true story, purpose-driven and with a divine dimension. Narrated in her own voice, scripted
in her own handwriting, and corroborated by her contemporaries, this story is undoubtedly real.
This experience transformed Ida Scudder from a rebel to a firebrand missionary, who then
committed her life to the upliftment of women and children in Vellore and its surroundings.
Retold several times over, it has reverberated through the following century, inspiring many
others to do the same. The end result of that experience is the Christian Medical College (CMC)
Vellore, journeying on towards the fulfilment of the divine purpose enshrined in the story.
Challenged by the death of these three young women for want of acceptable medical aid, Ida
Scudder returned to America and graduated as the first woman doctor from Cornell University.
She did not wait to do her internship there, but returned to India to join her father’s practice,
knowing that the ‘harvest was plenty and workers were few’. She started a small one-bed clinic
in Vellore in 1900. Little did Ida realize that she was laying the foundation of an institution that
would become a ‘beacon of hope’ for millions of people seeking healthcare. This one-bed clinic
became a life giver for thousands of poor rural patients at that time. Now, 117 years later, it
continues to be that beacon of hope. Some who have come as patients to receive care have
described CMC as the ‘home of the healing God’.
Ida began small. Her response to the simple needs of women and children made her begin her
work with local nurse aids. A donation of USD 10,000 from a generous donor helped her
establish a 40-bed hospital in 1902, just two years after she started. Realizing the acute shortage
of women for patient care, she started a nursing school in 1909, ahead of the medical school. Set
back by World War 1, Ida was able to start the Missionary Medical College for Women only in
1918, training only lady doctors towards the LMP degree. Almost three decades later, in 1947,
the first batch of men students joined to make CMC co-educational. With Indian independence
came the need for a change in governance. Ida handed over the ownership of the institution to a
council of Christian protestant churches that supported about 700 mission hospitals in various
parts of India. The 1950s marked the establishment of several speciality departments, many of
them as the first such departments of their kind in India. Pioneering work in these areas brought
patients from the entire country. The relentless pursuit of excellence and the high level of
commitment made CMC Vellore one of the most sought after medical institutions in India.
Today, CMC Vellore is a 2,700-bed teaching, referral, multi-speciality medical college training
100 undergraduate and 178 postgraduates a year. These students receive education of the highest
grade in the art and science of medicine for service in relieving suffering and promoting health.
They do so by committing wholeheartedly to the motto of the institution: ‘Not to be served, but
to serve’.
Being more than a century old, people accord different attributes to CMC Vellore. The oldest,
the foremost, the best—are some descriptions. They may or may not be accurate. But what is
irrefutable is that CMC Vellore is unique in its origin, formation, philosophy, and functioning. A
combination of all these, fine-tuned over a century, has been responsible for what the institution
has come to be—a beacon of hope.
The vision statement of CMC Vellore states: ‘The Christian Medical College, Vellore seeks to
be a witness to the healing ministry of Christ through excellence in education, service and
research’. This vision has remained undiluted for 117 years because of the commitment to the
cause by generations of faculty and staff. The emphasis of excellence in all three domains led the
institution towards its stated goals of relief of suffering, especially of the poor, disadvantaged,
and downtrodden. This ethic is rather strong and influences every aspect of the institution’s
functioning. Healthcare as service, not a business, has been the dominant theme of training and
patient care in CMC Vellore.
What is the formula that has enabled the institution to preserve its vision and mission for more
than a century? It is believed that the original vision of any large organization lasts for 40 years.
Thereafter, it undergoes either an apoptosis or a metamorphosis to adapt to change. The CMC
has, thus far, adapted to changes without altering its original vision and mission. The track record
of ‘continuity with change’, seemingly an oxymoron, is a reality for this institution.
The CMC’s uniqueness can be appreciated through the following lenses.

Training
As a teaching institution, education is a priority. The journey of excellence in healthcare starts
with good education. The college’s commitment to education can be seen from the vision of its
founder in having started training courses for nurses, compounders, and lady doctors ahead of
establishing hospital care. Education of the highest standards involves selection, structured
teaching, nurturing, and hands-on training. This college developed its unique system of selection
that evolved from the belief that the practice of medicine is a calling, not a career. While merit is
essential, that alone is not adequate. Merit by academic performance has to be complemented
with a sense of mission and suitability to serve. Attitude along with aptitude is a non-negotiable
prerequiste for the formation of a complete doctor. Social sensitivity, high moral values, honesty,
and ethics are essential ingredients that go onto the broth of medical training. It is this approach
that prompts CMC to take medical students to the villages three times in their training years.
Exposure to the real world of rural India and interaction with the poor in rural areas helps the
students to understand that medicine is much more than prescribing drugs. They begin to
understand that being a healthcare professional is an opportunity to serve and transform
communities. It is this philosophy that has resulted in 78.5 per cent of CMC’s postgraduates
serving in hospitals and medical colleges in India, contributing significantly to the health of the
country. After undergraduate training and internship every CMC alumnus is required to spend
two years in a rural hospital without which he/she cannot apply for postgraduate training in
CMC. Only now, 70 years after independence, has it become a statutory recommendation from
the ministry of health. The college has been practising this for the past 50 years, catering to the
needs of rural India.
Foster Care: Every medical student is allotted a staff family whose home becomes his/her
home away from home for their studentship years. The relationship which develops transcends
the borders of the classroom. By becoming a part of the family, students imbibe values and begin
to enjoy the security of fostered parental presence. They learn many formative life skills through
this informal forum built on the principles of the traditional Indian gurukulam system.
Invariably, the foster parent becomes a role model, mentor, and counsellor for life. This system
does not exist in other colleges and is a uniquely designed instrument that complements formal
medical education. It is not possible to put a price on the value this system has in enhancing the
personality of the budding doctor. But it remains evident through the life and practice of the
individual. Examples of distinguished service in needy areas by CMC alumni seen in Jamkhed,
Makunda, Alipur, Tezpur, Oddanchatram, and Bisamcuttack are the by-products of good medical
training and value education thus received.
Residential Living: All faculty members are required to stay on campus. This facilitates the
foster-care initiatives described above. With the security of an on-campus home, it allows the
faculty to work longer hours. Children grow in a healthy peer environment and enjoy the benefits
of community living. Exposure to music, dance, cultural activities, and worship enriches their
lives. There is a positive ripple effect of this at their workplaces. They say in Vellore that a wrist
watch is needed only to ensure you are coming to work. Going off work is not chronometer
dependent. Senior consultants can be seen to be working in the outpatient facility late in the day
and on Sundays as well.
Ethics and Core Values: Of recent interest is the introduction of ethics and leadership into the
undergraduate curriculum. The current realities of the medical practice that seem deficient of
ethics prompted the academia in CMC Vellore to reframe the curriculum and introduce ethics as
a taught subject. So is the case with leadership skills central to healthcare management. These
subjects are now taught in a didactic and interactive manner, helping the trainees to develop a
wholesome approach to medical practice
Service
Arising out of the motto of our institution: ‘Not to be ministered unto, but to minister’ (from the
Gospel according to St Mark, Chapter 10, Verse 45)—the fabric of service runs strong in the
organization. The service model is positioned on its strong, non-negotiable ethos and has evolved
over a century from the well-spring of its values, and tailored to fit with the needs of society. It is
the spirit of service that propels the faculty to work beyond the call of duty; it is service that
encourages them to work through personal and professional constraints. The philosophy of
service extends into costing, formulation of tariff, charity, and subsidy. Recognizing that the
people we serve belong to the most disadvantaged layer of society, CMC ensures that its
business model walks the talk of the service model. Most of our patients find the total package
affordable. When it is not, there is generous subsidy available, if the patient is found eligible.
There are three principles that govern CMC’s functioning: Self-sufficiency, Charity, and
Subsidy.
Being a private, not-for-profit institution unsupported by external funding forced the
management to look at a model of self-sufficiency that would not only sustain the daily running
of the institution but also uphold charity to the poor and the development of the institution.
Earning its own revenue and learning how to cut expenditure became a priority for the
leadership. All the financial principles evolved from this compulsion. The corollaries of that
philosophy are still practised in the institution—investing in value service, intellectual capital,
and compassionate technology. The attitude of financial austerity crossed over to personal
lifestyle in the staff and students. An interesting story is told about three or our senior faculty
who were invited by a world body to discuss CMC’s future. They were told to give up the quest
for specialization in exchange for unlimited funding for the poor. This was prayerfully turned
down and CMC pursued its mission of developing specialities without compromising its
commitment for the poor. There are stories of how, in the days gone by, legends like Dr Paul
Brand would detach his frayed shirt collar and stitch it back after turning it around, because he
had only two shirts in his wardrobe. This has been inspiring even for the current generation who
have much more to themselves. The austerity principle still operates.
The principle of charity is the lifeline of the institution. There are very few organizations in
India which consider charity not only a privilege, but a mandate as well. When the charity
statistics dip, clinicians begin asking questions as to why this happens, and thus become
conscience keepers and advocates of charity. No patient is denied access to care in an emergency
situation because of monetary reasons. The privilege of giving charity is given even to the junior-
most intern. In doing so, a culture of compassion is inculcated in them as they begin their
careers. This attitude converts to policies as well. For example, pricing of drugs and devices is
determined by a ‘mark-up’ policy rather than a ‘mark-down’ one. In the former model, the cost
of a drug is determined by cost price (CP). The lower the CP, the lower the selling price (SP) to
the patient, thus passing the cost benefit to the patient. In the commercial ‘mark-down’ practice
in the market, the maximum retail price (MRP) is used as the selling price which is fixed despite
the low landing price to the seller. Here the cost benefit is retained by the hospital and not passed
on to the buyer. An attitude of empathy, service, and fairness lies embedded in this business
model, where benefit to the organization is forfeited in favour of the patient. And this is a
contradiction to the profit-making paradigm of the corporate sector. The recent capping of stent
and device prices by the government testifies to the reality of unjustified profiteering by private
healthcare institutions.
 In a financially stretched environment, the formula of using the margins of profit from paid
private care to offer subsidized care to the poor in the general side has helped CMC fulfil its
commitment to the poor. Care is offerred to the paying class at market costs, ensuring that the
expectations and services are matched. Thirty-five per cent of our state-of-the-art hospital care is
for the paying class and privately insured who are charged competitive rates. The profit margin
—which is distributed as perks to doctors and dividends to shareholders in the corporate
hospitals—becomes the source of cross-subsidy for the remaining 65 per cent of patients in the
general category in CMC. General patients who are the recipients of subsidy are of three
categories:

i. Completely free care to those who are on the fringes—the poorest of the poor who have no
means of livelihood. They are referred from our community centres through the social workers
who assess and establish their eligibility.
ii. Major subsidy is for patients who have some resources but are unable to pay a major part of
the final bill. This is established again by strict assessment carried out by social workers.
iii. Minor subsidy is for those who need ‘just a little more’. They can pay most of the bill, but are
short by, say, 20 per cent.

Community Health and Outreach

Primary healthcare has been of great importance in CMC Vellore. The story of the three women
dying in childbirth had an inseparable element of primary care. That spurred our founder to
embark on novel approaches, like the village roadside clinics, bullock-cart ambulance service,
and outreach into villages. Even as the work of community health developed, primary healthcare
gained its due importance. There are three models of community health in CMC.
Community Health and Development (CHAD): This initiative implemented the principle of
social empowerment and healthcare going hand in hand. Early in their programme, CHAD
adopted the Kaniyambadi block where primary healthcare in the field and secondary care in the
base hospital were done. Antenatal care, immunization, endemic diseases prevention, leprosy,
and tuberculosis were delivered through the medium of village-based part-time community
health workers (PTCHWs). These were complemented with social-empowerment initiatives like
‘mathar sangams’, weaving and pottery, animal husbandry, women’s masonry, and other cottage
industries. The resultant improvement of the people’s socio-economic status and health is shown
in the drop in infant and maternal mortality rates in the block.
Rural Unit of Health and Social Affairs (RUHSA): This unit experimented with a higer
percentage of social initiatives and lesser component of direct health interventions, and achieved
practically the same results in the KV Kuppam block. This organization went one step further to
create a communty college where vocational programmes such as automobile repair, beautician
courses for girls, masonry, and carpentry are taught to school dropouts. The recruitment of these
trainees into good companies has been a game changer for them.
Low-Cost Effective Care (LCECU): This is a facility for the urban poor, where care is
offered practically free. The follow-up of patients is done by the medico-nursing team even in
the patients’ homes. If they are referred to the main hospital for high-cost interventions, it is done
for free or is heavily subsidized.

The Economy
In a day, the CMC attends to 8,000 outpatients, 2,700 inpatients, carries out 170 major surgeries,
and 18,000 lab tests. These large volumes have made CMC a volume-based economy. The
reputation of low-cost effective care has led to a high patient load, which, in turn, has helped the
organization to keep its per capita margins reasonable. During the demonetization drive that
happened in November 2016, there was an initial dip in patient load and income followed by a
rebound surge of patients, reinforcing the status of CMC as an affordable, accessible, and
available healthcare destination. In the yearly tariff revision exercise, much care is taken to keep
the common investigations unrevised so that it is still available to the common man without
additional expense.

The Administrative Model

World over, in most healthcare organizations, the CEO and the top layer of administration is
formed by trained professional non-medical administrators. Business strategizing and
administration not being the forte of clinicians, this has been standard practice. The CMC
Vellore, however, does the opposite. The CEO or director and his team of top administrators are
necessarily from the medical faculty. This has worked well in the governance of this institution.
Understanding the nuances of managing a multifaceted healthcare formula, where service
combines with business and needs combine with progress, the role of the clinican-administrator
has stood successfully time-tested. The ethos and vision have been driven undisturbed by this
unique legacy of home-grown in-house leaders. An example to illustrate the value of a clinician-
director is in the story below. When there was a need to explore the possibility of starting a state-
of-the-art in-vitro fertility (IVF) department, there was concern about its affordability to the
patient. There were no models or statistics to go by. Any CEO would ask for data, returns on
investment, projections, and profit capacity. At a cost of Rs 50,000, it would be inconceivable to
imagine allowing concessions to the first few patients. Yet that was exactly the decision taken by
a discerning, insightful director who permitted the treatment for the first 10 patients free of cost.
The rest is history. Goodwill, success, and long-term profits have followed. It took a clinician-
director to make that decision and his approach was influenced by his heart more than his head.
He was guided by experiential intution rather than an algorithm. Purchase of high-cost
equipment and manpower acquisition is vetted and regulated by special committees in order to
optimize expenses. Appropriateness of technology is an important filter that regulates unjustified
purchases. Although it causes delays and unhappiness in end users, this stringency has saved
enormous revenue for the institution. In the matter of purchases, CMC’s high-volume
requirements that translate to an economy of scale is used to the maximum for competitive
pricing from the dealers.

The Austerity Principle

Due to the compulsions of self-sufficiency, the CMC subconsciously practices the austerity
principle. Frills in external appearances, high-cost low-value additions, and new technology are
very carefully considered. Offices of the faculty, including that of the director’s, are not air-
conditioned. The interiors are comfortable but not extravagant. Great care is taken to ensure an
ambience of comfort without over-expenditure. Functional efficiency takes priority over
appearance. Administrators get no extra allowances in tenure, nor do doctors get overtime for
extra hours of work. All faculty travel economy for official work. Private practice is not allowed
and extra-instituional income, if any, must be surrendered to the institution.

Educational Subsidy
A medical student pays of Rs 3,000 as tuition fees. A postgraduate pays only Rs 400 for the same
purpose. This has been from the case since 1978. Paying for premium professional education at a
rate less than nursery school fees is either ridiculous or profound. When the actual cost of
undergraduate education is Rs 9,00,000 per year, is there sound logic in this? For CMC, there
certainly is, if it is in the service of its vision and mission. Any medical student, rich or poor,
who is a beneficiary of this low-fees privilege, begins to appreciate that some poor patient has
had a small role to play in his education. He completes his training and begins his career with a
deep sense of obligation to those unknown patients. A spirit of service emerges, which may be
strong enough to make him a lifelong missionary for the poor. When an entire institution is full
of such inspired workers, it converts to the business model we have been talking about. These
employees constantly push their boundaries to do more and more for the poor. And that
translates into policy and action.

The Future
Healthcare costs are a leading cause of poverty in India. This is a strange paradox, where the
reason for well-being becomes the reason of ill health. The escalating costs of healthcare and
unaffordable technology will only worsen the situation. More and more common people are
falling out of the paying bracket. On the other side, corporate healthcare has become so
competitive that unethical practices are resorted to in order to garner business. Over-
investigation, over-diagnosis, and overtreatment are the order of the day, so as to keep the high-
investment business of hospital care going.
It is in this environment that we, as stakeholders of healthcare, must collectively appraise the
situation and help the government deliver on health. It is time to recommit to the values
enshrined in the Hippocratic Oath. It is time to acknowledge that we are in the business of
service, not in the service of business. And simple approaches done with honesty and ethical
standards are all that are required.
Is CMC truly a beacon of hope? When we watch 8,000 people thronging the counters at 6
a.m. on a Monday morning, we know that it is. These are the helpless and the hopeless who have
come here as a last resort. Being not on the civil aviation map they have suffered to reach Vellore
by road. Rail travel is arduous for those who are febrile, immobile, and on supports. They have
surely not come because of CMC’s infrastructure or its facilities. Neither have they come chasing
after a famous individual doctor. The CMC cannot claim to have the most brilliant doctors in
India. Yet the milling crowds at every service desk tell us of the huge unmet needs of poor
people in India.
Feedback from patients describe three unique features of patient care—reliability, honesty,
and trust.
After a circuitous tour of several hospitals and with little money left in hand, many patients
come here for a reliable diagnosis. They have been left confused by the battery of needed and
not-so-needed investigations and different treatment options. They have lost hope as the
recommended treatment is way beyond their budget. All they want to hear is a reassuring word
that instills confidence that their well-being is our concern, that there is a more economical way
to treat their illness. They must be dispelled of the notion that as doctors and hospitals, we are
not making money out of their misery.
India needs a healthcare revival. The government must be lauded for the greater allocation for
public health spending. The stated goal of renewing the commitment to universal health coverage
is a good beginning. But the journey is long and winding, studded with the obstacles of poor
implementation. What will make a difference is an inner change in the collective conscience of
doctors and policy- makers that health is a right, health is sacred, and healthcare is service.
Healthcare in India must now reincarnate from being the most common cause of poverty to
becoming a beacon of hope for the poor and the disadvantaged.
‘No one cares how much we know, till they know how much we care’—may this be our daily
reminder as we look after our patients.
 CHAPTER THIRTY SEVEN
Challenges to Holding a Candle against Corruption
G.D. Ravindran

Established by the Catholic Bishops Conference of India (CBCI), the main object of St. John’s
Medical College, Bengaluru, has been to produce doctors to serve the under-served areas of the
country. As someone associated with the college for three decades, I have my own share of
experiences related to the training of medical students, the institution in which I work, and of
dealing with corruption.

Medical Students
Selection of students and cost of medical education ultimately drive corrupt practices in
medicine. A candidate who spends huge amounts on obtaining a medical education, is more
likely to become corrupt.

Selection
Since its inception the college has held an entrance exam as well as a battery of tests to gauge
aptitude, the ability to work in group settings, as well as psychological tests to select the
candidates. The college has about 10 different categories of reservations. The students are
admitted under each category through ‘inter-se’ merit. Table 37.1 lists the different categories
under which students are admitted for the MBBS course.

TABLE 37.1 MBBS Course Categories

Category No. of Students (2016)

General merit open merit 15
Religious Sisters 20
Catholic open merit 58
Tribal Catholics 10
Dalit Catholics 10
Karnataka Catholics 15
North Indian Native Catholics 10
Staff children 10
Differently abled 01
Central Government nominee 01
Total 150
Source: http://www.stjohns.in/medicalcollege/MBBS%20student%20NEET%20list.pdf, accessed on 10 May
2017.

‘Inter-se merit’ means that students are selected in that particular category. For example, the
religious sisters who apply to St. John’s are strictly selected on the basis of the National
Eligibility Entrance Test (NEET) marks. If the seat is not filled, it is transferred to the Catholic
open-merit category, but in the past, the seat would be left vacant. Considering the needs of the
country it has been modified and transferred to the Catholic open-merit quota.
The college has strictly adhered to this principle since its inception. It does not charge any
capitation fees. It does not accept any form of recommendation. Candidates in the general merit
category often brought a lot of pressure on the management to secure seats and the management
consistently refused to waive their stated policy. In the early 1980s, the college was de-affiliated
from its university following an episode where an influential person’s child was denied
admission. Its stand has been vindicated by the Supreme Court judgement in the matter.
We shall now take up Writ Petition Nos. 284 of 1993 and 350 (sic 482) of 1993 which appear to stand on a
different footing altogether. The petitioner in W.P. No. 284 of 1993 claims to be a MEI established by the
Catholic Community, a religious minority community in Karnataka. It is averred by the petitioner that it runs
medical, engineering, dental, pharmacy and nursing colleges in the State of Karnataka, that they do not charge any
capitation fee from any student, that the fees charged by them in these institutions is not more than (and in some
cases less than) the fees charged in the government colleges and that the admission to their institutions is made on
the basis of an All-India Common Entrance Test separately conducted by the petitioner. It is submitted that the
admissions are made on the basis of merit as determined in the said test. It is also stated that the petitioners’
institutions are well-established institutions and in view of their reputation, thousands of students apply for and
appear in the entrance test every year. The learned Advocate General of the State of Karnataka does not dispute
the above facts though, we must record, no counter has as yet been filed in the matter. He did not also dispute that
at no point of time was any complaint of irregularity received against any of the colleges run by the petitioner-
institution. It is further submitted by the learned counsel for the petitioner that in pursuance of the order dated
May 24, 1993, the petitioner has conducted an All-India entrance test and the process of selection is complete.
What remains to be done is to admit the students which was not done in view of the aforesaid order. Shri Kapil
Sibal, learned counsel for the petitioner also advanced certain legal submissions which it is not necessary to deal
with at this stage.1

This stand was again emphasized by the Supreme Court in its judgement of 2003.
At this juncture it is brought to our notice that several institutions, have since long, had their own admission
procedure and that even though they have been admitting only students of their own community no finger has ever
been raised against them and no complaints have been made regarding fairness or transparency of the admission
procedure adopted by them. These institutions submit that they have special features and that they stand on a
different footing from other minority non-aided professional institutions. It is submitted that their cases are not
based only on the right flowing from Article 30(1) but in addition they have some special features which requires
that they be permitted to admit in the manner they have been doing for all these years. A reference is made to few
such institutions, i.e., Christian Medical College, Vellore, St. Johns Hospital, Islamic Academy of Education etc.
The claim of these institutions was disputed. However we do not think it necessary to go into those questions. We
leave it open to institutions which have been established and who have had their own admission procedure for, at
least, the last 25 years to apply to the Committee set out hereinafter.2

This consistency and transparency in admission policy leads to an environment that is not
conducive to corruption.
Training
The need to be virtuous and lead a life free of corruption is emphasized throughout the medical
training of students in the college. The college derives, in part, its inspiration in Sister Dr Mary
Glowrey and the founding members of the college (members of the CBCI Society) who
envisioned an institution that would be held to the highest ethical standards. As a result, the
college, from its inception, started classes in philosophy, which was a precursor to the pioneering
medical ethics programme offered here from 1963 onwards.
During the first week of college, all the students have to attend a ‘retreat’ where they are
urged to examine their motives for choosing this profession. Their role in society is explored
through talks, discussion, plays, and group work.
From the first year itself, students are exposed to medical ethics through discussions,
narratives, and talks. In the fourth and eighth semesters, they have formal classes on this subject.
In these classes the students are made to understand the ethical principles and legal stands related
to the practice of medicine. A range of topics are discussed, for example, consent,
confidentiality, negligence, pharmaceuticals, and so on (Ravindran et al. 1997). Through these
classes we hope that our students will take an ethical stand because they are convinced of its
righteousness and not merely because the law requires it. The emphasis does not stop at the
completion of education. Interns have to attend a bimonthly ethics programme in which they
discuss current ethical issues. The faculty of the college also participates in these discussions,
which include a range of topics, such as strikes by doctors, violence against doctors, etc.
Similarly, special courses on research ethics are conducted for postgraduate students before they
start their thesis work.
Apart from a research ethics board (IREB) and a committee to deal with anti-sexual
harassment, the institution has an ethics committee that address ethical issues that arise in the
institution. If any person has a complaint against unethical practice he/she can complain to the
ombudsman committee of the hospital. This committee will investigate and recommend a course
of action to the management.
One of the important ways to promote the fight against corruption is for students to have
appropriate role models. The college carefully selects teaching staff who volunteer to serve as
mentors to the students. Each student is assigned to a mentor. It is hoped that this closer
interaction with role models embedded in the practice of medicine will help the students to have
positive attitudes and make them less corrupt.

Cost of Medical Education

One of the often-stated reasons why medical practitioners become corrupt is the cost of medical
education, which they presumably seek to recover often through corrupt means. Private medical
education is expensive. The college does not collect any capitation fees. The fee that is charged,
while higher than that of government medical colleges, is less than the base fee fixed by the
government for private medical colleges. The college expects its students to serve in underserved
areas of the country after they complete their course for a period of two years. On fulfilment of
the service they are given a preference for postgraduate studies. The same principle of inter-se
merit is applied for admission to these courses.3
If the student does not fulfil the bond, then the fee difference is recovered from him/her and
they do not get any preference for postgraduate studies. The college tries to fight against
corruption through this means.

Institutional Issues
St John’s Medical College Hospital is a 1,200-bed teaching hospital in Bengaluru. The hospital
has a general wing and a private wing. All patients pay for their services. The general ward
treatment is subsidized and is lower than the private wards which cross-subsidize the cost of
healthcare for the general patients. Patients who cannot afford treatment are given free care or
concessions. The hospital has a medical social-work department that accesses the economic
status of the patient and helps them to obtain free treatment. Bengaluru has many private and
corporate hospitals. This raises unique problems for the hospital as the hospital has to compete
with these corporate hospitals. And it gives rise to some unique problems, some of which are
listed below.

Purchase Policy
Drugs and equipment purchase can give rise to corruption in an organization. To reduce the
chances of corruption in the purchase of drugs, the hospital formed a drugs and therapeutic
committee in 1989, with senior faculty, administrators, and pharmacists as members. The
committee has strict criteria for stocking drugs in the pharmacy. Apart from generic drugs only
one brand is stocked and that is selected based on the cost, quality, and supply that the company
provides. The contract is for one year. If the company does not keep up its contractual terms, the
company is blacklisted for two years. It helps prevent the influence of the companies on the
doctors and encourages them to use generic drugs (even before the current directive by the
Medical Council of India). The medical representatives are allowed inside the hospital premises
between 12.30 and 2.00 p.m. only and meet with the pharmacists. By these means we aim to
ensure that our staff and students are not influenced by the drug industry.
Purchase of equipment can be another avenue for corruption. In 2010 the hospital evolved a
purchase system and established a purchase committee. The consultants who need new
equipment or a replacement are asked to give the features of the instruments and not the brand.
The purchase department then will scan the market and asks the vendors to submit a quotation as
well as all the features of their product. The purchase committee and the department finally
decide on the equipment that is to be bought. Since the committee has been formed there have
been substantial savings for the hospital.

Marketing of the Hospital

Many hospitals have marketing teams to promote their hospitals and liaise with the media. St
John’s hospital, however, does not, nor does it encourage the staff to interact with the press. It
does not pay any kickbacks for referrals or lab investigations. The hospital does not advertise nor
does it hold speciality camps in the community. As a result only genuine referrals that need
expertise are referred to the hospital and consultants.

Retention of Staff
Retention of staff is a major concern for the institution. In 1974 the college adopted a non-
practising policy. After the third pay commission revision, the hospital could not pay salaries to
the staff as per the guidelines. The college appointed its own pay commission under the
chairmanship of Justice Kudor, which increased the salaries. To compensate the clinical staff, it
introduced a system by which a part of the collection from the private wards was shared with the
clinical staff and the non-teaching staff was given a non-practising allowance. The staff decided
to share this income within the department and the money was split into a ratio of 5:3:1
(Professor: Assistant Professor: Lecture). The department benefitted greatly through this scheme.
The commission allowed the hospital to start an evening consultation service. Patients were
charged and part of the charges was paid to the consultant. The evening consultation was
voluntary for the staff. As the government had allowed private practice for the teaching staff, the
commission allowed the staff to practise only in their homes. Members of the Staff staying in the
staff quarters were not allowed to practise and no staff member was allowed to practise in a
clinic. This was strictly implemented. Any person who violated this rule was asked to leave the
institution. Over the years we have lost staff because of this.
Since the hospital is located in major city with numerous ‘corporate’ hospitals located
alongside—the pay differentials between the institution and these hospitals has had considerable
impact; the hospital initially witnessed an exodus of staff due to these salary differences.
In addition to this scheme, the hospital introduced a new incentive scheme in 2002. Under this
the patients were charged extra for the surgery that they underwent and for visits by physicians.
The proceeds from this collection were given as incentive to the individual consultants. While it
substantially improved the incomes of the consultants, it also opened a Pandora’s Box of
possible corruption, including the coercion of patients to opt for private wards, recommendations
for surgical procedures, and possibilities of unnecessary interventions and soliciting of patients.
It also increased the costs for the patients and it destroyed team work, as the consultants did not
treat patients as patients of St. John’s but as their own. I highlight this to illustrate the pressures
that unaided not-for-profit hospitals face in trying to ensure staff continuity in the face of a
corporate financial model of healthcare that has gripped our cities. It also illustrates how
institutional responses to these pressures can create new problems.
Considering all these factors, the institution scrapped the system in 2014. Since then, it has
increased salaries and introduced a variable pay component incorporating the first scheme, and is
based on departmental performance. The variable pay amount that can be paid to the consultants
has been capped. Few of the consultants have resigned and others have threatened to follow suit.
The management has not yielded to this coercion. This scheme is being constantly monitored and
reviewed. It is hoped that it will totally eliminate corrupt practices.

Referral to Other Institutions

The institution does not have all the facilities for investigations that are available in the city. The
institution suspected that there may be temptations for some consultants to be influenced by
kickbacks from diagnostic centres in the city. To prevent this practice, the hospital has entered
into an MOU with these referral laboratories and diagnostic centres. All biological samples are
routed through the central lab. Similarly, any imaging study of inpatients is done only after
obtaining permission from the hospital administrator. It is a herculean task for the management
to satisfy the monetary considerations of the staff, reduce costs and prevent corruption in the
hospital.

Departmental Efforts
Individual departments also try to reduce corruption and the influence of drug companies. They
do not encourage any drug company to organize programmes in their departments nor do they
solicit any form of sponsorship from the drug companies for their travels or conferences.

At the Individual Level

I practise at home and I am vulnerable to temptations. Many drug companies offer gifts. Till it
was banned by the Medical council of India (MCI), I must confess that I have accepted ‘gifts’,
something which I have now stopped doing. I have strictly instructed my family not to accept
any parcel in my absence. For the last five years, I have accepted sponsorship only when it has
been provided by the organizers of the conference.
Labs and diagnostic centres offer kickbacks. These are euphemistically called as
interpretation fees. This is paid in cash and no receipt is issued. I have consistently refused to
accept such ‘fees’. I have no idea what happens to this money. A new representative once told
me that the previous representative had claimed that he had paid me. The dilemma was—should
I collect this money and use it for poor patients? After much soul-searching I decided that it was
wrong and to not do it.

Have these Measures had Any Impact in the Practice of Medicine?

We feel that all these measures will make our students to be better doctors. Yet it is not always
so. Occasionally, we hear of our students committing fraud in their thesis. I have also heard of a
few students who were involved in medical-insurance fraud. By and large, however, I do believe
we have made a small impact in ensuring corruption-free medical practice.
***
We need to be constantly vigilant to fight corruption in the medical system. When major
decisions are made by a committee, the chances of corruption are reduced. Constant monitoring
and reviewing of the practice is essential. Above all we need a strong management that can take
unpopular and tough decisions to fight corruption. The management must also protect whistle-
blowers. We have to constantly struggle to fight corruption in the medical profession.

Reference
Ravindran, G., T. Kalam, S. Lewin, and P. Pais, 1997, ‘Teaching Medical Ethics in a Medical
College in India’, National Medical Journal of India, 10: 288–89.
 CHAPTER THIRTY EIGHT
Changing the Paradigm
The Mahatma Gandhi Institute of Medical Sciences, Sevagram
S.P. Kalantri and Anshu

Nestled in the serene environs of Mahatma Gandhi’s karmabhoomi in Sevagram, you will find
the Mahatma Gandhi Institute of Medical Sciences (MGIMS). It is India’s first rural medical
college—a pioneer institute that has initiated several innovations in community-oriented medical
education and healthcare.
Kasturba Hospital, a teaching hospital attached to the MGIMS, has the distinction of being the
only hospital in the country which was started by the Father of the Nation himself. In the 1960s,
although India had many medical schools and produced thousands of medical graduates every
year, the rural areas faced an appalling shortage of doctors. In his address to the Central Council
of Health in 1964, Prime Minister Lal Bahadur Shastri suggested starting medical colleges in
rural areas to correct this skewed doctor-patient distribution. He hoped that these colleges would
produce graduates who would be sensitive to the underprivileged, and be willing to work in rural
areas. It took Dr Sushila Nayar five years to translate this idea into reality: she founded the
MGIMS in 1969 as a Gandhi centenary project.

Vision
The vision of the institute is to develop a replicable model of community-oriented medical
education which is responsive to the changing needs of our country and is rooted in an ethos of
professional excellence.

History
Mahatma Gandhi left Sabarmati Ashram in 1930, vowing not to return until India was
independent. Thereafter, in 1936, he set up his ashram in Sevagram, an obscure village in
Maharashtra. His presence turned this village into the epicentre of India’s independence struggle.
In 1938, Dr Sushila Nayar, a 22-year-old graduate from Delhi’s Lady Hardinge Medical
College, visited Sevagram to meet her brother Pyarelal, who incidentally was Gandhi’s secretary.
In the tumultuous times of the Indian freedom movement, she was drawn by Mahatma Gandhi’s
charismatic leadership. Soon, the young Sushila began to work in Sevagram and her selfless
service to the community endeared her to the local people.
When cholera broke out in Sevagram, Gandhi urged her to tackle the outbreak. Here, she
received her first practical lessons in community health as she struggled to contain the epidemic
with little help. In the austere ashram environment, experiences such as these shaped and
chiselled her into one of the ‘heroes of public health’. Highly influenced by the Mahatma’s
ideology, she served him as his personal physician for a year.
She returned again to Sevagram after completing her MD in medicine in 1942 to zealously
participate in the Quit India Movement. Consequently, in August 1942, she was arrested with
other leaders and imprisoned with Kasturba and Mahatma Gandhi at the Aga Khan Palace in
Pune. It was here that Kasturba Gandhi passed away in 1944.
In 1944, Dr Nayar started a small dispensary in the ashram premises at Sevagram. Since the
steady flow of patients disturbed the peace of the ashram, the clinic was moved a little further
down to a guest house donated by Mr G.D. Birla. Kasturba Hospital was started here in 1945, in
memory of Kasturba Gandhi. It had 15 beds and began by rendering services to women and
children, and later extended its services to men as well. Initially, the hospital continued to grow
under the care of the ashram. After 1954, the hospital was taken over by the Gandhi Smarak
Nidhi (Mahatma Gandhi National Memorial Trust). On 11 September 1964, an independent
registered society—the Kasturba Health Society (KHS)—was formed to manage the hospital
with Dr Nayar as the president. She retained that position until her death in 2001, after which Mr
Dhirubhai Mehta, a chartered accountant donned her mantle.
After Mahatma Gandhi’s assassination, Dr Nayar had joined the Johns Hopkins University,
USA, where she received two degrees in public health (DrPh and MPH). Returning from the US
in 1950, she went on to set up a tuberculosis sanatorium in Faridabad and head the Gandhi
Memorial Leprosy Foundation. In 1952, she entered politics.
She served as the union health minister from 1962 to 1967. During this time, in line with
Prime Minister Shastri’s suggestion of opening medical schools in rural areas, a new medical
college was proposed to be set up in Sevagram as a part of the Gandhi Centenary celebrations. In
view of its historic legacy, Kasturba Hospital at Sevagram was the natural choice for setting up
India’s first experimental rural medical college. The Planning Commission approved the
proposal. It was agreed that the Government of India, the Government of Maharashtra, and the
Kasturba Health Society would share the expenditure of running the institute in the proportion of
50:25:25.
The Mahatma Gandhi Institute of Medical Sciences enrolled its first batch of 60 students in
1969. In the beginning, the institute was affiliated to Nagpur University and a common entrance
test was conducted to select students for admission to the All India Institute of Medical Sciences
(Delhi), Banaras Hindu University (Varanasi), and MGIMS (Sevagram). Right from its
inception, MGIMS has believed that autonomy given to the management with respect to
admission procedures, fees, and staffing—without disregarding the principle of merit—would
steer the school towards its mission.
The KHS runs the MGIMS and Kasturba Hospital. The various governing bodies of the
organization such as the Local Managing Committee, the Standing Finance Committee, and the
Governing Council meet periodically and take important decisions about the functioning,
planning, budgeting, and expansion of the activities of the institute and hospital. Representatives
from the state government (the Secretary of Medical Education and Drugs and the director of
Medical Education and Research), central government (the Secretary, Ministry of Health and
Family Welfare and the Director General of Health Services), six distinguished academicians,
and two MGIMS alumni are also a part of the board that meets twice a year to monitor the
MGIMS.
The KHS has explicit guidelines for functioning which ensures that each individual employee
contributes to institutional development. The functioning of the institute is decentralized and
several institutional committees comprising of faculty, non-teaching staff, and students look after
different aspects of governance and administration. The dean is the head of academic affairs and
deals with issues related to students, faculty, and parents. The secretary of the KHS looks after
all management issues of employees—both teaching and non-teaching staff. The medical
superintendent is responsible for the day-to-day running of the hospital and deals with concerns
of the patients and clinicians. The KHS president, along with his team of trustees, oversees all
these roles and also handles financial responsibilities.

MGIMS Today
Today, spread over a sprawling campus of 450 acres, Kasturba Hospital has grown from a 15 to
a 934-bed hospital. The institute also runs a 50-bed Dr Sushila Nayar Hospital in the tribal areas
of Utawali, in Melghat in Amravati district in Maharashtra, 350 km northwest of Sevagram.
Since 1998 the institute has been affiliated to the Maharashtra University of Health Sciences
(MUHS) Nashik. Besides MBBS, it offers Medical Council of India (MCI) recognized degrees
in 19 postgraduate disciplines, diplomas in nine disciplines, and PhDs in nine departments.
As of June 2017, there are 466 medical schools in India. They have a combined capacity to
produce 64,670 graduates annually. How is MGIMS different from other medical colleges?
At MGIMS, every effort is made to acquaint the medical student to the real rural India. The
spotlight on community-oriented medical education focuses on attempts to make our graduates
sensitive to the felt needs of the people they would be serving in their future. A parliamentary
standing committee on health and family welfare in a recent report stated that ‘Medical education
cannot be seen as an end in itself, but should be geared and attuned to providing general,
appropriate, accessible and affordable healthcare to all countrymen.’ And this is exactly what Dr
Nayar wanted her medical school to do, almost five decades ago.

Education
Student Admission
Dr Nayar, the founder-director of MGIMS, desired to create a model of academic excellence
which catered to the needs of rural India. And so, in 1974, MGIMS designed its own selection
methods based on the school’s unique philosophy, with emphasis on merit and excellence of
educational standards. Half the students at MGIMS are admitted from Maharashtra and the
remaining from all other states of India. The MGIMS entrance test consisted of papers on
biology, physics, and chemistry and a paper on Gandhian thought, which tested the student’s
ability to understand and interpret Gandhiji’s life and philosophy. From 2016, however,
admissions to the undergraduate course were conducted exclusively based on the National
Eligibility and Entrance Test (NEET) scores.
The MGIMS is a non-capitation-fee educational institution. It does not have any NRI quota
and charges tuition fees for its undergraduate and postgraduate medical courses at par with
government medical colleges. In 2016, of its total annual budget of Rs 1,200 million, students’
fees contributed Rs 36.6 million (3.05 per cent). Until 2016, almost 15,000 students would
compete for the 100 MBBS admissions. The method of selection of candidates for the medical
courses in MGIMS satisfied the triple test laid down by the Supreme Court in various
judgements, viz., transparency, merit, and non-exploitation. Right from its inception, the school
decided to empower rural students: 16 seats were reserved for students who had been educated in
village based schools or whose parents resided in a rural area.
For almost 45 years, MGIMS preferred to admit its own undergraduate students to its
postgraduate courses based on a merit list drawn from their aggregate performance scores in the
university professional examinations. Another prerequisite for the postgraduate admissions was a
two-year stint in a rural health centre approved and monitored by MGIMS after internship.
In March 2017, MGIMS students filed a writ petition in the Nagpur bench of the Bombay
High Court and subsequently in the Supreme Court, arguing for institutional preference for 50
per cent seats, based on their rural service. The Nagpur bench of the Bombay High Court, on 23
March 2017, struck down the provision that mandated a year of rural service by students of
MGIMS to be eligible for applying for admission to postgraduate medical courses. The court
order was challenged in the Supreme Court.
On 23 May 2017, the Supreme Court did not agree with the pleas that MGIMS students
should be accorded a preferential status in their alma mater for postgraduate admissions. The
court also did not agree that MGIMS-approved rural health centers fall under ‘remote or
difficult’ category. The Supreme Court directed the Maharashtra government to include MGIMS
in the counselling for admissions in postgraduate medical and diploma courses, based purely on
NEET scores. Ironically, on 7 June 2017, the Supreme Court quashed the Allahabad High
Court’s judgement that had set aside institutional preference in Aligarh Muslim University and
Banaras Hindu University. The court said that 10 per cent of the marks for each year can be
provided only to those in-service candidates who have served in remote or difficult areas.

Codes of Conduct
Khadi
In 1969, Dr Nayar wrote a unique code of conduct which students, faculty, and health workers
strictly adhered to. Wearing khadi, or handspun linen, was the key component of this code of
conduct. ‘Khadi is not merely a piece of cloth, but a way of life,’ said Dr Nayar who had worn
khadi all her life. Mahatma Gandhi felt that in a country where manual labour was looked down
upon, khadi would bridge the gap between the rich and the poor. This practice, he said, would
elevate the dignity of hand labour. Dr Nayar would be pleased whenever she saw her students
khadi-clad. ‘Khadi brings my students and doctors closer to the population they serve,’ she
would repeatedly say.

Shramdan
Ernst Schumacher once called Gandhi ‘the greatest economist of the century’ because human
worth, human dignity, and the human hand were key to the Gandhian concept of mass
employment. ‘Shramdan is a wonder drug which corrects the pathology of want and misery,’
said Dr Nayar. ‘Nature has intended man to earn his bread by manual labour—by the sweat of
his brow,’ she would often say, quoting her mentor. And she asked her students, faculty, and
paramedics to devote Friday evening for shramdan or voluntary self-labour. Thus, much before
the present government asked people to participate in Swachh Bharat Abhiyan, MGIMS had
already begun practising this concept, so dear to Mahatma Gandhi.

All-Religion Prayer
For Gandhi, prayer purified the heart, and could be offered even when observing silence. At the
Sevagram ashram, the all-religion prayer he started includes excerpts culled from different
religious texts including the Holy Quran, the Holy Bible, Guru Granth Sahib, the Bhagavad Gita,
the Upanishads, and Buddhist scriptures. These prayers are also recited by students and faculty
every Friday evening at MGIMS. Dr Nayar would often remind students and the faculty of the
first shloka of Ishopanishad, which loosely translated means that ‘The Lord is all pervasive in
nature. Only what you have gained by your own honest labour belongs to you. Do not covet what
belongs to others.’

Unique Model of Community-oriented Medical Education

The institute strives to produce doctors of high clinical competence, professional attitudes, and
ethical behaviour. It believes that Gandhian values are relevant even today and it displays a
fierce commitment to advancement of medical education without losing the humane touch.
The institute has been a pioneer in community-oriented medical education. Some of the
teaching innovations running for more than four decades now are: the village adoption scheme,
social service camp, orientation camp in Gandhi Ashram, the reorientation of medical education
(ROME) camp, and the rural placement scheme.

Value Inculcation in Orientation Camp

Immediately after admission into the MBBS course, students spend a fortnight in an orientation
camp in the Gandhi ashram, which is located a kilometre away from the college. Students stay in
dormitories. The curriculum followed has an inbuilt component of values, attitude building, and
ethics. Well-known Gandhians and renowned people from all walks of life interact with them
during this phase and urge them to explore the humanistic dimensions of their career choice.
Students are introduced to the relevance of Gandhian ideology in today’s world with reference to
hygiene, sanitation, nutrition, and spiritual health. They engage in self-help by washing their own
utensils and clothes. The importance of dignity of labour is impressed upon them with activities
like performing shramdan or spinning khadi. Students also participate in all-religion prayer and
yoga.

Village Adoption Scheme and Social Service Camp

The institute has an old tradition of adopting a village—located within 20 to 30 km of the college
—for each new batch of medical students. The 15-day-long social service camp is organized
with the cooperation of villagers. Students of the first MBBS batch spend a fortnight in their
adopted village, where each student is allotted four to five families for their camp activities. They
live with the villagers, visit their adopted families daily, and interact with them.
Students get a chance to see the impact of environment, ecology, education, and economy on
health first-hand during the camp. They also learn how social determinants of health—poverty
and illiteracy—impact access to healthcare. They conduct socio-demographic, dietary, and health
appraisals in their adopted families with faculty guidance. This community–academic partnership
offers a unique opportunity for students to observe how community leaders, social organizations,
and village health committees work together. The village thus serves as a laboratory and a
demonstration centre for students to learn the practice of public health. Auxiliary nursing
midwives, social workers, health educators, sanitary inspectors, psychologists, and public health
physicians working in the villages, all join in to showcase the concept of family healthcare to the
students.
In return for their hospitality, MGIMS extends its healthcare services free of cost to the
adopted village for the duration of the social service camp. Patients are screened for common
ailments, specialist visits are organized, and hospital admission is provided free of cost for a
week after completion of the camp.
The institute strongly believes that the community immersion experience is essential to make
an impact on the malleable minds of undergraduates. For most students, this experience comes as
an eye-opener as it is often their first exposure to the woes of rural India. As one student put it,
‘We are taught a lot of statistical facts about health, disparity, and inequity. But nothing prepares
you enough when you land in the village and see how people actually live. It comes as a cultural
shock at first. And then slowly you learn to see how people find happiness in less. It is an
experience which changes you for life.’
Following the social service camp, for the next three-and-a-half years, students visit their
adopted village every month. In the first year, the students study personal hygiene, basic
sanitation, housing, immunization, nutrition, growth, and development. During the subsequent
period, groups of students undertake small intervention projects on these themes. The bond
between the adopted families and the students is enduring and alumni often visit their ‘families’
when they visit Sevagram for their class reunions. As one alumnus said, ‘I guess we all shrink
looking at the immensity of purpose before us. I will always be grateful to my medical school’s
philosophy of community orientation for adding purpose to my life.’

Reorientation of Medical Education (ROME) Camp

A field camp lasting for two weeks is organized for students, during their third professional year.
Students stay at one of the rural health training centres of MGIMS. During this camp, students
are exposed to the healthcare delivery system where they interact with healthcare providers at
different levels and learn about their roles and responsibilities. District-level programme
managers for various national health programmes discuss the strengths, barriers, and challenges
in implementation of national health programmes with them.
Clinical case discussions organized at the family level help students understand the link
between social and environmental factors and disease. They learn about the impact of
community beliefs and practices on treatment-seeking behaviour. Students design and conduct
small surveys for the community-health-needs assessment, which acquaint them with basics of
data collection, entry and analysis, and report writing.

Rural Placement Scheme

In 1992, MGIMS designed a programme and policy for placement of its graduate students in
rural areas. Rural placement after graduation was linked to postgraduate admissions: students
had to do a two-year rural stint in MGIMS-approved rural health centres if they wanted to pursue
postgraduation at MGIMS. The institute collaborated with select non-governmental
organizations (NGOs) all across India, to identify rural healthcare centres with adequate patient
load, facilities, and supervision. Until 2015–16, 24 batches (1,155 students) had been posted to
over 80 rural centres across India. This symbiotic system worked well as these centres had a
steady supply of doctors, while students had good clinical exposure and supervision.
In 2007, the Report of the task force on Medical Education of the National Rural Health
Mission spelt out the need to draw upon MGIMS Sevagram’s initiatives and experience in the
rural placement of its graduates in order to formulate national guidelines. Unfortunately, this
visionary scheme lies in the doldrums after the Supreme Court decision in May 2017. Students
were forced to beat a hasty retreat from these rural centres, as these villages were deemed not
being located in ‘difficult and hilly’ terrain.

Essential Community-based National Health Research

To build research aptitude, undergraduate students are provided opportunities to conduct
community-based research on priority health topics (Essential National Health Research).
Initially, a two-day workshop is organized to orient them to research methodology. Students are
provided skills to ask the right research question, choose the appropriate study design, search
relevant literature, and write protocols for carrying out a project. Students work in groups to
identify a topic of their interest for further enquiry. They conduct these projects in their adopted
villages under the guidance of a faculty member from the department of community medicine.
Community-based projects with behaviour-change interventions are encouraged, so that the
community also benefits in this process.

Research
Medical research in India is often critiqued for being poor in quality, and largely irrelevant.
Priority areas are often neglected. A recent analysis of the research output from 2005–2014 from
579 Indian medical institutions and hospitals showed that the distribution of published research
was highly skewed: only 25 (4.3 per cent) institutions produced more than 100 papers annually,
and their contribution comprised 40 per cent of the country’s total research output. A little over
half the medical colleges did not have a single publication during this period. Here, too, MGIMS
remains an exception.
Beginning 1971, MGIMS faculty and residents have published a total of 3,570 papers, 1,170
(32 per cent) of which are PubMed listed. The focus firmly remains on themes relevant to the
local community such as tuberculosis, filariasis, coronary heart disease, cancers, diagnostic tests,
immunology, medical education, and community-based issues. These papers have found their
way into prestigious journals with high-impact factors. Several papers have been cited more than
200 times and have been accorded high ranks on citation indices.
The institute exemplifies that even in a resource-limited setting, a teaching hospital can
produce high-quality research. Being located in a village has never been a hurdle in acquiring
either funds or facilities. It has consistently received funding from the Indian Council of Medical
Research, Department of Science and Technology, Department of Biotechnology, University
Grants Commission, WHO, UNICEF, PATH, Fogarty AIDS Research and Training Program,
Canadian Institute of Health Research, Population Health Research Institute, Canada, National
Institutes of Health (NIH), National Heart Lung Blood Institute (NHLBI), and several such
organizations. With the support from extramural funding agencies, some of the pre- and para-
clinical departments have developed good research laboratories with sophisticated instruments
and infrastructure, including a CPCSEA- (Committee for the Purpose of Control And
Supervision of Experiments on Animals-)registered animal house to conduct studies on applied
immunology, cellular, and molecular biology.

Community Extension Activities

Academic institutions need to be socially accountable, and MGIMS is a perfect example of how
medical colleges must ally with the health system to improve the existing healthcare scenario.
The institute’s commitment to the community is well known. It believes in engaging with the
people and empowering them with knowledge to improve their own health. Several novel
community-based programmes have been initiated and implemented by the institute towards this
end.
The department of community medicine in the college has adopted three primary health
centers and has developed a model of decentralized healthcare delivery at the village level
through community-based organizations and panchayati raj institutions. With a lot of hand
holding, the department mobilizes communities, creates platforms for dialogue, and using
participatory processes, enables people to decide, plan, implement, and take charge of their own
health. Local members form committees to monitor sanitation, hygiene, and nutrition in their
villages. Several self-help groups, Kisan Vikas Manch (farmers’ development clubs), and Kishori
Panchayats (adolescent girls’ groups) have been formed in the adopted villages—activities that
have empowered people with ways and means towards better health and happiness.
The department of obstetrics and gynecology has launched community-based interventions
that can be applied at home, via community health workers. The direct causes of maternal
mortality—postpartum hemorrhage, unsafe abortion, and eclampsia have been successfully
addressed in villages around Sevagram with substantial reduction in maternal mortality. The
‘three delays’—delay in deciding to seek care, delay in reaching care in time, and delay in
receiving adequate treatment—have been identified and selectively targeted. The National Rural
Health Mission (NRHM) has lauded the ‘positive contribution of MGIMS in maternal health
activities conducted in partnership with the Government of India’.
Cataract accounts for 50–80 per cent bilaterally blind people in India. The institute’s
healthcare workers perform door-to-door surveys in all villages of 80 blocks of the Wardha
district to screen people for cataracts and operable blindness. In 2016–17, 30,006 villagers in 855
villages were screened at their doorsteps, 5,285 of whom underwent cataract surgeries and 5,276
individuals received intraocular lens implants. People who needed cataract surgery were
provided free transport to the Kasturba Hospital. So far, 60,456 rural patients have undergone
cataract surgery.

Providing Affordable and Accessible Healthcare

‘Whenever you are in doubt…recall the face of the poorest and the weakest man whom you may
have seen, and ask yourself, if the step you contemplate is going to be of any use to him.’

This is an excerpt from one of the last notes written by Gandhi in 1948, and Dr Nayar always
urged her residents and doctors to follow this talisman.

Kasturba Hospital
As mentioned earlier, Kasturba Hospital has a total of 934 beds and the KHS also runs a 50-bed
Dr Sushila Nayar Hospital in the tribal areas of Utawali, in Melghat in Amravati district. Almost
three-fourths of the patients seeking healthcare come from rural backgrounds—from Vidarbha in
Maharashtra, and from the adjoining areas of Andhra Pradesh, Telangana, Madhya Pradesh, and
Chhattisgarh. Despite its rural location, the hospital has all the amenities of a tertiary-care
hospital at prices which are affordable to rural patients.
In 2016–17, 8,26,808 patients attended the hospital as outpatients and 47,304 patients were
admitted. The hospital has intensive care units (ICUs) in medicine, surgery, obstetrics and
gynecology, pediatrics, an accident and emergency unit, a blood bank and component unit, and a
cardiac catheterization laboratory. There are no super-speciality departments. Facilities for
magnetic resonance imaging, computed tomography, and mammography are available. Recently,
the hospital transitioned from 2-D radiotherapy to 3-D conformal radiotherapy (CRT) and
intensity modulated radiotherapy (IMRT). The pathology, microbiology, and biochemistry
laboratories, put together, perform over 2,000 tests each day. All routine laboratory test reports
are available within two hours of submission of sample.
The hospital has constructed a new operation theatre (OT) complex this year. It features ten
modular OT suites, an ICU, and pre-operative assessment ward. In September 2016, a model
maternal and child health (MCH) wing was inaugurated. The MCH wing has beds for obstetrics
and gynecology as well as pediatrics and neonatology. It includes the outpatient department,
antenatal and postnatal wards, high dependency units, operation theatres, sick newborn critical
unit, labour rooms, obstetric intensive care units, and skills labs.

Peripheral Hospital in a Resource-limited Tribal Setting

Melghat is a hilly forest area in the midst of the Satpura mountain range. It is a tribal belt
inhabited by Korku adivasis in the north-eastern fringes of Maharashtra. The villages of Melghat
appear in a time warp—with treacherous roads, closed schools, and erratic electricity or piped
water supply.
The health-related data in Melghat is dismal: every 14th child dies in Melghat before reaching
the age of six, often owing to malnutrition-related causes. With an under-five mortality rate of
74, a child in Melghat is thrice as likely to be severely malnourished compared to an average
child in Maharashtra. Melghat comprises of Dharni and Chikhaldara tehsils of Amravati district
and has been witnessing high rates of infant and maternal mortality. Doctors are reluctant to
serve in such resource-limited settings, and hesitant to stay in the villages there. For a population
of over 3,00,000 in Melghat, there is only one sub-district hospital, two rural hospitals, and 11
primary health centres (PHC). The tribal population found it very difficult to access affordable
healthcare.
In 1998, a physician and an ophthalmologist couple—both faculty at MGIMS—decided to
take the path less travelled and chose to live in a village in Melghat. They were fully supported
by MGIMS. Over the last two decades, this couple has invested the best years of their life to care
for patients with medical and eye-related problems. Mahatma Gandhi Adivasi Dawakhana and
Dr Sushila Nayar Netralaya, at Utawali in the Dharni block, where the couple work, have offered
much-needed respite to the tribal poor.
In January 2012, MGIMS decided to go a step ahead and planned the establishment of a
community-based healthcare facility where its doctors, nurses, and paramedics would actually
stay and treat patients. With funding support from the Shri Brihad Bharatiya Samaj, a Mumbai-
based trust, a makeshift hospital was started where pregnant women and sick children could be
treated. The diagnostic and treatment-related equipment and facilities were upgraded.
In 2016, MGIMS started the 50-bed multi-speciality Dr Sushila Nayar Hospital in Utawali
village. Hostels have also been constructed for young graduates and faculty. Presently, MGIMS
posts senior residents (in obstetrics and gynecology, pediatrics, medicine, and anesthesia),
postgraduate students, interns, and other paramedics in the hospital to offer preventive,
promotive, and curative services that this region so badly needs. Over the last four years,
MGIMS has cared for 20,467 outpatients, admitted 1,811 inpatients, performed 700 surgeries,
delivered 210 babies, performed 85 caesarean sections, and operated on 30 women who required
hysterectomies and surgery for ovarian tumours.

Health-assurance Schemes
Healthcare costs can be a major cause of indebtedness and impoverishment. The health-
assurance schemes of the institute has won several accolades as it seeks to alleviate this malady.
The institute runs two schemes—the Health Insurance Scheme and the Jowar Health Assurance
Scheme. Under the first scheme, villagers can insure themselves and their family of five by
paying Rs 400 a year. In return they get 50 per cent subsidy on OPD and inpatient bills. Under
the Jowar (Sorghum) Health Assurance Scheme the membership fee is related to one’s ability to
pay. In this scheme, out-of-pocket expenditures by poor communities are channelized into
‘community financing’ schemes to help cover, in part, the costs of community-based health
delivery. The scheme offers the benefit of 50 per cent coverage of OPD visits and planned
hospitalizations (including normal deliveries) and 100 per cent coverage for emergencies and
unplanned hospitalizations. In 2016–17, 18,807 families (86,199 members) around Sevagram
sought health insurance from this hospital. Similarly, 40 villages (90,201 rural people) were
insured under this scheme. No other medical institution has achieved this kind of coverage so
consistently and at so affordable a rate.

Low-Cost Drug Initiative

Beginning 2010, a low-cost drug initiative was implemented at MGIMS aimed at providing
appropriate and affordable drugs to the patients. This initiative to reduce the cost of drugs to the
patient was made possible by first minimizing the ‘supply chain effect’ and then by overcoming
the ‘marketing effect’. This was done by using a multi-pronged strategy. Healthcare workers first
selected a list of essential drugs and surgical items required for our setting. Almost all drugs
mentioned in the National List of Essential Medicines were made available in the hospital
pharmacy. Drugs were procured at substantially cheap prices by inviting competitive quotations
from drug distributors. The electronic hospital information system was used to buy, stock, and
dispense drugs and surgical items. As far as possible, each drug was not to have more than two
brand-name drugs; the brand names were not chosen on the basis of reputation of the company
but the price. The doctors were encouraged to use electronic prescriptions—details which could
be seen in the pharmacy. The patients do have to pay for their drugs, but the hospital drug policy
made it possible that a patient with high blood pressure, diabetes mellitus, coronary artery
disease, and hyperlipidemia could purchase required drugs at just a little over Rs 100 per month.
This was made possible by making the drugs available at the procurement price, adding a 20 per
cent administrative cost to the procurement price. This initiative not only considerably reduced
the cost of drugs but also made it possible to break the nexus between the drug industry and
hospital doctors. We encouraged the use of generic as well as low-cost branded generic drugs in
the hospital.

Rajiv Gandhi Jeevandayee Arogya Yojana (RGJAY)

In 2012, the Maharashtra government launched Rajiv Gandhi Jeevandayee Arogya Yojana
(RGJAY) —renamed Mahatma Jyotiba Phule Jan Arogya Yojana in June 2017. The main
objective of this health insurance scheme is to ensure that no poor person in Maharashtra, when
faced with catastrophic medical or surgical illnesses, is denied healthcare for want of money.
Kasturba Hospital is one of the public hospitals in the state which runs this cashless scheme. The
scheme entails access to around 971 surgeries/therapies/procedures along with 121 follow-up
packages in 30 identified specialized categories. The major beneficiaries of the scheme are
patients with cancer, those seeking emergency healthcare because of traumatic accidents and
seriously ill patients requiring intensive care because of life-threatening medical, pediatric, or
surgical illnesses.

Harnessing Technology in a Rural Setting

Advanced Hospital Information System
The Hospital Information System (HIS) at MGIMS is a state-of-the-art, fully integrated
electronic hospital information system. The system, funded by the ministry of information
technology in 2004, provides health workers in the hospital with a full suite of tools for
registering patients, ordering tests, retrieving test results, and generating electronic discharge
summaries. The system captures, stores, and retrieves all data related to 8,00,000 outpatients and
50,000 inpatients every year. Most laboratories are paperless now, and residents and consultants
are able to access all laboratory test results including radiologic images—anytime anywhere on
campus because of the campus-wide wireless connectivity. The system captures data from
registration, insurance, admission and discharge counters, outpatient departments, inpatient
departments, laboratories, blood bank, operating rooms, pharmacy, and kitchen. A picture
archival and communication system (PACS) now enables doctors to access the radiology images
on their desktops. Electronic queue management systems have been installed in all OPDs to
make patients wait comfortably instead of crowding around consultants.

E-prescriptions
Kasturba Hospital has introduced computerized prescriber order entry (CPOE) to prescribe
drugs. We also created e-prescriptions on the iPad app, specially designed for this purpose. The
electronic applications help doctors identify drugs by both their generic names, check for their
availability in the drug store, and display their prices—thus minimizing prescription errors and
improving the quality of evidence-based therapies.
No-Q Card
A No-Q Card is a card which seeks to minimize long hours of waiting in queues and thus help
patients enjoy a hassle-free experience at the hospital. No-Q Card is a unique ATM-like card
(with pre-deposited cash) that can be easily and effectively used at various counters across the
hospital to save time. On an average, the No-Q card helps patients save 90 minutes whenever
they revisit the hospital, get tested and buy drugs.

Electronic Resources on Campus

The campus, hostels, faculty residences, and peripheral centres are completely linked by high-
speed broadband. Each student and faculty has an individual email ID on the intra-mail. The
central library at MGIMS has gone digital and acquired a 24x7 dedicated library server. With
this new facility, its users can access all its resources at their computer terminals or smart phones
and other Wi-Fi-enabled gadgets.
In 2013, MGIMS bought campus-wide subscription for UpToDate, an electronic evidence-
based, physician-authored clinical decision support resource. Worldwide, clinicians use it to
make the right point-of-care decisions. Although close to 90 per cent of medical schools and
hospitals in the US rely on UpToDate to provide the best care, there are very few medical
schools in India which subscribe to it. The campus-wide free wireless connectivity ensured that
all students, interns, residents, and faculty members could access UpToDate, whenever and
wherever they wanted. Thus, residents learnt very early in their formative years of training that
evidence-based electronic resources were infinitely better than knowledge gained from
interactions with medical representatives.

Shunning the Lure of the Drug Industry

MGIMS Says No to Drug Representatives
In 2009, MGIMS closed its doors to drug representatives. It did so based on personal experience
and the published research showing that drug samples, sales pitches, and free food influence
physicians to prescribe medications contrary to the best evidence for clinical effectiveness and
cost-effectiveness. This initiative, limiting the potential influence of pharmaceutical and other
biomedical companies in its day-to-day clinical and educational activities greatly reduced the
subtle influence that the industry-doctor relationship leads to.

Conferences Sans Pharma Sponsorship

In 2004, MGIMS faculty and management decided that drug industry or medical equipment
manufacturers could no longer sponsor or support any conference, seminar, or workshop in
Sevagram. The guidelines also specified that continuing medical education (CME) organizers
could not accept advertisements or money from drug companies for publishing the proceedings,
souvenirs and flyers. The institute committed to underwrite a substantial proportion of
conference expenses. The rest of the funding would have to come from delegate fees and grants
from funding agencies. It thus became the first medical institute in the country to keep the drug
industry away from the sacred field of medical education. Over the last 13 years, MGIMS has
shown that high-quality medical conferences can be held in medical schools if we choose to keep
them simple. Much before the MCI notified the ethical guidelines under the Indian Medical
Council (Professional Conduct, Etiquette and Ethics) (Amendment) Regulations, 2015, MGIMS
had already taken steps to keep drug industry away from the hospital. As one conference
delegate aptly put it, ‘The serenity and scientificity that Sevagram offers is unmatched. I could
never imagine that an international conference could be so beautifully managed in a village
without any support from the drug industry but you did it. And you were ahead of time—you
took this path breathing decision a decade ahead of MCI guidelines.’
An editorial in an American journal wrote: ‘Several years ago, the Mahatma Gandhi Institute
of Medical Sciences, a rural medical college in Sevagram, Maharashtra, India, decided to refuse
drug industry support for any conferences, seminars or workshops, thus becoming “the first
medical institute in the country to keep [the] drug industry away from medical education”.
Surely, if a rural medical college in India can afford to scorn the bribes of Pharma, one medical
school in the US could show the same leadership?’

An Exemplar of Public–Private Partnership

Over the last 47 years, MGIMS has built its credibility and reputation as a vanguard of
community-oriented medical education in its pursuit of exemplary standards of professional
excellence. Strong community linkages allow us to teach and train our graduates differently
using community-oriented teaching innovations and conduct community extension work. In
addition, affiliations with all levels of the health system have led to faculty participation in
framing several health policy and guidelines at the national level. In recognition of its efforts to
maintain quality, the National Accreditation and Assessment Council (NAAC) accredited
MGIMS as an ‘A’ grade medical institution in 2011 and again in 2017.
It must be mentioned here, that community engagement and support is mandatory if one seeks
to replicate the Sevagram model of community-oriented medical education in another centre. The
credibility of these strong linkages and robust extension activities form the very foundation on
which this model can be sustained. Equally important will be the role of a dedicated faculty
which understands the alternate vision and is passionate about pursuing this mission. While we
have been lucky to find like-minded faculty members who share our zeal and stay on, the going
has not always been smooth. The allure of corporate pay packages in metropolitan cities is often
too seductive to forego and we have struggled to hire or retain super-specialists who will develop
these departments.
Looking back, the relative autonomy we have enjoyed so far compared to other government
institutes has given us the freedom to be creative and provided ample opportunities to innovate in
healthcare, teaching, and research. However the consequences of NEET make the future of
several of our leading schemes, especially our rural placement scheme, uncertain.
Kasturba Hospital and MGIMS are one of the best examples of public-private partnership
working to the advantage of the public. The institute runs on funding from the Government of
India (50 per cent), Government of Maharashtra (25 per cent), and the KHS (25 per cent). The
institute is an excellent exemplar of a ‘not-for profit’ hospital which combines the efficiency and
missionary zeal of private voluntary sector, and the concern for access of services and high
coverage, compliance to rules and equal opportunities in employment of the public sector.
***
At MGIMS, we are conscious that medical education needs to maintain the right balance in the
eternal triangle of ‘quality, relevance, and equity’. In our perennial quest to attain the perfect
blend, we never forget that these three arms are not in conflict, and equity cannot be kept in
abeyance. Our students are expected to adhere to professional norms which include altruism,
compassion, empathy, accountability, honesty, and integrity. Over the last four-and-a- half
decades, the MGIMS faculty has been striving hard to imbibe the philosophy which makes it
pursue excellence in academics, healthcare, and research, more than mundane needs and money;
and to maintain excellence in quality.
Dr Nayar had a vision for MGIMS. In her absence, the faculty and students at MGIMS strive
hard to bring her vision to fruition. Building a medical school in a small village in central India,
convincing top faculty to teach, conduct research, and look after patients, insisting on academic
excellence, while adhering unwaveringly to her mission of keeping the community perspective
foremost was no mean task. That she was able to steer the boat between the Scylla of
government regulations and the Charybdis of privatization of medical education is a testimony to
her courage and vision.

References
Arora, M., J.K. Banerjee, P. Sahni, G.K. Pande, and S. Nundy. 1996. ‘Which are the Best
Undergraduate Medical Colleges in India?’, National Medical Journal India, 9(3): 141–44.
———. 2007. ‘Task Force on Medical Education for the National Rural Health Mission’,
Ministry of Health and Family Welfare, Government of India, New Delhi, available at
http://www.mciindia.org/InformationDesk/ForStudents/ListofCollegesTeachingMBBS.aspx,
accessed on 19 June 2017
———. 2016. ‘The Functioning of Medical Council of India’, Parliamentary Standing
Committee on Health and Family Welfare, 92nd report
Fugh-Berman, A. and S. Batt. 2006. ‘This May Sting a Bit: Cutting CME’s Ties to Pharma’,
Virtual Mentor, 8(6): 412–15, available at http://journalofethics.ama-assn.org/2006/06/oped1-
0606.html, accessed on 18 June 2017.
———. 2015–16. Kasturba Health Society’s Mahatma Gandhi Institute of Medical Sciences.
46th Annual Report, available at https://www.mgims.ac.in/index.php/about-us/annual-report,
accessed on 15 June 2017.
Nundy, S. 2014. ‘Corruption in Indian Medicine’, Current Medicine Research and Practice, 4:
99–100, available at http://www.thehindu.com/sci-tech/health/betraying-the-
oath/article17362851.ece, accessed on 19 June 2017.
Ray, S., I. Shah, and S. Nundy. 2016. ‘The Research Output from Indian Medical Institutions
between 2005 and 2014’, Current Medicine Research and Practice, 6: 49–58.
 CHAPTER THIRTY NINE
Experience with Health Worker-Based Medical Programmes
Binayak Sen

This piece is about some of the lessons from health worker-based medical programmes with
which I was involved in different contexts in Chhattisgarh during the period 1981–2005.
One of the major conclusions I can draw from these experiences is that the state can never
substitute for the alternative ontology of a counter hegemonic process. The state, when it tries to
imitate a people-based programme, can only produce a fake substitute, where the control, in the
name of the people, is held by a bureaucracy which thinks it knows best or sectarian political
leadership. Many of us have had the privilege of participating in several such initiatives. Any
recommendations for changes in healthcare policy that invoke the welfare functions of the state,
address themselves to a chimera. World Health Organization’s (WHO) Commission on the
Social Determinants of Health tells us that inequity is killing people on a grand scale (Sen 2014);
the state is the agency responsible for keeping that inequity in place. This is beautifully
illustrated by the shameful way in which the recommendations of the high-level expert group
(HLEG) on the universalization of healthcare set up by the late lamented Planning Commission
were trashed by the same body. Another example is the deplorable levels of chronic calorie
deficiency in the population of a country which is surplus in food production. At the same time, a
genuinely community-based democratic programme can provide a platform for the articulation of
this alternative ontology, whether in the field of health or any other field. In many historical
contexts, people have unleashed their creativity as part of their struggle to build a world based on
equity and social justice. Without the struggle, the model loses its context and becomes, at best, a
mere technical fix.

Shaheed Hospital
The Shaheed Hospital came into existence in 1981–82 as a result of the struggles of the
contractual mine workers in the public sector iron ore mines of Dalli Rajhara, captive to the
Bhilai Steel Plant (BSP), in the southern part of Durg, now in Chhattisgarh. A strong and militant
workers’ rights organization, the Chhattisgarh Mines Shramik Sangh (CMSS) led by the
charismatic Shankar Guha Niyogi, created this initiative as part of its struggle for equity and
dignity (Sen 2014). The initiative can be understood in the larger context of democratic upsurge
in post-emergency India, and was remarkable for its many social and cultural initiatives under
the broad rubric of Sangharsh aur Nirman (Struggle and create) which was the organization’s
watchword. The health work was joined by several young doctors, who were active in the
political struggle around equity in healthcare. Although the health work in the initial years
included a significant element of community-based work, in later years, the hospital-based
curative work became dominant. The principles of our work were ease of access, demystification
of technology, abolition of hierarchies of function, rational and affordable therapy, and low cost
of procedures and medicines.
Inducting health workers into the programme was based on certain challenges that, one would
like to believe, were turned into opportunities by the programme. As a trade-union-based health
initiative that was entirely funded out of workers’ contributions, there was limited scope for
hiring trained professionals and paying them at market determined rates. There was also a
reluctance to place professionals in a dominating position in an initiative with a strong
community ownership. Most of the organization’s members and office bearers had minimal
levels of formal education and had suffered neglect in healthcare institutions. The movement
itself was based on the issue of achieving dignity and respect in a society in which such a
community faced constant humiliation.
A solution that satisfied these preconditions lay in inducting mine workers and community
volunteers with basic literacy skills, and training them as health workers to fulfil the various
professional requirements needed. In the early years, there was an enormous pride and ownership
of the hospital and its work by the workers, and many workers, after their regular work at the
mines, volunteered for service at the hospital. Visiting relatives were always brought to the
hospital for a guided tour of the facilities. Apart from the ongoing medical work, there were
always vibrant discussions in the corridors and waiting areas about the trade union and its
antecedent social activities.
The induction of health workers was motivated by the principle of demystification of
technology and science. The necessary training and academic protocols were designed in-house
and were continuous and comprehensive. The process made liberal use of existing community
health-worker training modules, translations, and newer material was contextually designed.
Over time, the training programme in nursing became a regular feature of the hospital’s
educational calendar with de facto recognition over the wider geographical region, and many
girls trained at the Shaheed Hospital found employment in health facilities of all sizes in
Chhattisgarh.
Today, the hospital caters to a large population in Dalli Rajhara as well as a large hinterland.
It is also recognized as a referral hospital at the district level. The health workers, nurses, and
technicians trained in-house continue to be the backbone of the facility. Even as I write this, the
hospital is in the process of constructing the premises of an ANM training school affiliated to the
state board.
However, the CMSS which gave birth to this institution is today in decline, largely because of
the attrition of the workforce, something attributable in turn to the dynamics of the mining
industry. With the decline of the iron ore reserves in the Dalli Rajhara mines, no new recruitment
has been made to the mines since 1987. The workforce that struggled valiantly for regularization
of employment has found partial success in selective absorption into the BSP’s regular
workforce. Many have not been absorbed, particularly the once 5,000-strong female workforce.
The trade union office, once alive late into the night, today wears a deserted look, and the
hospital, having lost some of the live contact with workers’ organizations, is a pale reflection of
its embedded nature, although the quality of its medical work remains excellent.

Nagri and the Mitanin Programme

In the early 1990s, I began to work in the southernmost part of the then Raipur district, with an
organization of dam-displaced communities who had tried to build settlements in the forest,
based on the ideas of socialist leader Ram Manohar Lohia. In comparison with Dalli Rajhara, the
area and its people, and their ‘illegal’ settlements were deprived of any facilities that citizens
might ordinarily expect even in the backwaters of what was then Madhya Pradesh. At the time
our work began, many villages had no electricity, school, or health facilities, since they were
regarded as illegal settlements that the state had tried several times since independence to
destroy. However, the people always came back and rebuilt their homes and recreated their
agricultural fields, staying strong and united in their search for alternative settlement sites.
The connection with these villages had come about through a project of the national literacy
mission, and we were invited by the local people for a three-day health worker training camp;
they wished to acquire skills in basic healthcare since they lacked any access to medical facilities
or personnel. The area was adjacent to western Odisha, and endemic to falciparum malaria, with
several malaria deaths every year. As the organization’s connection with the people grew deeper,
malaria detection and treatment became one of the central planks of a new health initiative. At
the time when this was undertaken the procedure was extremely long; a government malaria
worker would collect blood smears of those with ‘fevers’ from the area, send the slides to the
district headquarters, and wait for two weeks for the reports to come back, before the treatment
could start. It was often too late. What we focused on was the rationalization of malaria care.
Village health workers in far-flung communities learnt to collect blood for malaria testing, make
slides, and rush them to a laboratory with a trained technician in a central village, so that the
diagnosis was quick, and treatment for falciparum malaria could start early. This work was very
important at the time, and much appreciated in the community, although it was a challenge for a
small civil society group and a cash-starved rural community to raise the resources to continue.
An opportunity seemed to present itself when the new state of Chhattisgarh was announced,
and a major programme of restructuring the health services was launched with a village-based
woman actor, the mitanin, at the centre of the community outreach. We were very happy to
support this programme, and to dovetail our efforts with that of the state’s. However, it was soon
apparent that there were major differences in conceptualization among the various people
shaping the programme (Sen 2005). From where we came, we saw the mitanin as a community
representative, one who could articulate peoples’ healthcare needs, a belief bolstered by the
official literature about the mitanin articulating the ‘demand’ side of the new state’s health
programme. In practice, however, she was given training in basic community health, and
expected to perform certain functions and maintain records as directed by the health department,
although she was not paid a salary, as someone who was not an employee of the state. In later
years, some of these tendencies became clearer, when the ASHA (accredited social health
activist), the current avatar of the mitanin in the National Rural Health Mission (NRHM),
became, in effect, the lowest-level unpaid functionary of the health and family welfare
department.
***
It has been a rare privilege to have had the opportunity to build healthcare service programmes
for communities in search of their own destinies. The outcomes have not always withstood the
ravages of time. Nevertheless, our own experiences, reinforced by the experiences of others
engaged in similar work, leads us to believe that democratic communities acting on their own
behalf to create institutional structures for themselves can develop alternatives than the ‘false
dawn’ of unimaginative state-based policy imperatives.
This volume is about corruption in healthcare. Recent concepts and developments in local
food sovereignty and universal healthcare provide us with a historical opportunity to build an
ethos for a society based on sharing and caring. Healthcare provides a unique platform on which
to base these counter-hegemonic goals. It is important to link these advances with the peoples’
own efforts and keep away from the corruption of state-based thinking to be able to seize this
moment.

References
Sen, Binayak, 2005, ‘The Myth of the Mitanin: Political Constraints on Structural Reforms in
Health Care’, Medico Friend Circle Bulletin, June–July.
Sen, Ilina, 2014, Inside Chhattisgarh, a Political Memoir Delhi: Penguin.
 CHAPTER FORTY
In All Honesty
Amrita Patel

When I first heard about it, I did not take it seriously. But then I was told that this was a practice
that all medical colleges experienced. It took some time to sink in but when it did, there was
disbelief and shock. I was then the managing director of the National Dairy Development Board,
the body that led India to self-sufficiency in milk. My father, who was the chairman of the trust
that managed the Pramukhswami Medical College established in 1987 at Karamsad in Gujarat,
with permission to admit 100 students, had taken seriously ill before he passed away in 1993.
The burden of managing the affairs of the trust fell on my shoulders. The college had undergone
an inspection by the Medical Council of India (MCI) for recognition of the MBBS course and as
usually happens, had some deficiencies that were asked to be rectified. It was at the second and
the compliance inspection that we were advised by others who had undergone a similar exercise
that what was important is not how compliant you were but whether you were able to satisfy the
demands of those who apparently controlled the council. Incredulous as we were, we were
equally clear that we would never succumb. We tried all possible means—meetings with the
council’s office bearers, officials in the ministry, other individuals who carried influence, and
presented our case, with facts, data, and documents. What was clear was that there were indeed
powerful vested interests that controlled the entire process and it seemed no one could question
or interfere. As expected, the compliance was not found satisfactory and not only a third, but a
fourth inspection had to be faced. There was enough lobbying done by then and enough noise
generated so it was expected that there would be a favourable outcome. That’s when we were
delivered another shock. The college received recognition for only 50 of its 100 seats. A couple
of batches had graduated by then and with the registration from the Gujarat Medical Council,
they were permitted to practise only in Gujarat. It was a bizarre situation and that’s when we
realized that we would not receive justice unless we took a radical alternative path. And this we
did. We went in appeal against the council’s recommendation to the Ministry of Health. It was
our good fortune that the ministry’s response was to have an independent assessment of the
college carried out by the office of the Director General of Health Services. On receiving their
assessment, the ministry granted recognition for 100 seats. While we never received a formal
letter of recognition from the council, we became the first medical college in the country to have
its recognition accorded by the Ministry of Health.
Since its establishment by the late Dr H.M. Patel, my father and a former finance and home
minister during the Janta Party regime, Charutar Arogya Mandal, the trust that manages the
college, its teaching hospital—Shree Krishna Hospital—and a host of other medical institutions,
has travelled a journey that has seen numerous situations where we have had to decide whether
we should remain silent or speak out. Invariably though, it is our experience that if you wish to
remain upright, with your head held high, remaining quiet almost never pays. One has to take a
position, raise one’s voice and persevere till justice is served. There is a price to be paid—that’s a
given. But unless one is willing to do so, public life and public institutions have no meaning.
What is heartening, however, is that when you do raise your voice, justice is eventually served
and makes all the hardship worth the effort. What’s more, you emerge as a stronger institution
and one with far greater character compared to the institutions you see today.
Let me relate some more of our experiences. The college was set up as a grant-in-aid
institution with the Government of Gujarat underwriting 90 per cent of the expenses or the actual
deficit, whichever was lower. In reality, the grants were never received in time or in adequate
amounts and came after considerable follow-ups and elaborate audits. As the college had no
other means of funding itself (the seats were considered government seats and therefore carried
no fee), this meant that meeting essential expenses such as salaries, library books, etc., was
always a matter of great concern and uncertainty. After going through this ordeal for about a
decade, the Mandal approached the government to consider granting the college the status of an
‘autonomous 3’ institution so that it could admit 50 per cent of the students who would pay a fee.
The government agreed, primarily because it freed them of the responsibility of paying a grant,
which, by then, was quite substantial. It was, therefore, decided that autonomy would be granted
from the year 2000 after all pending dues were cleared following an audit by the government
auditors. That’s when the trouble began. Our accounts officer presented the books of accounts
only to be told by the auditor that he would only open the books after he was paid Rs 200 for
every service book (a government employee has a service book which records details such as
salaries and leave) that he had to audit. The amount was paltry, but it violated our values and we,
therefore, did what we believed we should. We brought the matter to the attention of the then
minister of health. There were consequences, of course. While the auditor was removed, it was
ensured that the audit report was prepared in a manner that made claiming the balance money
from the government an extremely difficult process indeed. The college had to forgo a claim in
excess of Rs 1 crore as a result. But I do believe that in the process, we acquired a reputation of
an institution that stands up to dishonest practices and we have created a positive impression on a
number of people, including some bureaucrats, which helps us even today in our dealings with
the government.
The second situation involved even greater stakes. Following the T.M.A. Pai vs State of
Karnataka judgement by the Supreme Court, the college was entitled to receive a fee for all of its
seats, subject to its approval by a committee headed by a retired high court judge and convened
by the health secretary of the state government. When we presented our accounts and proposal
for a fee to the first committee appointed by the government, we were confident that as an
independent and neutral body, the committee would make an objective assessment of the facts
and audited financial statements and approve a fee that met the expenses and developmental
needs of the college. But we were wrong. The committee was as much led by the government’s
desire to be popular as the expectation of parents of students that fees be kept as low as possible.
The fee that we were conveyed was half of what we had asked for. This would have led to a
serious financial crisis (as we do not take a capitation fee), not just for that year but for all times
to come. Moreover, in our view, the decision of four the committee violated the directives of the
Supreme Court on how the fee should be fixed. We approached the high court and received a
judgement in our favour for the committee to review the fee structure. Before we went back to
the committee, however, we considered it important that our accounts and fee proposal be
endorsed by someone who was not only eminent in finance, but could be expected to exercise
independent judgement on the matter. We, therefore, asked Mr Y.H. Malegam, a former
president of the Institute of Chartered Accountants of India and a member on the board of the
Reserve Bank of India (RBI), to help us develop a methodology to fix the fee that would not only
satisfy the fee committee, but would also enable all revisions in the fee structure subsequently.
This he did and his firm, SB Billimoria & Co., presented it to the fee committee. It led not only
to a satisfactory resolution of the issue then, but also created a basis for fee fixation which
continues till today.
These are just a few vignettes of the turbulent journey we have traversed. It has been rough,
but satisfying. Over the years, the vision that our staff has developed for the Mandal is to become
an example of the profession of medicine—an example of its nobility, service, and scholarship.
We realize that the profession as it is practised today leaves much to be desired and has caused
such a deep erosion in the confidence the lay public has in it, that all that we do in the name of
honesty and transparency needs to be continually and rigorously validated, time and time again,
before it is accepted that we really are who we say we are. That may be a travesty, but that is
exactly what keeps us going.
 CHAPTER FORTY ONE
Palliative Care Shows the Way to True Health
M.R. Rajagopal*

Labourer Madhavan goes to hospital in excruciating pain from a recurrence after laryngectomy
for advanced cancer, and spends money he cannot n afford; he has an MRI scan to assess the
extent of the disease and then has his tracheostomy tube changed. He is discharged with no real
treatment for his pain. He walks out of the hospital with his mother’s support and collapses on
the sidewalk. Passers-by bring him to a palliative care unit run by a non-government
organization. Once the pain is controlled, he returns home and receives weekly visits from a
palliative care team. He lives for a year and dies at home in reasonable comfort.
Das, from an affluent family, is breathless after his third heart attack. His lungs and kidneys
are not good either. In and out of intensive care units (ICU), he gets panic attacks even at the
very mention of them. His doctor of 20 years turns down his plea to be treated in a hospital
room, claiming it was ‘against protocol’. But, at a palliative care unit he gets morphine for
breathlessness, care, and his family close by. He returns home, and lives for another three
months. He dies on his son’s lap.
Madhavan and Das were two terminally ill patients from Kerala state in India. They were
from economically different backgrounds. But they had things in common: both got high-tech
imaging and intervention but were rejected by hospitals when they needed compassionate care.
They also belonged to the 1 per cent population in India who have access to palliative care. In
hospitals, they received expensive disease-focused care, an offshoot of transforming health
service into a healthcare industry. While advances in technology and pharmaceuticals have
improved our ability to diagnose and cure disease, the person in the patient is forgotten in the
maze of hospital corridors, imaging rooms, and ICUs. It is here that the palliative-care movement
in Kerala offers a humane approach.
But this gentle, compassionate system did not evolve overnight. In the late 1980s, as the head
of anaesthesiology at the Calicut Medical College Hospital, I was unable to remain a mere
witness and began treating people’s pain. Soon I realized that pain is only one element of
suffering and it led me to palliative care.
A colleague, Dr Suresh Kumar and his friend, Asok Kumar, joined me in the cause. Asok’s
presence can be said to be the catalyst for community involvement in palliative care in the state.
He helped us doctors to see the patient’s point of view. For instance, when I created a brochure,
which included the phrase, ‘victims of cancer need your help’, it was he who pointed out that the
word, victim, could be stigmatizing.
More people joined us and we registered a charitable organization, the Pain and Palliative
Care Society (PPCS). We opened an outpatient clinic in a tiny room outside the operation
theatre. We had no paid staff. I would see patients in between my work.
Two housewives, Meena and Lissy, volunteered to help. Their role was to listen to and
support patients and families, and help with nursing chores. Asok, Meena, and Lissy, armed only
with compassion, inspired many to do their best to relieve suffering.
We focused on the quality of life. Thanks to the assistance of well-wishers from developed
countries, we learnt scientific assessment and management of symptoms, and of psychological,
social, and spiritual suffering. When we found that some patients were too ill or geographically
isolated to reach us, we started home visits.
While some doctors offered support, many ridiculed us. ‘That crazy bunch’ was the common
refrain. Anger followed. Two senior doctors banned us from their wards. One found our record
of morphine dispensation on a patient, angrily tore it, and threw it at him with a warning, ‘never
let me catch you with that again’.
One young man with severe pain was told never to take morphine or he would die a miserable
death as a street addict. He ran away only to return a week later. ‘It is okay if I become an addict;
I don’t care; I cannot bear this pain anymore.’
Within two years, the World Health Organization (WHO) declared PPCS a model project for
developing countries.
The media was supportive. As news of our work spread, there was growing enthusiasm
among the people, but mounting anger among some colleagues. Our actions to improve people’s
quality of life were taken as criticism of traditional medical practices. Surely, our approach was
new in a profession where treatment had generally been diagnosis- and cure- centred. In case of
incurable diseases which involved a lot of suffering like advanced cancer, the patient’s family
was routinely told: ‘There’s nothing more we can do; take him home.’ Palliative care meant
doctors no longer had to reject patients when they needed them the most.
Medical students were, however, deeply touched and pleased with our work; many became
volunteers and most of them returned after graduating for formal training. Supported by
palliative-care activists from the UK—Gilly Burn, Dr Robert Twycross, Val Hunkin, Bruce
Davis, Dr Jan Stjernsward and others—we developed certificate courses to cater to the training
needs.
Around the same time, I met Dr Abdul Rahman, an internist, who had heard about palliative
care and wanted to open a clinic in his town. Our discussions led to the first link centre outside
Kozhikode. That non-profit facility had a trained palliative-care doctor and was led and managed
by a non-medical person. That was another step towards community involvement in palliative
care.
Initially, poor patients with incurable diseases took refuge in palliative care after being
subjected to futile curative treatment and enduring enormous physical, emotional, and economic
suffering. It was common to see families starve after their meagre resources were wasted on
useless medicines. A mother in severe cancer pain, when asked what bothered her the most, said:
‘My daughter hasn’t eaten in 24 hours.’ The little money the family had was spent on medicines,
which did not help. In another case, a man with advanced cancer was borrowing money from a
loan shark to pay for a nutritional supplement prescribed by an oncologist, believing it would
cure him.
In the years that followed, more organizations became active in palliative care. While some
were stand-alone clinics, most were housed in existing hospitals.
Sustained advocacy with the support of David Joranson and his Pain and Policy Studies
Group (PPSG) resulted in a directive from the Government of India to all state governments to
simplify opioid regulations.
States were not duty-bound to obey. We worked from state to state conducting opioid-
availability meetings to ease the process, with significant impact only where palliative care was
already growing. Medical opioid consumption in the country slowly increased.
In 2003, we created Pallium India and gradually helped develop palliative-care services in 14
states and two union territories. We also focused on advocacy. For example, inviting the then
principal health secretary Keshav Desiraju to a side event at the World Health Assembly in 2012
led to the setting up of a National Programme for Palliative Care (NPPC). Sustained advocacy
with the Government of India Department of Revenue contributed to the amendment of the
NDPS Act in 2014.
Finding that the growth of palliative care would be augmented if one state government could
take it up as a health issue, Pallium India, in 2005, proposed a palliative-care policy to
Government of Kerala. Many discussions later, in 2008, Kerala declared a palliative care policy,1
which envisaged development of palliative care across all levels of healthcare—primary,
secondary, and tertiary—as was later advised by the World Health Assembly resolution of 2014.2
Unfortunately, Kerala didn’t have an adequate budget. But implementation became partly
possible through the Government of India’s National Rural Health Mission (NRHM), which
could operate only at the primary and secondary levels, leaving major hospitals with no palliative
care to offer.
The impact of palliative care on primary health in Kerala has been huge. Every primary health
centre has a palliative-care nurse who can offer a monthly home visit to bedridden patients.
Without it, for a change of catheter every three weeks, a bed-bound patient would have to be
transported to hospital at enormous cost and significant suffering. With the palliative policy in
place, everyone in need got a catheter change in home, along with advice and help to prevent and
manage problems such as pressure sores.
Palliative care is now a familiar medical option in Kerala. We know that most people in the
state have access to palliative care of some kind. Community involvement has resulted in more
than 300 independent non-government organizations providing palliative care in various parts of
the state.
In Thiruvananthapuram, Pallium India works with 11 local non-government organizations,
which have trained volunteers to look after patients and support families in their neighbourhood,
and act as the connecting link to medical assistance.
This mobilization of social capital (Lewis et al. 2011) in a healthcare situation points to the
possibility that the dream of true healthcare—in the physical, social, psychological, and spiritual
domains—is indeed a practical possibility. Healthcare becomes more than something delivered
only by hospitals. It becomes a partnership between the community and professionals. Richard
Smith, former editor of British Medical Journal (BMJ), once said: ‘The Kerala model does
provide a feasible way of achieving Murray’s vision of palliative care covering “all patients, all
diseases, all nations, all settings, and all dimensions. It’s hard to see how it will be achieved in
another way’ (Smith 2012).
However, there are numerous inadequacies as have been pointed out both in the lay press3 and
in scientific literature (Jayalakshmi et al. 2016). Paradoxically, the active involvement of the
community and the nurse-oriented palliative services in primary health centres seems to have
conveyed an impression to major hospitals and medical professionals that it has nothing to do
with them. The result is that a patient and family have to go through unrelieved symptoms and
psychosocio-spiritual issues through months or years of disease-focused treatment, finally
receiving palliative care only in the last few days of life.
The fact that hospitals do not offer pain management is evidenced by the low per capita
medical opioid consumption in the state (1.56 mg) which was only about one-fourth of the global
average of 6.27 mg and only about less than one in 200th of what is generally believed to be
ideal as in UK (241 mg), which is reputed to have attained a balance between adequate access for
pain relief and prevention of misuse.
Despite the inadequacies, there are important lessons to be learned from the Kerala model:

1. Even in the face of paucity of resources, quality palliative care can be delivered, because it is
relatively inexpensive.
2. Majority of people with advanced illness prefer to live and die at home. Unless care at home is
encouraged, health status can have only modest improvement.
3. Collaboration between non-governmental agencies and the government is essential for
providing true healthcare. The social capital—the essence of goodness in the community—
could be made use of anywhere in the world because in any community, there are good people
who are willing to help others.

There seems to be no reason why such home-based care with community participation should
be limited to palliative care. Palliative care has shown how such holistic care can be given. Its
application could transform the current disease-focused healthcare system to person-oriented
healthcare aimed at overall well-being.

References
Jayalakshmi R., S.S. Chatterjee, and D. Chatterjee, 2016, ‘End-of-Life Characteristics of the
Elderly: An Assessment of Home-based Palliative Services in Two Panchayats of Kerala’,
Indian Journal of Palliative Care, 22: 491–98.
Lewis J.M., M. DiGiacomo, T. Luckett, et al., 2011, ‘A Social Capital Framework for Palliative
Care: Supporting Health and Well-Being for People with Life-limiting Illness and their Carers
through Social Relations and Networks’, Journal of Pain and Symptom Management, 45(1):
92–103.
Smith R., 2012, ‘A Way to Provide Palliative Care Globally’, BMJ (opinion), available at
http://blogs.bmj.com/bmj/2012/06/25/richard-smith-a-way-to-provide-palliative-care-
globally/, accessed on 20 April 2017.

* The author gratefully acknowledges the help of Ms Sindhu S. in editing the draft of this chapter.
 Conclusion
Sanjay Nagral, Keshav Desiraju, and Samiran Nundy

As individuals who have worked long and hard in caring for patients both in the public as well as
in the private sectors and sometimes helping in framing policies, we have been troubled by how
corruption is corroding the already tottering healthcare system of our nation. Till now we have
only been speaking and writing about these concerns through brief pieces largely in medical
journals and occasionally in the popular media. In fact, most of the discourse on the subject of
healthcare corruption in India has been restricted to journalistic exposés and opinion pieces. We
now felt we should reach out to a wider public and this book has been our attempt to do just that
—to examine the historical, structural, sociopolitical, and cultural factors that have contributed to
healthcare corruption and what can be done to eliminate this evil.
A formal publication on this subject was never going to be easy. For starters, there was the
basic problem of what precisely constituted corruption. We defined it as ‘misusing conferred
authority for personal benefit’. While some extreme obvious practices were easy to slot into this
definition, the growth of market medicine has spawned a large number of mainstream trade
practices that are now considered to be legitimate and defy easy classification. The profits made
by the healthcare industry through margins on drugs and equipment which are sold to them in
bulk at costs much lower than the MRP, but which in turn are sold to patients at the MRP is one
such example. Or the targets of patient numbers set by for-profit hospitals for their doctors in an
effort to recover costs. Or for that matter, pharmaceutical companies organizing camps in the
community to lure patients. In general, the inflated high costs of healthcare and the supplier-
induced demand which are intrinsic to a profit-driven industry.
Of course there was also a certain amount of fear amongst mainstream healthcare providers
and other players to openly talk about corruption for fear of being harassed or losing their jobs. It
was also difficult to substantiate rumours and allegations with reliable evidence other than
newspaper reports. Finally, the amount of hard data available on the subject was limited. Hence
there is an inevitable anecdotal tone to many of the chapters in this book. So we admit that
making the material representative of the stories from the ground and yet academically sound has
been a tightrope walk. Thus, one of the challenges we tried to negotiate was to cover both the
everyday petty corruption that impacts citizens and at the same time, address the larger picture of
grand corruption which occurs at the political level. We therefore deliberately chose a mix of
authors ranging from those with a mainly academic background to those who work or have
worked at the frontiers of healthcare. As a result we have voices from rural doctors, specialists,
administrators, activists, economists, and philosophers. This has resulted in a variation in form
and substance and maybe a certain unevenness in writing styles across chapters, for which we
ask you to bear with us.
The section called ‘Beacons of Hope’ was an attempt to highlight the fact that in the midst of
this rather depressing overall scenario, there are individuals and institutions who have actually
provided us grounds for optimism. We realize that some of these institutions represent certain
alternative models of healthcare often based on conscious religious and ideological premises and
in that sense, do not represent the ‘mainstream’. Also, since the authors of these pieces work in
the very institutions they are writing about, there is an obvious conflict of interest. However, we
believe our readers can make up their own minds knowing this. It would have been difficult to
ask an ‘outsider’ to write about a beacon of hope with the same authority and knowledge. After
much deliberation we concluded that it was important to give space to these individuals and
institutions to keep alive the idea that it is not necessary to be corrupt to be a ‘successful’
medical institution. And that these alternatives, though rare, are possible.
We are all aware that India as a nation is not doing well in delivering healthcare to its citizens.
There has been a huge amount of high-quality writing on the failures of basic policy and
governance. Simultaneously, there is a growing body of work on corruption in our nation’s
public life. The detrimental effects of healthcare corruption on our nation has been substantial.
We hope this book can stimulate more rigorous and informed scholarship on this aspect of the
fault lines of healthcare and how they can be repaired.
Our people deserve better.
 Notes

Introduction
1. Speech at Geneva, 24 May 2017.
2. Information as on 23 June 2017.
3. 60th Report of 30 October 2012, Rajya Sabha.
4. 8 March 2016, Rajya Sabha.

Chapter One: The Structural Basis of Corruption in Healthcare in

India
1. See www.transparency.org.
2. Formal providers of health services include doctors and other personnel in the three-tiered health services of
the public system and in the private sector clinic, nursing home, or big hospital, as well as informal providers
of both traditional and modern systems.
3. From the Hippocratic Oath that has survived till date as the ritual commitment of European physicians and
traditions derived from them, to professional guilds of surgeons across the world, the pithhas and … of
codified Asian systems, to self-regulatory professional councils, they have all set the tone for the desired
relationship between them and the rest of society.
4. In some countries the state became directly a major provider through public services, in some it assumed the
role of being a financier of largely private or public and private provisioning, while in others of being the
main regulator. In some societies the government has taken full responsibility while in others partial
responsibility for healthcare.
5. Historically, knowledge systems of health and their practice was guided and regulated by the ethics evolved
by professional groups themselves as well as by the institutions of community, religion, and the state. Since
local materials from nature were used after processing by the physicians for their own patients with whom
they were in a direct community relationship, commerce was a small element in the healthcare systems. Over
the twentieth century, as the modern system became increasingly dependent on mass produced medical
products, commerce became a big component. This was regulated to some extent by the international and
national welfare regimes. However, in the colonized countries, the power of the expert acting as the
intermediary remained largely unchecked.
6. Also, see Huss et al. (2011), Hammer et al. (2007), and Vian T. (2008) for various representations of the
structures involved in corruption of the health sector. These authors are, however, ahistorical in their analysis
of the structures and processes.
7. For instance, the limited implementation of provisions such as the Nursing Home Act in some states, the
attempt by other states at enhanced role of Panchayati Raj Institutions over personnel of the rural health
services was made ineffectual, and the NRHM’s initiative of community-based monitoring was continued in
only two states after the initial pilot in nine states.
8. Overuse of diagnostic modalities and aggressive treatment modalities is sometimes justified as defensive
practice.
 9. Franchisee networks in small towns act as feeders to large city hospitals or surgeons pay brief visits to the
franchisee centres to perform procedures and leave.
10. ‘Sink tests’ refers to medical tests done by just discarding the patient’s sample while the results are reported
as desired by the treating doctor (Gadre and Shukla 2016).
11. Responding to this trend, State governments are creating special legal provisions with stricter punishment for
attacks on doctors (The Hindu 2017).
12. This section is largely from the invited presentation made by the authors to the Parliamentary Standing
Committee on Health and Family Welfare on the structure and functioning of the MCI, 6 October 2015.

Chapter Three: The Commodification of India’s Healthcare Services

1. It has at times climbed to 1.2 per cent, by the sleight of hand of including expenditure on convergence.
2. Of this dismal public funding, up to 70 per cent goes towards the wages and salaries of employees in public
facilities (MoHFW, National Commission for Macroeconomics and Health 2005). More than most
developing countries, public funds for health have also been funnelled largely towards tertiary rather than
primary levels, which largely benefit the middle classes and detract from the provision of public services for
the rest of the population (Dasgupta 2012).
3. The two transitions, of urbanization and an increase in the burden of chronic illness, taken together with
longer life expectancy, etc. will increase demand for healthcare services (as well as insurance cover to
finance these services), and will be reinforced by parallel transitions, for example, the rise of private sector
employment, income levels amongst the urban middle and upper classes, and so on (Burns 2015b). The
author cites a 2007 McKinsey Global Institute Report, titled The ‘Bird of Gold’: The Rise of India’s
Consumer Market, that as a share of household spending, healthcare is expected to grow from 7 per cent in
2013 to 13 per cent in 2025, and by 2015, an estimated 250 plus million Indians would be able to afford
western allopathic medicine (Burns 2015b).
4. Conceptually, public health services are different from medical/healthcare services, in so far as their main
goal is to reduce a population’s exposure to disease, and includes vector control, monitoring sanitation and
water systems, and so on (Dasgupta 2012). Policies in newly independent India detracted from public health
services provision in this broader preventative sense, not least with the merging of public health services with
medical services in the 1950s, as well as vertical programming for the treatment of communicable diseases
and later, non-communicable diseases (Dasgupta 2012). Consequently, public health system providers here
refer to medical/healthcare services.
5. For example, the Rajasthan government has invited proposals for private players to run their primary health
centres altogether (Gopalakrishnan 2015).
6. For health policy under the British, see Jeffery (1988).
7. The report supported insurance-based services for industrial workers but did not see this route as a practical
possibility for the mass of the population.
8. Of course, the term ‘urban’ itself refers to a wide range of geographies, from the metropolitan, to the small
town and the urban village, and the quality of tertiary care to be found in each varies a lot.
9. Regular reports in the media attest to hospitals routinely disregarding the requirement that they provide free
services for economically weaker section (EWS) patients. One can speculate that mushrooming corporate
hospital drives to set up free blood pressure and eye check-up vans in upmarket neighbourhoods, recreational
clubs, and malls in metropolitans is in order to rather serve the middle classes, garnering their goodwill, and
attaining free publicity and future clientele in the process.
10. For example, the Rashtriya Swasthya Bima Yojana (RSBY) is publicly funded yet has mostly private
(empanelled) provision. Some states resisted such insurance schemes—for example, Tamil Nadu rejected
RSBY, demanding that up to 90 per cent funds in RSBY be reserved for government hospitals, a request that
was turned down by the Central government.
11. In the first decade of the twenty-first century, healthcare became the fifth largest sector for private equity
investment in India, the bulk of which went to contracted research, pharmaceutical, and hospital sectors.
12. The six pillars of the health system according to WHO are: human resources in health, data, drugs and
 medical equipment supply chains, finance, leadership and governance, and service delivery (WHO 2000).
13. In actuality, the report gave contradictory indications on the role of the funding of UHC by insurance versus
tax supplemented by partnerships with the private sector and CSR [emphasis author’s own], and a very
confused roadmap. In terms of sequencing, it was suggested that tax-based financing would follow insurance-
based financing, even though no country in the world has achieved UHC with insurance-based funding.
Apart from public insurance, the Insurance Regulatory and Development Authority allowed private provision
of insurance, as well as FDI in the sector, so that from being non- existent in 2000, health insurance has
become the second largest business in the non-life segment (Sen et al. 2015).
14. Managed care plans are a type of health insurance, that contracts healthcare providers and medical facilities
to provide care for members at reduced costs. These providers make up the plan’s network. In principle, they
seek to promote greater coordination of care, wherein a patient receives all primary, secondary and tertiary
care services within the network and the primary physician acts as a gatekeeper.
15. Universally derided for being highly expensive and inequitable in provision, leading to relatively poor health
outcomes compared to other advanced countries.
16. The HLEG had recommended the prioritization of primary health care, and that the EHP includes essential
services at all levels of care. Nowhere did the Health Chapter commit to HLEG’s attendant
recommendations, that expenditures on primary healthcare should account for at least 70 per cent of all
expenditures and that delivery of EHP is left to the public health system, supplemented by contracted—in
private providers whenever required to fill critical gaps.
17. The Draft Health Chapter itself mentions how the system creates strong incentives for whoever is managing
the network to minimise total cost, reduce patient choice, and needs careful regulation to maintain the quality
of medical care.
18. This move also offsets the additional fiscal maneuvering room given to states by the Fourteenth Finance
Commission in 2015, which had increased the proportional share of states under unconditional grants—
Central Assistance to State Plans (CASP)—from 32 per cent to 42 per cent of the total amount devolved
(Fourteenth Finance Commission 2015, Chakraborty and Gupta 2016).
19. Many of those who could not afford it, too, were forced towards out of pocket payments and
impoverishment.
20. Vian 2008 systematically outlines various areas of corruption in the health sector: medical research;
education of health professionals; construction and rehabilitation of health facilities; purchase of equipment
and supplies, including drugs; distribution and use of drugs and supplies in service delivery; regulation of
quality in services, facilities, products, and professionals; and provision of services by medical personnel, of
which this article has only touched upon a few.
21. For morbidity and costs of care estimations from NSS 71st round, see Sundararaman and Muraleedharan
(2015).

Chapter Four: Globalization and Corruption in the Health Sector

1. http://aud.ac.in/upload/Neoliberalism%20and%20Democracy%20-%20Prabhat%20Patnaik.pdf
2. Corruption as defined by Transparency International (www.transparency.org).
3. http://www.transparency.org/whatwedo/publication/global_corruption_report_2006_corruption_and_health
4. See, for example, Kutzin (2000).
5. http://www.dmiller.info/images/docs/Miller_Neoliberalism-Politics-and-Institutional-Corruption_Against-
the-Institutional-Malaise-Hypothesis.pdf
6. For details, see Swasthya Adhikar Manch’s website: http://www.unethicalclinicaltrial.org/
7. For details of amendment made to 122 DAB, recently notified by CDSCO, see
http://fcrindia.org/news/amendment-made-to-122-dab-recently-notified-by-cdsco-07
8. http://cpim.org/views/indiaasksobama-say-goodbye-affordable-medicines-if-obama-hashis-way
9. https://thewire.in/24621/india-assures-the-us-it-will-not-issue-compulsory-licences-on-medicines/
10. Interview with Dominic Keating, Secretary, Intellectual Property, by KPO Consultants, 2009.
11. USTR Requests Public Comments for the 2014 Special 301 Out-of-Cycle Review of India, Office of the
United States Trade Representative. https://ustr.gov/federal-register-notices/USTR-Request-Public-
Comments-2014-Special-301-Out-of-Cycle-Review-India
12. India’s Trade and Investment Policies during 2014-15 will be focus of new USITC investigation. News
Release 14-109, Inv. No. 332-550, 28 October 2014,
http://www.usitc.gov/press_room/news_release/2014/er1028mm1.htm
13. See, for instance, Pfizer’s testimony available at
http://waysandmeans.house.gov/uploadedfiles/pfizer_testimony31313.pdf and industry letter to the US
President available at http://www.theglobalipcenter.com/wp-content/uploads/2013/01/India-Business-
Community-Ltr-6.6.13.pdf
14. Baucus, Hatch Fight for U.S. Businesses, Workers Against India’s Unfair Trade Practices, United Senate
Committee on Finance, June 14, 2013 http://www.finance.senate.gov/newsroom/chairman/release/?
id=99255812-aceb-4607-851f-7b2901e1c981
15. The text of letter is available at http://keionline.org/sites/default/files/06-18-13-House-India-Letter_1.pdf

Chapter Five: The Role of the Medical Council of India

1. ‘Medical Council: Inaugural Meeting in Bombay’, The Times of India, 25 September 1912.
2. ‘Medical Registration: Opposition to the Bill’, The Times of India, 22 November 1911.
3. ‘The Bombay Medical Act’, Indian Medical Record, February 1912, p. 64.
4. Bombay Medical Council. Woman Member’, The Times of India, 18 October 1937.
5. ‘Ethical Suggestions for the Guidance of Medical Practitioners’ (issued by the Bombay Medical Council),
Indian Medical Record, July 1926, pp. 219–21.
6. Bombay Medical Council, Indian Medical Record, November 1928, pp. 344–45.
7. ‘India Government’s War on Quacks: Drastic Step Proposed’, The Times of India, 3 October.
8. ‘Medical Training’, The Times of India, 25 October 1926.
9. ‘Indian Medical Degrees’, The Times of India, 28 November 1929.
10. ‘Medical Conference. Proposed Formation of All India Council’, The Times of India, 30 December 1929.
11. ‘B.M.C’s Decision. Bombay Demand for an All-India Council’, The Times of India, 7 April 1930.
12. ‘Standards of Medical Education in India. All-India Official Conference Appoints New Body’, The Times of
India, 26 June 1930.
13. ‘Medical Council Bill and Licentiates. Sir Nasarvanji Choksy’s Views. Bombay Medical Union’s Attack on
the Measure’, The Times of India, 29 March 1932.
14. ‘Govt.’s Medical Council Bill Severely Criticized. Ignores Indian Interests and Sentiments. Viceroy’s
Proposed Nomination Powers Condemned’, The Times of India, 28 March 1932
15. ‘Establishment of All-India Medical Council’, The Times of India, 22 April 1930.
16. Act No. XXVII of 1933. 1934. ‘An Act to constitute a Medical Council in India’ in A Collection of The Acts
of the Indian Legislature for the Year 1933, Delhi: Manager of Publications, available at
http://lawmin.nic.in/legislative/textofcentralacts/1933.pdf, accessed on 20 November 2016.
17. ‘The Indian Medical Council Act, 1956 (102 of 1956)’, http://www.mciindia.org/acts/Complete-Act-1.pdf,
accessed on 25 November 2016.
18. Amendments to the Indian Medical Council Act, 1956’, can be studied at
http://www.mciindia.org/ActsandAmendments/AmendmentstotheAct.aspx, accessed on 29 November 2016.
19. http://www.gmc-uk.org/about/index.asp, accessed on 14 December 2015.
20. http://www.mpts-uk.org/decisions/fitness_to_practise_decisions.asp. An example of such a decision, made in
the case of Sandhya Mashar on 2 December 2016, can be viewed in full at http://www.mpts-
uk.org/decisions/data/11639.asp/Sandhya_MASHAR_02_December_2016.pdf
21. http://www.mciindia.org/
22. Interested readers may refer to the full text of the review available at http://ijme.in/articles/medical-council-
 of-india-the-rot-within/?galley=pdf
23. This essay can be accessed at http://ijme.in/wp-content/uploads/2016/11/1554-5.pdf
24. Report No. 92. 2016. ‘The Functioning of the Medical Council of India (Ministry of Health and Family
Welfare)’, presented to the Rajya Sabha on 8 March. Laid on the table of Lok Sabha on 8 March. New Delhi:
Rajya Sabha Secretariat.. The full text of the 127-page report is available at
http://164.100.47.5/newcommittee/reports/EnglishCommittees/Committee%20on%20Health%20and%20Family%20Welfare/92
25. An analysis of this report is available at http://ijme.in/wp-content/uploads/2016/11/2110-5.pdf
26. Report No. 92. 2016,
http://164.100.47.5/newcommittee/reports/EnglishCommittees/Committee%20on%20Health%20and%20Family%20Welfare/92

Chapter Seven: Corruption in Everyday Medical Practice

1. Marginal kidneys are those which are not completely normal and function below full capacity, but are still
capable of sustaining life.

Chapter Eight: Hospital Practices and Healthcare Corruption

1. data.worldbank.org/indicator/SH.XPD.PUBL.ZS, accessed on 12 December 2017 and 13 March 2018.
2. clinicalestablishments.nic.in/cms/home.aspx, accessed on 13 March 2018.
3. clinicalestablishments.nic.in/cms/home.aspx, accessed on 13 March 2018.

Chapter Nine: Ethical Issues in Organ Transplantation

1. http://indianexpress.com/article/india/india-others/egg-donors-death-internal-bleeding-ovaries-severely-
enlarged-says-report/
2. http://timesofindia.indiatimes.com/city/mumbai/Three-doctors-get-anticipatory-bail-in-egg-donor-death-
case/articleshow/37805102.cms.
3. http://www.dnaindia.com/mumbai/report-it-s-easy-fly-to-singapore-fix-kidney-1552446.
4. http://timesofindia.indiatimes.com/city/delhi/Gurgaon-kidney-racket-Gang-had-smooth-run-bribed-its-way-
out/articleshow/19177391.cms.
5. http://content.time.com/time/world/article/0.
6. http://indianexpress.com/article/india/india-news-india/apollo-hospital-kidney-racket-recipients-dodge-cops-
likely-to-face-arrest-2870276/.
7. http://indianexpress.com/article/india/india-news-india/hiranandani-kidney-racket-case-hospital-ceo-4-other-
doctors-sent-to-judicial-custody-till-august-26-2973025/.
8.
https://www.thefreelibrary.com/German+transplant+surgeon+Christoph+Broelsch+embroiled+in+payment+for...-
a0100232705.
9. https://www.theguardian.com/world/2013/jan/09/mass-donor-organ-fraud-germany.
10. http://archive.sltrib.com/story.php?ref=/nationworld/ci_3067917.
11. http://www.latimes.com/news/la-me-newtransplant27sep27-story.html.
12. http://www.standard.co.uk/news/nhs-child-loses-out-as-surgeon-gives-liver-transplant-to-private-patient-
from-the-gulf-6845658.html.
13. http://fortune.com/2013/12/08/the-surgeon-who-gave-steve-jobs-a-new-liver-and-two-more-years-faces-new-
questions/.
14. http://thehockeywriters.com/senators-owner-melnyk-on-road-to-recovery-from-live-liver-transplant/.
15. http://news.nationalpost.com/news/canada/ottawa-senators-owner-eugene-melnyks-plea-for-liver-donor-
answered-but-ethical-questions-raised.
16. http://news.nationalpost.com/news/canada/ottawa-senators-owner-eugene-melnyks-plea-for-liver-donor-
 answered-but-ethical-questions-raised.
17. http://triblive.com/investigative/specialprojects/transplantingtoosoon/2030550-74/pittsburgh-allegheny-
health-clash-of-philosophies-transplant-upmc-marcos-liver.
18. http://www.wsj.com/articles/SB122722880819446359.
19. http://triblive.com/x/pittsburghtrib/news/health/s_556350.html.
20. http://triblive.com/investigative/specialprojects/transplantingtoosoon/2030720-74/pittsburgh-allegheny-
health-risk-versus-benefit-quot-transplant-clarian-patients.
21. http://triblive.com/investigative/specialprojects/transplantingtoosoon/2030359-74/pittsburgh-allegheny-
health-ethics-vs-economics-liver-patients-transplant-transplants.
22. http://www.tradingeconomics.com/india/gdp-per-capita.
23. http://data.worldbank.org/indicator/SH.XPD.TOTL.ZS?locations=IN
24. http://triblive.com/investigative/specialprojects/transplantingtoosoon/2030359-74/pittsburgh-allegheny-
health-ethics-vs-economics-liver-patients-transplant-transplants.
25. http://epaper.timesofindia.com/Repository/getFiles.asp?
Style=OliveXLib:LowLevelEntityToPrint_MIRRORNEW&Type=text/html&Locale=english-skin-
custom&Path=MMIR/2010/12/09&ID=Ar01200.
26. http://archive.sltrib.com/story.php?ref=/nationworld/ci_3067917.
27. http://www.wphealthcarenews.com/college-students-liver-transplant-case-sparked-feud-prompted-review-of-
live-donor-complications/.
28. http://www.wsj.com/articles/SB122722880819446359.
29. http://timesofindia.indiatimes.com/city/mumbai/KEM-panel-to-probe-liver-donors-
death/articleshow/7056820.cms.
30. http://www.japantimes.co.jp/news/2016/02/08/national/science-health/seventh-liver-transplant-death-linked-
kobe-hospital-revealed/#.WFVLqxt942w.
31. http://www.japantimes.co.jp/news/2015/06/08/national/science-health/kobe-probes-hospital-liver-transplant-
deaths/#.WFVMJht942w.
32. http://www.japantimes.co.jp/news/2015/04/23/national/science-health/3-4-kobe-hospital-liver-transplant-
recipients-died-saved-report-suspected-malpractice/#.WFVNFxt942w.
33. https://www.scoopwhoop.com/Dhaniram-baruah-mad-doctor/#.kxywtytgt.

Chapter Eleven: The Unholy Nexus

1. The author has benefitted over the years in discussions with Dr C.M. Gulhati, Editor, MIMS India; and
specifically with respect to this chapter, Colin Gonsalves, legal counsel to petitioner Anand Rai in the PIL
mentioned in the text. Some formulations are borrowed from affidavits drafted by the author, for the PIL as
an invited resource person for which the author has received no financial or other benefit.
2. See, for instance, ‘Income Tax Officers Raid Pharma Distributors, Healthcare Centres and Path Labs
Suspecting Non-disclosure of Accounts’, available at http://www.pharmabiz.com/NewsDetails.aspx?
aid=105797&sid=2\, accessed on 6 December 2017. Also see Gadre and Sardeshpande (2017).
3. For details, see Srinivasan and Aisola (2018).
4. For instance, see‘Drug Regulatory System Set to Get Make in India, Ease of Doing Biz Makeover, More’,
available at http://www.financialexpress.com/opinion/drug-regulatory-system-set-to-get-make-in-india-ease-
of-doing-biz-makeover-more/332303/, accessed on 20 December 2016.
5. See, for instance, Dr Shirish Hiremath,‘Price Cap on Medical Devices Will Stunt Innovation and Harm
Patients’, The Huffington Post, available at http://www.huffingtonpost.in/dr-shirish-ms-hiremath/price-cap-
on-medical-devices-will-stunt-innovatnion-and-harm-pati/. Also see ‘Doctors Oppose Move to Cap Price of
Medical Devices’ available at http://timesofindia.indiatimes.com/city/nagpur/Doctors-oppose-move-to-cap-
price-of-medical-devices/articleshow/51502657.cms, accessed on 1 March 2017.
6. See Arushi Bedi, ‘Heart for Mart Sake’, available at http://www.outlookindia.com/magazine/story/heart-for-
 mart-sake/298255, accessed on 24 December 2016. Also see RemaNagarajan,‘The Cuts that Complicate
Efforts to Cap Stent Price’, available at http://timesofindia.indiatimes.com/india/the-cuts-that-complicate-
efforts-to-cap-stent-price/articleshow/56323967.cms, accessed on 4 January 2017.
7. ‘Stent Price Down, but Angioplasty Cost Still Same: Insurance Firms’, in Indian Express, 7 September 2017,
http://indianexpress.com/article/india/stent-price-down-but-angioplasty-cost-still-same-insurance-firms-
4833726/, accessed on 7 December 2017.
8. http://epaperbeta.timesofindia.com/Article.aspx?eid=31804&articlexml=Docs-lured-with-gold-coins-to-
push-vaccines-20012017001061, accessed on 1 March 2017.
9. Dr Vashishta had raised apprehensions over immunization guidelines being changed to favour certain
vaccine manufacturers. See http://timesofindia.indiatimes.com/city/bengaluru/whistleblower-doctor-seeks-
police-help/articleshow/56711498.cms, accessed on 1 March 2017.
10. For details, see Srinivasan, Shiva, and Aisola (2016).
11. Note on Clinical Trials in India (as of 30.8.2013). GOI note mimeo.
12. EOW Report copies filed as part of PILS in Supreme Court by Swasthya Adhikar Manch and Dr Anand Rai
& Ors. (WP (Civil) 33/2012 and 79/2012). Also see Krishnan and Politzer (2012).
13. ‘So far, 32 people enrolled in various trials at Maharaja Yashwantrao Hospital have died between 2005 and
2010; the state government has attributed the deaths directly to the testing’, extracted from Krishnan and
Politzer (2012).
14. See Reply Affidavit of December 2013 by the Ministry of Health and Welfare, Government of India to IA
Nos 6 and 7, in WP (Civil) N0 33/2012 in Swasthya Adhikar Manch and Ors vs Union of India. Also
see’Bhopal Gas Victims Used as Guinea Pigs for Drug Trials’, available at
https://timesofindia.indiatimes.com/india/Bhopal-gas-victims-used-as-guinea-pigs-for-drug-
trials/articleshow/27495772.cms; ‘From Tragedy to Travesty: Drugs Tested on Survivors of Bhopal’,
available at http://www.independent.co.uk/news/world/asia/from-tragedy-to-travesty-drugs-tested-on-
survivors-of-bhopal-6262412.html; ‘Illegal Drug Trials on Victims of Bhopal Gas Tragedy’, available at
https://www.ndtv.com/india-news/illegal-drug-trials-on-victims-of-bhopal-gas-tragedy-565178; ‘Indian
Council of Medical Research Washes Hands off Drug Trials in Bhopal Hospital’, available at
https://timesofindia.indiatimes.com/city/bhopal/Indian-Council-of-Medical-Research-washes-hands-off-drug-
trials-in-Bhopal-hospital/articleshow/29784489.cms, accessed on 20 December 2016.
15. See, for instance, Bracken (2009).
16. Between 2011 when the newly constituted NDACs met till 31 December 2012, the DCG(I) had given
approval to conduct 157 GCTs of NCEs—that is before the Supreme Court directions on 3 January 2013.
17. A sample of the numerous studies on this subject: Bhandari et al. (2004); Ioannidis (2016); and Moynihan et
al. (2008).
18. WP (Civil) 289/2016.S.Srinivasan vs. Union of India &Ors.
19. The 2009 amendment to the MCI Code of Ethics [or rather the Indian Medical Council (Professional
conduct, Etiquette and Ethics) Regulations, 2002] introducing Section 6.8 (Code of Conduct for doctors in
their relationship with pharmaceutical and allied health sector industry) is at http://www.mciindia.org/Rules-
and-Regulation/Gazette%20Notifications%20-%20Amendments/Ethics%20-%2010.12.2009.pdf, accessed
on 1 March 2017. The amendment to Section 6.8 putting associations of doctors outside the purview of the
Code is at http://www.mciindia.org/Rules-and-Regulation/Gazette%20Notifications%20-
%20Amendments/Ethics-01.02.2016.pdf, accessed on 26 December 2016.
20. See S. Srinivasan, ‘Ethical Minefield: Pharma Industry’s Gifts to Doctors Can Be Tax Deductible, Rules
Tribunal’, at https://scroll.in/pulse/827501/ethical-minefield-pharma-industrys-gifts-to-doctors-can-be-tax-
deductable-rules-tribunal, accessed on 1 March 2017.
21. The current draft, at the time of writing, has many loopholes and infirmities and in many cases violations of
the code would amount to a mere slap on the wrist if at all.
22. See ‘An Unethical and Unwarranted Assurance’, Editorial, Economic and Political Weekly, LI(12). See also
http://economictimes.indiatimes.com/industry/healthcare/biotech/pharmaceutical/pharmaceutical-research-
approval-system-to-be-put-on-fast-track/articleshow/55465744.cms. Also see Srinivasan (2016).
Chapter Thirteen: Healthcare Corruption and Traditional Medicine
in India
1. With contributions from Natasha D’Lima and Shivangini Kar Dave. The author would also like to thank
Anuja Joshi, Nupur Chaurasia, Namita Pandey, and Utplakshi Kaushik.
2. See Nagral et al. (2016); Gangolli et al. (2005); Shanmugasundaram et al. (2006); and Kaptchuk (1998).
3. The media has reported several stories, including amongst them: ‘Dead Bodies on Bike a Common Sight in
Nabarangpur’, Odisha Television Limited, 2016, http://odishatv.in/odisha/body-slider/dead-bodies-on-bike-a-
common-sight-in-nabarangpur-148894/; ‘Odisha: Denied a Mortuary Van, Man Carries Wife’s Body on
Shoulders’, Hindustan Times, 25 August 2016, http://www.hindustantimes.com/india-news/odisha-denied-a-
mortuary-van-man-carries-wife-s-body-on-shoulders/story-iCPpMsKueZIdINW2ONZDjN.html; ‘Odisha:
Apathy Forces Father to Carry Dead Daughter on Shoulder for 15 kms’, Deccan Chronicle, 7 January 2017,
http://www.deccanchronicle.com/nation/in-other-news/070117/odisha-deprived-of-hearse-van-father-carries-
dead-daughter-on-shoulder-for-15-kms.html; ‘Odisha: Dead Woman’s Legs, Hip Broken for Easy Transport;
Probe Ordered’, Hindustan Times, 26 August 2016, http://www.hindustantimes.com/india-news/dead-
accident-victim-s-legs-hip-broken-for-easy-transport-probe-ordered/story-
eTFZxIdGEKGHu9DCrFer9H.html; ‘Man with Five-Day-Old Baby Thrown out of Bus after Sick Wife Dies
during Journey in Madhya Pradesh (with Video)’, NewsCrunch, 28 August 2016,
http://www.newscrunch.in/2016/08/man-five-day-old-baby-thrown-out-bus-after-sick-wife-dies-during-
journey-madhya-pradesh; ‘Denied Ambulance, Odisha Man Carries Son’s Body on Trolley Rickshaw’, The
New Indian Express, 4 June 2017, http://www.newindianexpress.com/states/odisha/2017/jun/04/denied-
ambulance-odisha-man-carries-sons-body-on-trolley-rickshaw-1612888.html; ‘Shamed Again: Odisha Tribal
Man Dinabandhu Khemudu Walks Carrying Dead Daughter in Arms (with Video)’, NewsCrunch, 3
September 2016, http://www.newscrunch.in/2016/09/shamed-again-odisha-tribal-man-dinabandhu-khemudu-
walking-dead-daughter-arms-malkangiri.
4. ‘Mohini Jain v. State of Karnataka, Right to Education’, http://r2e.gn.apc.org/node/680, accessed on 13 June
2017.
5. ‘People and Corruption: Asia Pacific—Global Corruption Barometer’, Transparency International,
http://files.transparency.org/content/download/2118/13484/file/2017_GCB_AsiaPacific_EN.pdf.
6. ‘India 2013—World’s Largest Opinion Survey on Corruption—Transparency International’, Transparency
International, https://www.transparency.org/gcb2013/country/?country=india, accessed on 27 March 2017.
See also Berger (2014).
7. Ecorys, Study on Corruption in the Healthcare Sector.
8. ‘Government of India Order No. R14015/25/06-U & H(R) (Pt.)’,
http://www.erdoindia.org/gen/downloads/DelhiHealthMinistry.pdf.
9. ‘Promotion of AYUSH System of Medicines’, Press Information Bureau, Government of India, Ministry of
Health and Family Welfare, 7 April 2017, http://pib.nic.in/newsite/PrintRelease.aspx?relid=160652.
10. ‘India and WHO Sign a Landmark Agreement for Global Promotion of Traditional Systems of Medicine’,
Press Information Bureau, Government of India, AYUSH, 14 May 2016,
http://pib.nic.in/newsite/PrintRelease.aspx?relid=145352.
11. ‘Draft National Policy on AYUSH 2016’, http://ayush.gov.in/sites/default/files/-
Draft%20National%20Policy%20on%20AYUSH.pdf, accessed on 14 June 2017.
12. Pal (2002); Struthers, et al. (2004); King et al. (2009); Graz et al. (2011); Boozang (1998); ‘Study on the
Role of Informal Providers in Health Care Delivery’, Centre for Health Markets and Innovations (CHMI),
http://healthmarketinnovations.org/sites/default/files/IP%20Study_Summary%20for%20HSR_10%2010%2010.pdf
13. Kemper et al. (2017); Boon et al. (2006); Boon (2002); Bodeker (2001); Holliday (2003); Hong (2001);
Exeome and Anarado (2007); Pitman (2006); Adib (2004); Waqar (1992); Fischer (2014); and Muralidharan,
et al. (2001).
14. ‘Certificate Course in “Modern Pharmacology” for Homoeopaths by MUHS’, Homeobook, 22 May 2015,
http://www.homeobook.com/certificate-course-in-modern-pharmacology-for-homoeopaths-by-muhs/.
15. ‘Certificate Course in “Modern Pharmacology” for Homoeopaths by MUHS’, Homeobook, 22 May 2015,
 http://www.homeobook.com/certificate-course-in-modern-pharmacology-for-homoeopaths-by-muhs/.
16. See Narang (2010); Jonas (2002); McDonald (1981); Elling (1981); Zollman and Vickers (1999); Bodekar
and Kronenberg (2002); Ergler et al. (2011); Gautham et al. (2014); ‘Policy Roundtables: Collusion and
Corruption in Public Procurement 2010’, OECD, http://www.oecd.org/competition/cartels/46235884.pdf;
‘Building Anti-Corruption into the Millennium Development Goals’, Transparency International,
https://www.transparency.org/news/feature/building_anti_corruption_into_the_millennium_development_goals
accessed on 23 March 2017; Madhok (2013); Reddy et al. (2011).

Chapter Fourteen: Healthcare Corruption

1. http://timesofindia.indiatimes.com/india/Why-private-hospitals-make-you-buy-costly-
drugs/articleshow/53359130.cms
2. https://www.psychologytoday.com/blog/the-doctor-is-listening/201305/should-you-be-patient-or-healthcare-
consumer
3. http://indiatoday.intoday.in/story/doctors-made-liable-under-consumer-protection-laws-by-supreme-court-
ruling/1/290191.html
4. http://www.nytimes.com/2011/04/22/opinion/22krugman.html
5. http://www.bmj.com/content/348/bmj.g3169
6. http://timesofindia.indiatimes.com/india/Unregulated-private-insurance-wont-help-people-cut-health-costs-
Dr-David-Berger/articleshow/49212374.cms
7. http://economictimes.indiatimes.com/industry/healthcare/biotech/healthcare/open-secret-doctors-take-cuts-
for-referrals/articleshow/37374676.cms
8. http://www.nipfp.org.in/media/medialibrary/2013/04/wp_2012_100.pdf
9. http://timesofindia.indiatimes.com/india/Insurance-cover-up-but-medical-expenses-push-more-into-
poverty/articleshow/55761149.cms; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4536075/;
http://www.cddep.org/blog/posts/63_million_indians_are_pushed_poverty_health_expenses_each_year%E2%80%94and_drugs
10. https://www.researchgate.net/publication/267863589_Cata​-
strophic_Payments_and_Impoverishment_due_to_Out-of-Pocket_Health_Spending
11. http://timesofindia.indiatimes.com/india/India-ranks-3rd-in-region-in-out-of-pocket-med-
spend/articleshow/13178290.cms
12. http://timesofindia.indiatimes.com/home/sunday-times/deep-focus/How-Indians-spend-their-
money/articleshow/38289537.cms;
http://www.livemint.com/Politics/30z97MDZDMewkJHsfM5D6I/Medicine-costs-form-bulk-of-outofpocket-
health-expenses-N.html
13. http://in.reuters.com/article/india-pharma-kickbacks-idINDEE88G0A320120917
14. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3663160/
15. https://www.telegraphindia.com/1040905/asp/opinion/story_3718881.asp
16. http://indiatoday.intoday.in/story/india-rural-household-650-millions-live-on-rs-33-per-day/1/451076.html
17. http://www.tapanray.in/kickbacks-and-bribes-oil-every-part-of-indias-healthcare-machinery-a-national-
shame/
18. https://www.ncbi.nlm.nih.gov/pubmed/21555085; http://www.thehindu.com/opinion/columns/Pushed-into-
hysterectomies/article14416695.ece; http://www.frontline.in/the-nation/a-tale-of-
exploitation/article9583441.ece#test; http://timesofindia.indiatimes.com/india/The-uterus-snatchers-of-
Andhra/articleshow/6239344.cms; http://www.bbc.com/news/magazine-21297606;
http://timesofindia.indiatimes.com/city/patna/4-yrs-on-MCI-yet-to-take-action-against-uterus-scam-
accused/articleshow/55592314.cms
19. http://timesofindia.indiatimes.com/india/Needless-hysterecto​mies-on-poor-women-rampant-across-India-
Study/articleshow/18422865.cms
20. http://timesofindia.indiatimes.com/city/patna/Uterus-scam-Medical-body-yet-to-take-action-against-
doctors/articleshow/54335848.cms
21. http://www.hindustantimes.com/health-and-fitness/why-women-are-opting-for-c-sections/story-
TcAI7nq2wpgHsQpCHwHWpL.html; https://scroll.in/pulse/831397/why-we-all-need-to-know-how-many-c-
sections-each-hospital-in-india-is-conducting
22. http://www.atimes.com/real-causes-alarming-rise-c-section-births-india/
23. http://rchiips.org/NFHS/pdf/NFHS4/India.pdf
24. https://opinionator.blogs.nytimes.com/2016/01/19/arsdarian-cutting-the-number-of-c-section-births/
25. http://timesofindia.indiatimes.com/india/alarming-rise-in-caesarean-sections/articleshow/57302940.cms
26. http://www.hindustantimes.com/punjab/docs-criticise-maneka-gandhi-s-statement-on-c-section-
deliveries/story-njLFcUCK9XbjBIWcZOUDoM.html
27. http://timesofindia.indiatimes.com/india/profit-on-stents-ranges-from-270-to-
1000/articleshow/56610294.cms
28. http://timesofindia.indiatimes.com/india/Profits-from-medical-devices-used-to-bribe-
doctors/articleshow/42484806.cms
29. http://health.economictimes.indiatimes.com/news/medical-devices/stents-costing-rs-40000-sold-to-you-at-rs-
1-2-lakh/46226247
30. http://timesofindia.indiatimes.com/city/mumbai/its-not-only-stents-other-high-cost-med-devices-too-bleed-
patients-dry/articleshow/57176031.cms
31. http://timesofindia.indiatimes.com/india/Syringemaker-hospital-gouging-patients-
CCI/articleshow/50460771.cms; http://timesofindia.indiatimes.com/city/delhi/No-action-yet-against-errant-
diagnostic-labs/articleshow/41561641.cms; http://www.business-standard.com/article/news-ani/health-
minister-says-will-probe-news-nation-s-operation-jonk-medical-fraud-expose-114072201157_1.html
32. http://dghs.gov.in/content/1361_3_NationalCouncilClinicalEstablishments.aspx
33. http://economictimes.indiatimes.com/industry/healthcare/biotech/healthcare/us-hospitals-are-fined-millions-
for-unethical-acts-indian-ones-go-free/articleshow/39155177.cms;
http://timesofindia.indiatimes.com/india/Clean-slate-for-doctors-on-medical-
negligence/articleshow/27394151.cms
34. http://www.dailypioneer.com/print.php?printFOR=storydetail&story_url_key=those-error-
deaths&section_url_key=sunday-edition
35. http://www.dailymail.co.uk/indiahome/indianews/article-2475431/Kolkatas-AMRI-Hospital-pay-record-Rs-
11-41-crore-compensation-NRI-doctor-wife-died-medical-negligence.html
36. http://timesofindia.indiatimes.com/india/MCI-shrinks-own-ambit-doctor-bodies-out-of-ethics-
code/articleshow/30873980.cms
37. http://timesofindia.indiatimes.com/city/patna/4-yrs-on-MCI-yet-to-take-action-against-uterus-scam-
accused/articleshow/55592314.cms; http://www.indiamedicaltimes.com/2016/11/30/bihar-government-asks-
mci-to-cancel-registration-of-doctors-accused-in-uterus-scam/
38. http://epaperbeta.timesofindia.com/Article.aspx?eid=31808&articlexml=Private-hospitals-test-reports-spook-
babus-16052015017034
39. http://timesofindia.indiatimes.com/india/private-hospitals-reuse-disposables-make-you-pay-for-
them/articleshow/57228172.cms
40. http://timesofindia.indiatimes.com/city/delhi/GB-Pant-rip-off-Doctors-fancy-costly-
stents/articleshow/46561044.cms; http://timesofindia.indiatimes.com/city/delhi/Cheaper-ones-of-poor-
quality-theyre-told/articleshow/46561049.cms

Chapter Fifteen: Corruption in Medical Research

1. The author is grateful to Sarojini N.B. for alerting him to the parliamentary report (‘Department-related
parliamentary standing committee on health and family welfare’, Fifty- ninth report on the functioning of the
Central Drugs Standard Control Organisation).
2. http://www.corruptionwatch.org.za/learn-about-corruption/what-is-corruption/our-definition-of-corruption/,
accessed 31 December 2016.
 3. Merriam-Webster Dictionary, https://www.merriam-webster.com/dictionary/corruption, accessed on 31
December 2016.
4. The Shorter Oxford English Dictionary, p.432.
5. Department-related parliamentary standing committee on health and family welfare’, Fifty- ninth report on
the functioning of the Central Drugs Standard Control Organisation (CDSCO), 8 May 2012.
6. Letter from Dr Mark McDonald to Mrs Sheeba Manoj Nair, 12 April, available at
http://apps.who.int/prequal/info_applicants/NOC/2016/NOC_Semler12April2016.pdf, accessed on 31
December 2016.
7. SOMO briefing paper on ethics in clinical trials, February, available at https://www.wemos.nl/wp-
content/uploads/2016/07/examples_of_unethical_trials_feb_2008.pdf, accessed on 31 December 2016.
8. http://www.mciindia.org/RulesandRegulations/CodeofMedicalEthicsRegulations2002.aspx, accessed 30
December 2016.
9. https://www.ama-assn.org/sites/default/files/media-browser/code-of-medical-ethics-chapter-7.pdf, accessed
on 30 December 2016.

Chapter Sixteen: Corruption in Healthcare

1. See Transparency International (2006). Also see ‘Fighting Corrup​tion in the Health Sector: Methods, Tools
and Good Practices’, United Nations Development Programme, available at
http://www.undp.org/content/undp/en/home/librarypage/democratic-governance/anti-
corruption/fighting_corruptioninthehealthsector.html
2. Datta et al. (2013).
3. ‘An Instinct for Growth: Meeting Challenges—Tapping opportunities to Achieve 50 Billion Vision for
Medical Technology sector’, Grant Thornton Report. CII. New Delhi. September 2016, p. 4.
4. ‘World Bank warns against excessive health care in India’, The Economic Times, 31 July 2014; ‘44% advised
unnecessary surgery: Second opinion givers’, The Times of India, 4 January 2015.

Chapter Nineteen: The Consequences of Corruption in Healthcare

1. Code of Medical Ethics 2002 (Amended up to 8 October 2016), available at
http://www.mciindia.org/RulesandRegulations/CodeofMedicalEthicsRegulations2002.aspx, accessed on 17
March 2017.
2. ‘CMO Dr. B P Singh Shot Dead in Lucknow’, India Medical Times, 3 April 2011, available on
http://www.indiamedicaltimes.com/2011/04/03/cmo-dr-v-p-singh-murdered-in-lucknow-doctors-strike-work-
in-protest/, accessed on 17 March 2017.

Chapter Twenty: Judicial and Legislative Responses to Healthcare

Corruption
1. The authors would like to thank Mannat Sabikhi and Shreya Srivastava for their research assistance. Errors, if
any, are the authors’ alone.
2. ‘The Functioning of Medical Council of India’, Department-related Parliamentary Standing Committee on
Health and Family Welfare, 92nd Report, 8 March 2016.
3. ‘The Functioning of the Central Drugs Standard Control Organisation (CDSCO)’, Department-related
Parliamentary Standing Committee on Health and Family Welfare, 59th Report, 8 May 2012. See also Berger
(2014).
4. Report of the Professor Ranjit Roy Chaudhury Expert Committee to Formulate Policy Guidelines for
Approval of New Drugs, Clinical Trials and Banning of Drugs, July 2013.
5. Modern Dental College and Research Centre v State of Madhya Pradesh (2016) 7 SCC 353.
 6. Writ Petition (Civil) No. 33 of 2012 with Writ Petition (Civil) No. 79 of 2012.
7. Dinesh S. Thakur v. Union of India, Writ Petition (Civil) No. 137 of 2016.
8. Modern Dental College and Research Centre v. State of Madhya Pradesh (2016) 7 SCC 353.
9. ‘The National Commission for Human Resources for Health Bill, 2012’, 30 October, Department-related
Parliamentary Standing Committee on Health and Family Welfare, 60th Report.
10. A Manupatra search of Supreme Court cases from 1950 revealed the following results with different
combinations of keyword searches: 253 cases for a combined search of ‘medical’ and ‘corruption; 53 cases
for a combined search of ‘medicine’ and ‘corruption’; and 186 cases for a combined search of ‘health’ and
‘corruption’. We excluded high court cases from this analysis because of the sheer volume of results (over
3500) that our search revealed.
11. ‘Private sector bribery under proposed anti-corruption law: Parliamentary Committee’, The Indian Express,
12 August 2016, available on http://economictimes.indiatimes.com/news/politics-and-nation/private-sector-
bribery-under-proposed-anti-corruption-law-parliamentary-committee/articleshow/53672937.cms, accessed
on 17 January 2017.
12. Kumari Sangita Tukaramji Rokde v. Union of India, Complaint No. 76 of 2014, National Consumer Disputes
Redressal Commission.
13. Section 10A, Indian Medical Council Act, 1956.
14. Sri Manakula Vinayaga Educational Trust v. Deputy Superintendent of Police, CBI, Special Police
Establishment, Anti-Corruption Bureau MANU/TN/2456/2015; Lord Buddha Pratisthan Saharsa v. Union of
India MANU/DE/2104/2014; N Diviya v. Chairman, Ethics Committee, Medical Council of India
MANU/TN/1997/2015; Balvir S Tomar v. Union of India MANU/DE/0865/2016.
15. A Manupatra search using the keywords ‘Medical Council of India’ and ‘corruption’ gave up 95 results, of
which 59 were post-2010 (Caveat: Not all of these results were directly related to corrupt practices by private
medical institutions or the MCI).
16. Dr K Nedumaran v. The Chairman, Ethics Committee, Board of Governors in Super-session of the Medical
Council of India and Melmaruvathur Adhi Parasakthi (2013) 3 MLJ 263; Shalik Bhaurao Ade and others v.
Medical Council of India 2016(5)BomCR769.
17. Sri Balaji Educational and Charitable Public Trust, represented by its chairman, M.K. Rajagopalan v.
Pondicherry University MANU/TN/0965/2004.
18. Rama Medical College Hospital and Research Centre v. Union of India MANU/DE/3814/2011.
19. NEET was instituted for the first time by the Medical Council of India with effect from 27 December 2010.
See Simran Jain v. Union of India, (2014) 2 SCC 393. It was held only once in May 2013, before being
struck down by the Supreme Court as unconstitutional in July 2013.
20. Article 19(1)(g) reads:
‘(1) All citizens shall have the right—
(g) to practise any profession, or to carry on any occupation, trade or business.’
21. Article 30(1) reads:
‘(1) All minorities, whether based on religion or language, shall have the right to establish and administer
educational institutions of their choice.’
22. The chapter will focus on the MCI notification as shorthand for a notification ordering NEET.
23. Christian Medical College, Vellore and others v. Union of India and others, (2014) 2 SCC 305 (Per Kabir
CJI and Sen J.). So pervasive is the presence of corruption in private medical admissions that there were
several seeming suggestions that several lawyers knew the contents of the judgement beforehand. See
Sankaranarayan (2013).
24. Per Dave J., (2014) 2 SCC 305, at 384.
25. Per Dave J., (2016) 4 SCC 342.
26. Sankalp Charitable Trust v. Union of India, 28 April 2016; Association of Managements of Unaided Private
Medical and Dental Colleges v. Union of India, 9 May 2016.
27. Modern Dental College and Research Centre v. State of Madhya Pradesh (2016) 4 SCC 346.
28. State of Maharashtra v. DY Patil Vidyapeeth (2016) 9 SCC 401.
29. The Indian Medical Council (Amendment) Act, 2016 was passed in August 2016, postponing NEET by one
academic year.
30. Article 19(6) allows ‘reasonable restrictions in the interest of the general public’. Proportionality has been
read into Indian constitutional law. An early enunciation of it may be seen in Chintaman Rao v. State of
Madhya Pradesh, AIR 1951 SC 118. More recently, it was used in Modern Dental College and Research
Centre v. State of Madhya Pradesh, (2016) 4 SCC 346.
31. This was held by a Constitution Bench of the Supreme Court in Pramati Educational and Cultural Trust v.
Union of India, (2014) 8 SCC 1. It was held (at p. 100):
“Unaided minority educational institutions have unfettered rights to admission of students under Article
30(1). The State cannot impose on them the admission of any non-minority students, even for the
advancement of any socially and educationally backward classes of the citizens or for Scheduled Castes or
Scheduled Tribes.
32. Setting up an educational institution has been considered to be squarely covered under the freedom of
occupation in Article 19(1)(g). TMA Pai Foundation and others v. State of Karnataka and others, (2002) 8
SCC 481 at 533-34.
33. Setting up an educational institution has been considered to be squarely covered under the freedom of
occupation in Article 19(1)(g). TMA Pai Foundation and others v. State of Karnataka and others, (2002) 8
SCC 481 para 161 at p. 587.
34. Setting up an educational institution has been considered to be squarely covered under the freedom of
occupation in Article 19(1)(g). TMA Pai Foundation and others v. State of Karnataka and others, (2002) 8
SCC 481 at p. 588.
35. (2002) 8 SCC 481 (hereinafter TMA Pai).
36. (2002) 8 SCC 481 (hereinafter TMA Pai) 588.
37. Id.
38. The classic test of proportionality was laid down by Lord Clyde in Defreitas v. Ministry of Agriculture
(1998) UKPC 30. It had three components: first, whether the object of the restriction is sufficiently important
to restrict a fundamental right; second, whether the restriction is rationally connected with the object; and
third, the means are no more than necessary to achieve the object.
39. (1993) 4 SCC 111.
40. This is recorded in TMA Pai, paras 37, 38.
41. Under section 10A of the Indian Medical Council Act, 1956, the MCI may only make recommendations to
grant or withhold approval; the final decision is taken by the central government.
42. Section 3, Indian Medical Council Act, 1956.
43. Entry 26, List III (Concurren List), Seventh Schedule, Constitution of India.
44. Entry 6, List II (State List), Seventh Schedule, Constitution of India.
45. For arguments in favour of greater decentralization, see Debroy (2015).

Chapter Twenty One: Global Medical Corruption

1. http://www.bmj.com/content/348/bmj.g3169/article-info
2. https://www.wma.net/policies-post/wma-declaration-of-geneva/
3. http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0041436
4. http://www.bmj.com/too-much-medicine
5. http://www.kevinmd.com/blog/2016/12/one-year-later-physicians-letter-medicare-patients.html
6. http://www.economist.com/news/united-states/21603078-why-thieves-love-americas-health-care-system-
272-billion-swindle
7. http://www.post-gazette.com/business/healthcare-business/2017/05/02/Robert-Coury-salary-Mylan-EpiPen-
pricing-Heather-Bresch/stories/201705020038
 8. http://edition.cnn.com/2015/09/28/health/us-pays-more-for-drugs/index.html
9. http://www.huffingtonpost.ca/2016/11/17/prescription-drug-prices_n_13057392.html
10. https://www.wsj.com/articles/why-the-u-s-pays-more-than-other-countries-for-drugs-1448939481
11. http://dx.doi.org/10.1136/jme.2010.040923
12. http://www.bmj.com/content/355/bmj.i5396
13. http://onlinelibrary.wiley.com/doi/10.1111/anae.13938/epdf
14. http://stemlynsblog.org/fake-news-lies-fraud-errors-statistics-st-emlyns/
15. http://bmj.com/cgi/content/full/bmj.j1955?ijkey=X33zmHJ4pik9Cl1&keytype=ref

Chapter Twenty Five: Patient-Centric Healthcare: Through

Institutional Regulation
1. A ration card is a document issued by state governments in India to facilitate access to a public distribution
system which distributes food grains to people. Each family has a specific set of entitlements. In Maharashtra
this document was also linked to eligibility for the healthcare scheme discussed here.
2. Figures from Public Health Department, Government of Maharashtra.
3. Personal communication dated 18 March 2013.
4. From the website of the Maharashtra
government.https://www.jeevandayee.gov.in/RGJAY/RGJAYDocuments/Clinical%20data%20Form%20for%20Cardiology.pdf
accessed on 28 October 2016.
5. Henceforth the word ‘Society’ would be used to refer to the State Health Assurance Society.
6. Detailed information about the indicators and explanations are available in training documents on the
government website: https://www.jeevandayee.gov.in/RGJAY/RGJAYDocuments/NABHRGJAY.pdf
7. Indian Non-Life Insurance Industry Yearbook, 2014-15, General Insurance Council; p 52.

Chapter Twenty Six: Regulating Healthcare Establishments

1. The author has used the terms ‘healthcare providers’ and ‘clinical establishments’ interchangeably to include
hospitals, maternity homes, nursing homes, dispensaries, clinics (including single-doctor and dental clinics),
laboratories, diagnostic, therapy centres, by all recognized systems of medicine in public and private
facilities.
2. The Clinical Establishments (Registration and Regulation) Act, 2010 [Gazette Notification], New Delhi:
Ministry of Law and Justice (Legislative Department), Government of India; 19 August, available at
http://clinicalestablishments.nic.in/WriteReadData/969.pdf.
3. Under the Constitution of India, in the seventh schedule it clearly states that public health and sanitation;
hospitals and dispensaries fall under the purview of the state subject wherein regulation of clinical
establishment falls under its responsibility. The parliament generally has no power to legislate on items from
the state list, including public health, hospitals and sanitation. However, two or more states may ask
parliament to legislate on an issue that is otherwise reserved for the state. Other states may then choose to
adopt the resulting legislation. The central government wrote to all the states governments that the centre
would be keen to enact a central act. Four states, that is, Arunachal Pradesh, Sikkim, Mizoram, and Himachal
Pradesh gave their concurrence, which enabled the central government to enact the central act. In the
parliament there was consensus among all the political parties for the CEA, 2010.
4. ‘Docs up against Clinical Establishment Act’, The Times of India, 31 October 2010.
5. AIR 28 August 1989. SC 2039, available at http://indiankanoon.org/doc/498126/

Chapter Twenty Seven: Can Digital Technology Help Curb

Healthcare Corruption?
 1. http://www.transparency.org/cpi2011/in_detail, accessed in November 2017.
2. For information on the US scenario, see Hsiao (1988); for India, refer to Chatterjee (2013).

Chapter Twenty Eight: Healthcare Corruption: Responses from

People’s Health Movements
1. McCubbin et al. (2001).
2. Phadke et al. (2013).
3. Indian Journal of Medical Ethics, available at https://ijme.in
4. http://patientrightsindia.blogspot.in/2010/11/survey-for-patient-rights-in-pune.html
5. http://www.aarogya.com/health-resources/patients-rights-forum/e-petition-for-patients-rights.html
6. http://indianexpress.com/article/cities/pune/first-convention-of-patients-rights-forum-held/
7. http://patientright.blogspot.in/2010/07/charter-of-patients-rights-and.html
8. http://www.sathicehat.org/index.php/our-projects
9. http://healthwatchforum.blogspot.in/2014/07/mariz-haq-campaign-28th-april-2014-to.html
10. http://clinicalestablishments.nic.in/En/1070-draft-minimum-standards.aspx
11. http://nhrc.nic.in/JanSwasthyaAbhiyan.htm
12. https://www.pressreader.com/india/the-times-of-india-mumbai-
edition/20160101/281814282838899/TextView
13. http://indianexpress.com/article/cities/mumbai/woman-returns-unheard-from-nhrc-hearing
14. www.ethicaldoctors.org
15. http://www.ethicaldoctors.org/index.php/media/1-july-doctors-day-meeting/
16. http://timesofindia.indiatimes.com/city/mumbai/Activists-Need-urgent-reforms-for-Maharashtra-medical-
council/articleshow/55763848.cms
17. http://www.hindustantimes.com/india-news/meet-the-man-who-fought-to-cap-coronary-stent-price-at-rs-30-
000/story-8Nbn7MSAH1NBy17TZjJdUP.html
18. https://aidanindia.wordpress.com/
19. http://www.business-standard.com/article/pti-stories/adeh-asks-govt-to-review-pricing-of-coronary-stents-
117010301223_1.html
20. http://www.nppaindia.nic.in/ceiling/press13Feb2017/so412e-13-02-17.pdf
http://timesofindia.indiatimes.com/india/stent-prices-slashed-by-up-to-85/articleshow/57136127.cms

Chapter Twenty Nine: Evidence-Based Interventions for Healthcare

Corruption
1. Annual Report for FY 2006, Health Care Fraud and Abuse Control Program, Department of Health and
Human Services, Department of Justice, 2007; Annual Report for FY 2006, Health Care Fraud and Abuse
Control Program, Department of Health and Human Services, Department of Justice, 2008.
2. Annual Report for FY 2006, Health Care Fraud and Abuse Control Program, Department of Health and
Human Services, Department of Justice, 2007; Annual Report for FY 2006, Health Care Fraud and Abuse
Control Program, Department of Health and Human Services, Department of Justice, 2008; Kang et al. 2010.
3. Society for Social Audit Accountability and Transparency, 2008, available at
http://www.socialaudit.ap.gov.in/SocialAudit/FrontServlet?
requestType=SALoginRH&actionVal=GetHomePage, accessed on 14 June 2017.
4. Society for Social Audit Accountability and Transparency, 2008, available at
http://www.socialaudit.ap.gov.in/SocialAudit/FrontServlet?
requestType=SALoginRH&actionVal=GetHomePage, accessed on 14 June 2017.
5. http://medimitra.org/?page_id=110
Chapter Thirty One: What Should We Do?
1. ‘Pharmaceuticals and Healthcare Programme’, Transparency International UK, available at
www.transparency.org.uk/our-work/pharmaceutical-a-healthcare-programme.
2. ‘Global Corruption Report 2006: Corruption and Health, Transparency International, available at
www.transparency.org/whatwedo/pub/global_corruption_report_2006_corruption_and_health; Nundy
(2014).
3. ‘Private Medical Colleges Selling Seats for Crores’, IBN Live, 3 April 2013, available at
http://ibnlive.in.com/news/private–medical-colleges in three states/
4. ‘Medical Council of India Ban to Hit Pvt Medical Colleges’, The Times of India, 16 October 2012.

Chapter Thirty Seven: Challenges to Holding a Candle against

Corruption
1. Supreme Court of India
Shahal H. Musaliar & Anr vs State of Kerala & Ors on 18 August 1993.
Bench: S.R. Pandian, S.C. Agrawal, S. Mohan, B.P. Jeevan Reddy, S.P. Bharucha CASE NO.: Writ Petition
(civil) 598 of 1993.
2. Islamic Academy Of Education And ... vs State of Karnataka And Others on 14 August 2003. Bench: Cji V.
Khare, S.N. Variava, K.G. Balakrishnan, Arijit Pasayat. CASE NO.: Writ Petition (civil) 350 of 1993. DATE
OF JUDGEMENT: 14 August 2003.
3. http://stjohnsadmissions.in/FORMAT.pdf, accessed on 16 May 2017.

Chapter Forty One: Palliative Care Shows the Way to True Health
1. Kerala State IT Mission. ‘Formulation and Declaration of State Policy for Pain and Palliative Care Services’,
available at
https://kerala.gov.in/documents/10180/46696/Pain%20and%20palliative%20care%20policy%202008,
accessed on 20 April 2017.
2. 67 World Health Assembly. ‘Strengthening of Palliative Care as a Component of Comprehensive Care
throughout the Life Course’, available at http://apps.who.int/gb/ebwha/pdf_files/WHA67/A67_R19-en.pdf,
accessed on 20 April 2017.
3. ‘Palliative Care in Kerala Not So Balmy’, The New Indian Express, 9 October, available at
http://www.newindianexpress.com/states/kerala/Palliative-care-in-Kerala-not-so-
balmy/2013/10/09/article1826405.ece, accessed on 20 April 2017.
 About the Editors and Contributors

Editors
Samiran Nundy is Emeritus Consultant, Sir Ganga Ram Hospital, New Delhi. He was
previously Chairman, Department of Gastrointestinal Surgery and Liver Transplantation at the
All India Institute of Medical Sciences, New Delhi. He has published extensively, with his most
recent published book being Complications after Gastrointestinal Surgery (co-edited; OUP
2017).

Keshav Desiraju is a former Union Health Secretary, Government of India. He is currently

Chairman, Population Foundation of India.

Sanjay Nagral is Consultant Surgeon, Department of Surgical Gastroenterology, Jaslok

Hospital, Mumbai, and Honorary Surgeon, KB Bhabha Municipal General Hospital, Mumbai.
He is the publisher of the Indian Journal of Medical Ethics.

Contributors
Anshu is a pathologist and a medical teacher. She graduated from Government Medical College
Nagpur, India. She is Professor, Department of Pathology, Mahatma Gandhi Institute of Medical
Sciences at Sevagram in Maharashtra, India. Her love for teaching urged her to explore medical
education and, in 2014, she was awarded a Masters in Health Professions Education cum laude
from Maastricht University, The Netherlands. She designs and conducts training workshops for
teachers of health professions in pedagogy. Currently, she is Secretary of the Academy of Health
Professions Educators in India.

Shehlina Ahmed is a public health expert with more than 30 years of experience working in
Bangladesh and across Asia. She is an alumna of the London School of Hygiene and Tropical
Medicine. Her experience spans both public and non-state health sectors with deep
understanding of participatory programme development to issues around policy formulation. She
has been instrumental in introducing a new cadre of professional in the public health system of
Bangladesh along with contribution to other key policy decisions, in the recent past.

David Berger, a UK-trained GP, currently lives and works in Australia, where he is a doctor in a
remote hospital dealing mainly with aboriginal people. He volunteered at a small community
hospital in Northern India in 2012–13 while his children attended a nearby school. Based on this
experience Berger wrote an opinion piece in 2014 for the BMJ on corruption in healthcare in
India, which was widely quoted in the popular press.
Sunil Chandy is Professor of Cardiology and former Director at the Christian Medical College,
Vellore. After completing his MBBS in Vellore, he served for two years in a rural hospital in
northern Bihar. After completing his MD in Internal Medicine and DM in Cardiology from CMC
Vellore, he joined the faculty of the college. After initial stints as Deputy Medical
Superintendent and Vice Principal of CMC Vellore, he was appointed Director. He initiated
major changes in human resource management, campus development, reviving small mission
hospitals, and trauma care. He believes that quality healthcare can be delivered at much lower
costs but excluding the frills and pomp that has infiltrated healthcare systems in India.

Rupa Chinai, an independent journalist based in Mumbai, is passionate about two neglected
areas of Indian journalism: public health and the Northeast of India. She has worked on the staff
of leading Indian English language newspapers and has also written for national and
international websites. As a reporter with The Indian Express, her daily, year-and-a-half long
coverage of the Lentin Commission of Enquiry into the JJ Hospital deaths and its aftermath had a
major public impact. In 1993–94 she was awarded a year’s fellowship to do advanced studies in
public health by the Centre for Health Communications, Harvard School of Public Health,
Boston, USA.

Abhijit Chowdhury is Professor and Head of the Department of Hepatology at the School of
Digestive and Liver Diseases of the Institute of Post Graduate Medical Education & Research,
Kolkata, India. He is a founding member of the Liver Foundation, the Society for Health and
Demographic Surveillance, the Institute of Public Health Kalyani, and the Indian Institute of
Liver and Digestive Sciences, all located in the state of West Bengal, India. Chowdhury’s
commitment to clinical practice and public health research aims to deliver the best possible
healthcare for everyone, irrespective of their social and economic background.

Harendra de Silva has an MBBS, MRCP (Paediatrics) and an MSc (Birm), and is a
Commonwealth Scholar and Fellow. He is now Emeritus Professor of Paediatrics at the
University of Colombo, Sri Lanka. He is known for his work towards improving and creating
laws pertaining to child abuse in Sri Lanka. His work has gained him awards and fellowships,
including an Honorary Fellowship from the Royal College of Paediatrics and Child Health, a
Fellowship from the College of Physicians and Surgeons of Pakistan, The Most Outstanding
Asian Paediatrician (APPA), and a Distinguished Career award from the International Society
against Child Abuse and Neglect (ISPCAN).

Vandana Gopikumar is co-founder of The Banyan and BALM. She is also Professor at the Tata
Institute of Social Sciences. Gopikumar has twenty-five years of experience as a social
entrepreneur, mental health practitioner, and advocate. She was also involved in drafting the first
mental health policy for India. Her research explores the nature of distress and personal recovery
experienced by those who are homeless and living with mental health concerns. She also
attempts to deconstruct themes of social exclusion, prejudice, inclusion, social defeat, and
resilience in relation to homelessness and mental illness.

Rakhal Gaitonde completed his MBBS from Government Kilpauk Medical College and MD
Community Medicine from Christian Medical College, Vellore. He has since worked with NGOs
implementing projects on community-based accountability and governance of health systems,
including at the state level in Tamil Nadu under the National Rural Health Mission. He is
presently pursuing a Ph.D. with the University of Umea, Sweden and is a senior scientist at the
Centre for Technology and Policy (CTaP) IIT-M, Chennai, India, where he works on vaccine-
related decision-making and the evaluation of medical technology from both systems and social
perspectives.

Prachinkumar Ghodajkar is currently Assistant Professor at the Centre of Social Medicine and
Community Health, Jawaharlal Nehru University, New Delhi, India. He completed his MBBS at
Topiwala National Medical College, Mumbai, India, and has an MPH from Jawaharlal Nehru
University, New Delhi, India. The areas of research that interest him include health systems,
health policy, access to and quality of healthcare services, nutrition, human resources for health
and health financing, national health programmes, communicable diseases, and epidemiology.

Kaveri Gill is Associate Professor, Department of International Relations and Governance

Studies at Shiv Nadar University. She completed a BA Tripos, M. Phil., Ph.D., and Postdoctoral
Smuts Fellowship in Economics and Development at the University of Cambridge, United
Kingdom. She has worked for over fifteen years at a range of organizations, including the
Planning Commission of India and UNICEF. Her research interests include the political
economy of urbanization, development, informality and the environment; welfare programmes
and service delivery in varied social sector spheres; development policies and the status of
adivasis in mainland India; and the political economy of public health policy and practice.

Md Khairul Islam is a public health and development professional in Bangladesh. He started

his career in the health service in Bangladesh, served in the Directorate of Health, Planning
Commission; and has worked with several national and international NGOs in Bangladesh and
Africa in leadership and managerial positions. Islam has contributed in the formulation of the
national health policy and national population policy of Bangladesh as a member of the drafting
committee. He sits on different national and regional committees formed by the Government of
Bangladesh and different regional bodies; and serves on the boards of various social and civil
society organizations.

Yogesh Jain is a paediatrician and public health physician in Chhattisgarh, India. He founded
and runs a community health programme, Jan Swasthya Sahyog (People’s Health Support
Group), in rural Bilaspur. Since 1999, this has been accessed by people from 3,000 villages. He
has been involved in addressing issues surrounding healthcare for the rural poor through clinical
care, careful documentation, observational research studies, developing appropriate health-
related technology, training, and lobbying. He is also involved in advocacy based on this lived
experience at the provincial, national, and international forums to highlight the burden and
causes of illness among the poorest in the world.

S.P. Kalantri is Director and Professor of Medicine at MGIMS and Medical Superintendent of
Kasturba Hospital, Sevagram. He completed his MD from Government Medical College, Nagpur
in 1981. In 2004, he won Fogarty AIDS International research scholarship, and obtained an MPH
in Epidemiology from the School of Public Health, University of California, Berkeley. Kalantri
heads an internal medicine unit, teaches medical students, mentors his residents, conducts
clinical research, and manages the hospital. He successfully campaigned against sponsorship of
medical conferences by the drug industry and introduced low-cost drugs in the hospital. His
general interests include evidence-based medicine, medical ethics, public health, and information
technology.

K.V. Kishore Kumar is a psychiatrist who has been associated with the National Institute of
Mental Health and Neurosciences (NIMHANS) for 30 years. He headed Community Health
Services within the Department of Psychiatry. He advised the World Health Organization
(WHO) and is presently Director of The Banyan and BALM, where he works with individuals in
the homeless and severe mental illness (SMI) brackets. His interests lie in enabling psychosocial
interventions to synchronize with primary care via the nodal agencies that work on this, local
resources utilization within the economics of care, epidemiology of mental illnesses, social
realities of mental illness and its after effects across stakeholders, disaster and trauma psychiatry,
training of general practitioners, and life-skills orientation for adolescents.

Vinay Kumaran is a Liver Transplant, Hepatobiliary, and Pancreatic surgeon at Kokilaben

Dhirubhai Ambani Hospital, Mumbai, India. He has edited Techniques of Liver Surgery (2016).
He has several scientific papers published in high impact journals including Nature Medicine,
Gastroenterology, Hepatology, Liver Transplantation, Journal of the American College of
Surgeons, and so on. He runs a group for Liver Transplant and HPB Surgery with over 4,000
members on LinkedIn. He is currently working on a collection of stories about patients
undergoing or needing to undergo transplantation tentatively entitled ‘Spare Parts: Stories from
the World of Transplantation’.

Ratna Magotra completed her MBBS at the Lady Hardinge Medical College in New Delhi and
earned MS degrees in General Surgery and Cardio-Thoracic surgery from Mumbai University.
She also trained at Guy’s Hospital in the UK and the Texas Heart Institute in Houston, USA. She
has served as Professor and Head of Cardiovascular & Thoracic Surgery at GS Medical College
and KEM Hospital, Mumbai until she retired in 2000. She participated actively in the India
Against Corruption movement led by Anna Hazare in 2011. She is a Trustee of the Public
Concern for Governance Trust, Mumbai that works for good governance, transparency, and
accountability in public life.

M.K. Mani, a pioneer in the study of diseases of the kidney, has been instrumental in
establishing it on a firm footing in India. His endeavours have been recognized by the award of
the Padma Bhushan, the John H. Dirks award of the International Society of Nephrology, the
Rabindranath Tagore oration award of the Indian College of Physicians, the Lifetime
Achievement award from the Indian Society of Nephrology, the Dhanvantari award, and various
fellowships from organizations both in India and abroad. He is known for his strong views on
medical education, ethics, and the doctor–patient relationship.

V.I. Mathan obtained his MBBS, MD, and Ph.D. from the Madras University through the
Christian Medical College, Vellore. He joined the Faculty of CMC Vellore in 1965 and
established the Department of Gastrointestinal Sciences in 1972. This included the establishment
of a Wellcome Trust (UK) Tropical Disease Research unit under his direction in 1975. Professor
Mathan was elected a member of the Royal College of Physicians of London, a Fellow of the
Indian National Science Academy and several other academies, and has won numerous prizes
and awards, the most notable being the Ambedkar Award of the Indian Council of Medical
Research for his lifetime contributions to health research.
Dhvani Mehta is Senior Resident Fellow at the Vidhi Centre for Legal Policy, New Delhi,
where she jointly leads the Vidhi Aid Initiative, focusing on health, environment, and education.
She has a Doctor of Philosophy in Law from the University of Oxford. She has authored reports
on organ transplantation, advance directives, and grievance redressal mechanisms in public
healthcare establishments. She has worked with the Indian Council of Medical Research on end-
of-life care and clinical trial regulation and has provided legal and drafting assistance to an
expert committee chaired by the late Dr Ranjit Roy Chaudhury on reforms to the Medical
Council of India.

Meeta is in the IAS (1990), Maharashtra Cadre. She has authored (along with Rajivlochan), a
number of research papers in journals like the Economic and Political Weekly and a number of
books, including Farmers Suicide: Facts and Possible Policy Interventions (2006) and Jal
Swaraj: Case Studies in Community Empowerment (2009), both published by YASHADA, Pune.

Shishir Moral is a senior journalist and the news editor of one of the most circulated national
dailies in Bangladesh. He covers health, nutrition, and water including transboundary water. He
has co-authored a number of books and articles on health in national and international journals.

S.V. Nadkarni is a retired surgeon who has been in the medical profession from 1951 to the
present day. He studied general surgery at B.J. Medical College in Pune, and subsequently spent
12 years in the semi-urban towns of Mangalore and Panaji as Reader and Associate Professor of
Surgery. He also spent 13 years as Head of the Department of Surgery at LTM Medical College,
Mumbai. He is credited for having developed an intensive care unit for trauma, the first of its
kind in India, where injured victims receive prompt treatment within minutes of arrival. He has
worked to find ways to reduce the costs of healthcare through improvements in skills and
organization.

Rema Nagarajan is a senior assistant editor at The Times of India in Delhi. She writes on public
health policy and other health-related issues, and other development issues including disability
rights, gender, and primary education. In recent years, her writing has focused on corruption in
healthcare delivery and the inadequacy of regulatory oversight in medical education, the medical
profession, and the private health sector. As a Bosch Foundation fellow in 2015, she studied how
the German health insurance system worked to control healthcare costs. She was a Nieman
Global Health Reporting fellow at Harvard University in 2011-12, a Hubert Humphrey fellow at
the University of Maryland on the Fulbright exchange programme in 2005-06, and was at the
University of Westminster, London on the Chevening Journalism fellowship programme in
2000.

Sunil Nandraj is a social scientist by education and was instrumental to the drafting and
implementation of the Clinical Establishment Act, 2010. He advises the Government of India
and various state governments on the issue of regulation. He also served with the WHO heading
the cluster for Health Systems Development in the India Country Office and as Technical Officer
- National Health Planning and Health Financing in the South East Asia Regional Office. He has
served as a technical expert in various national committees on issues of health systems
development and is co-founder of medileaks, a website on the lines of wikileaks, that documents
irrational practices and irregularities in the healthcare sector in India.
Lakshmi Narasimhan has a Masters in Social Work in Social Welfare Administration from the
Tata Institute of Social Sciences and has been working in the areas of homelessness and mental
health since 2005 with The Banyan. She currently heads the BALM-Sundram Fasteners Centre
for Research and Social Action in Mental Health where she leads the implementation and
research of projects aimed at quality-of-life gains using community-based approaches to mental
health. She has also served as the principal investigator and project lead for action research
projects at The Banyan. Her interests include understanding and developing social approaches to
deal with complex issues at the intersection of poverty, homelessness, and mental health.

Kavita Narayan is Technical Advisor, National Human Resources for Health Systems Cell at
the Ministry of Health and Family Welfare. As one of the youngest and first Indian Fellows of
The American College of Healthcare Executives (ACHE), Kavita has several years of experience
as a hospital systems administrator and leader in the United States and in India. Her last role was
that of Chief Operating Officer of a multi-specialty health system, a partnership with the Hospital
Corporation of America and Emory Healthcare, Atlanta, USA. She was also associated with
PHFI for the last five years in her role as Head, Healthcare Institutional Services.

Surajit Nundy was trained in Internal Medicine at Massachusetts General Hospital in Boston
and has an MPH from the Harvard School of Public Health. He holds an MD/Ph.D. from
Washington University in St. Louis/Duke University where he worked on deep-learning in
cognitive neuroscience. In 2011, Nundy founded Raxa, a health information company based in
India with contributors throughout the world with the goal of using machine intelligence to
provide good healthcare for all, especially the underserved.

Sanjay A. Pai is a consultant pathologist at Columbia Asia Referral Hospital, Bangalore. He has
also been associated with Tata Memorial Hospital, Mumbai and Manipal Hospital, Bangalore.
Sanjay did his MBBS from Grant Medical College, Mumbai, his MD (Pathology) from Tata
Memorial Hospital, and a Postgraduate Diploma in Medical Law and Ethics from the National
Law School of India, Bangalore. Besides surgical pathology, his interests and publications are in
the fields of history of medicine and medical ethics. He is associated in an editorial capacity with
the Indian Journal of Cancer, the National Medical Journal of India, the Indian Journal of
Medical Ethics, and Current Science.

Sunil K. Pandya is a neurosurgeon at the Jaslok Hospital and Research Centre in Mumbai,
India. His research interests include medical ethics and the history of medicine, with special
reference to Bombay and India. He edited Neurosciences in India: Retrospect and Prospect, an
account of their development in India. He is the Emeritus Editor of Indian Journal of Medical
Ethics.

Amrita Patel chairs the Charutar Arogya Mandal, a Trust that manages a well-equipped and
nationally accredited modern 800-bed rural hospital and medical, physiotherapy, and nursing
colleges which serve the rural people in and around the Kheda district of Gujarat. Her work at
the Mandal reflects her strong commitment to healthcare services for rural people, and women in
particular. Her life and contribution, however, have centred on livestock. She was the Chairman
of the National Dairy Development Board, the organization which steered India’s cooperative
dairy movement and led the country to becoming the largest milk producer in the world. Patel
has been conferred many honorary degrees and awards, including the Padma Bhushan and Dr
Norman Borlaug Award.

Ritu Priya is Professor at the Centre of Social Medicine and Community Health, Jawaharlal
Nehru University, New Delhi, India. A medical graduate with a Ph.D. in Community Health, her
work uses an eco-social approach for health systems research, linking epidemiology, popular
culture and political economy for decentralized planning and policy. She was Advisor (Public
Health Planning) with the National Health Systems Resource Centre, under the National Rural
Health Mission, and has been a member of various ministries’ task forces. She has also been
active with civil society groups on issues of health and democratic processes.

M.R. Rajagopal is Director of the WHO Collaborating Center for Policy and Training on
Access to Pain Relief at Trivandrum Institute of Palliative Sciences (TIPS) and Founder-
Chairman of Pallium India, a trust founded to improve access to palliative care in India. While
working as Professor and Head of Anesthesiology in Calicut Medical College, Rajagopal, with
his colleagues, had founded the Pain and Palliative Care Society in 1993, offering free pain
management and palliative care to poor patients. In 2017, he was named one of the 30 most
influential leaders in hospice and palliative medicine by American Academy of Hospice and
Palliative Medicine (AAHPM).

Rajivlochan is the Director, Internal Quality Assurance Cell, Panjab University, Chandigarh. He
has authored (along with Meeta), a number of research articles in journals like the Economic and
Political Weekly and books, including Farmers Suicide: Facts and Possible Policy Interventions
(2006) and Jal Swaraj: Case Studies in Community Empowerment (2009).

G.D. Ravindran is Professor of Medicine and Clinical Ethics at St. John’s National Academy of
Health Sciences (St. John’s Medical College), Bangalore. He trained in bioethics at University of
Toronto. Apart from ethics, he specializes in the study of infectious disease and HIV/AIDS. He
is one of the founding members of the AIDS Society of India. He helped in drafting the ICMR’s
Ethical Guidelines. He was the organizing secretary of the 5th National Bioethics Conference
held in Bangalore. He is a regular contributor on clinical ethics in various journals and
conferences.

Sumit Ray is Senior Consultant and Vice-Chair of the Department of Critical Care and
Emergency Medicine of a trust-owned, not-for-profit tertiary care hospital in Delhi, India. He has
published many articles and delivered lectures on critical care at multiple national and
international fora and journals. He has been an intermittent commentator on socially relevant
healthcare issues.

Kunal Saha is a doctor and professor working in the USA in the field of HIV/AIDS, but he is
best known as a social activist against healthcare corruption and medical negligence in India.
Saha graduated from NRS Medical College in Kolkata more than three decades ago before going
on to train at UT-MD Anderson Cancer Center in Texas and the College of Physicians &
Surgeons at Columbia University, New York before joining Ohio State University in Columbus,
Ohio. Following a family tragedy, he dedicated his life to the fight against healthcare corruption
in India. He founded People for Better Treatment (PBT), a registered humanitarian organization
that has been working for promotion of better healthcare and medical education system and to
eradicate the wide-spread incidence of medical negligence in India.
Soumendra Sahoo is currently Professor and Head of Ophthalmology at Melaka Manipal
Medical College, Malaysia. He is best known for his research on clinical/experimental
ophthalmology & medical education. He has a Ph.D. in medicine and is a CMCL-FAIMER
Fellow.

Binayak Sen is a doctor who has spent a large part of his working life engaging with
community-based health volunteers in the state of Chhattisgarh. A graduate of the Christian
Medical College, Vellore, he trained in paediatric medicine and spent some time at the Centre for
Social Medicine and Community Health at Jawaharlal Nehru University in New Delhi before
moving into full-time community-based work. An active member of the Medico Friend Circle
(MFC), his research interests have been in malnutrition and its interface with disease in our
society, as well the closely interlinked fields of health and human rights.

Amit Sengupta is Associate Global Co-ordinator of the People’s Health Movement (PHM). In
this role, he has also functioned as the Managing Editor of two recent editions of the Global
Health Watch report. He is member of the International Council of the World Social Forum and
a former All India General Secretary of the All India Peoples Science Network. He has been
involved in implementation of a number of action research programmes and research studies in
the areas of health, intellectual property rights, and rural industrialization. His interests include
issues related to public health, pharmaceuticals policy, and science and technology related policy
issues like intellectual property rights.

Arghya Sengupta is Founder and Research Director of the Vidhi Centre for Legal Policy, New
Delhi. He has a Doctor of Philosophy in Law from the University of Oxford. He has jointly
edited a forthcoming volume of essays on judicial appointments. He has a number of other
academic publications on the Indian Supreme Court, Parliament, fundamental rights, and
federalism, and writes regularly for The Hindu, The Times of India, and Economic and Political
Weekly.

Abhay Shukla is a public health physician, who has been working on health issues in
collaboration with people’s movements and grass-roots NGOs in Maharashtra for over two
decades. He is Senior Programme Coordinator at SATHI, Pune, and is a member of the National
Rural Health Mission Advisory Group for Community Action (AGCA) as well as member of the
core group on health at the National Human Rights Commission (NHRC). He is actively
involved in initiatives on patient’s rights, the social regulation of the private medical sector,
networking among ethical medical professionals, and developing a system for universal
healthcare.

S. Srinivasan (‘Chinu’) is Co-founder Trustee of the Vadodara based LOCOST (Low Cost
Standard Therapeutics), which makes and markets medicines at low prices and is involved in
advocacy of related issues of access to medicine. He is a graduate of IIT Kharagpur and IIM
Bangalore, and studied epidemiology at Johns Hopkins School of Public Health. He has been
involved with the community health movement on issues of affordability, availability, and
accessibility of healthcare for over 35 years. His research interests include the politics and public
health aspects of pharmaceuticals including pricing policy, and pharma regulatory and IP issues.

Sandhya Srinivasan is a Mumbai-based freelance journalist, researcher, and editor with a

bachelor’s degree in philosophy and master’s degrees in sociology and public health. She was
executive editor of the Indian Journal of Medical Ethics for 14 years. She is currently consulting
editor of IJME and a consulting editor with Scroll.in, a digital daily of political and cultural news
from India. She was on the faculty of the Centre for Studies in Ethics and Rights and has served
on the institutional ethics committees of the National Institute for Research in Reproduction and
of the Anusandhan Trust. She is also on the board of trustees of the Centre for Communication
and Development Studies, Pune.

Avinash Supe is Director of Medical Education and Major Hospitals (MCGM) and Dean of Seth
GS Medical College and KEM Hospital, Mumbai, India. He is also Professor of Gastrointestinal
Surgery and Medical Education. He is Director of the GSMC – FAIMER Regional Institute. He
has been a member of various committees of the Ministry of Health and Family Welfare,
Government of India, the Medical Council of India, Maharashtra University of Health Sciences
and the National Board of Examinations. He is a former president of the Indian chapter of the
International Hepato Biliary Pancreatic Association and Academy of Health Professions
Educators.

Shershah Syed was a reluctant student of medicine. Interested in pursuing a career in

journalism, he took admission in a medical school at his father’s insistence. Gradually, he
developed interest in the field and, after leaving Pakistan to avoid military service, he developed
a career in obstetrics and gynaecology in Kenya, Ireland, and the UK, before returning to practise
in Pakistan. His interest in journalism remains and alongside his medical career Syed writes
Urdu short stories that reflect life in Pakistan’s poor communities and contributes regularly to the
Daily Dawn newspaper about safe motherhood, women’s rights, and against nuclear
proliferation.

George Thomas is an orthopaedic surgeon currently working at St. Isabel’s Hospital, Chennai.
He completed his medical education at Kilpauk Medical College and Trivandrum Medical
College. He worked as an orthopaedic surgeon for 25 years for the Indian Railways, before
obtaining early retirement from the Railways in 2008. With a group of friends, he started the
Medical Action Forum in Chennai in 1982 to campaign for ethical healthcare. He has been the
editor of the Indian Journal of Medical Ethics. He is Chairperson of the Institutional Ethics
Committee of Christian Medical College, Vellore.

Farokh Erach Udwadia is a distinguished physician in the field of respiratory and critical care
medicine. He is Emeritus Professor of Medicine at Grant Medical College and JJ Hospital,
Senior Consultant Physician and Physician in charge of the Intensive Care Unit at Breach Candy
Hospital, and Senior Consultant Physician at the Parsee General Hospital in Mumbai. He has
written several major monographs on emergency medicine, respiratory failure, pulmonary
eosinophilia, tetanus and the principles of critical care. The latter work is the first book of its
kind in India and among the very few published in South-East Asia. He received a Padma
Bhushan award in 1987 and the Dhanvantri award in 1996.

M.S. Valiathan is a National Research Professor at the Manipal Academy of Higher Education,
Karnataka. He spent his professional years as a cardiac surgeon, when he also led a team which
developed cardiac devices such as a mechanical heart valve employing frugal innovation. He has
also held a term as Vice-Chancellor of the Manipal Academy of Higher Education and written
three volumes as redactions of the three Ayurvedic classics of Caraka, Susśruta, and Vāgbhaṭa.
He was instrumental in setting up a programme in Āyurvedic Biology with the support of the
Department of Science Technology, which promotes research in modern biology based on cues
from Ayurveda.

Nisha Vinayak is a counselling psychologist who currently leads The Banyan’s Rural Mental
Health Programme, a well-being based model for community mental health based in Tamil
Nadu. Trained in the physical and life sciences, her diverse background gives her the analytical
and problem-solving bent that influences her role as a therapist, researcher, and leader.

Shiv Visvanathan is currently Professor at Jindal Global Law School, Sonipat and Director of
the Centre for the Study of Knowledge Systems at O.P. Jindal Global University, Sonipat, India.
He holds an Adjunct Professorship at Raman Research Institute, Bengaluru and has held
professorships at various universities across the world, including Stanford University, the
University of Maastricht, the University of London, and University of University. His wide and
eclectic research interests ranges from violence and conflict studies, truth and reconciliation,
cognitive justice, futures and alternative imagination, the sociology of corruption and ethics, the
history, sociology, and philosophy of science and technology, social movements, to the culture
and politics of ecology.