Graft in health care impoverishes millions in India

NEW DELHI: Digamber Rawat rarely emerges from the tiny windowless room he shares with his parents because a mysterious illness has wasted away the strength in his legs. His family can’t afford private health care, but they must pay for it anyway, even when they go to free government hospitals for help.
Rawat said that at a government hospital in central Delhi, a doctor ordered X-rays and scans that could have been performed in-house. “But when we would go to the hospital lab for the tests, they would give us the name of a private clinic and say, ‘Go get it done there and then we will look at it,’” he said.
Tests at the hospital lab would have been 1,500 rupees ($25). At a private clinic, they cost more than $130. Rawat’s parents make a combined 15,000 rupees ($245) per month, barely enough to feed the family and buy medicine for their 21-year-old son.
“They knew we were poor, but they just didn’t care,” said Rawat’s mother, Bhavna Devi, wiping tears with her threadbare sari.
Rawat’s story is played out across India, where hundreds of millions of poor people without any kind of health insurance are forced to seek medical treatment at private clinics because of poor services and corruption at government hospitals. Those clinics are widely accused of ordering unnecessary tests to run up costs.
Government officials, health experts and many physicians agree that India’s $74 billion health care industry is preying on poor people, thanks to a cozy nexus among unethical doctors, hospitals and diagnostic laboratories.
Health care costs push some 39 million people into poverty every year in India, according to a 2011 study in the Lancet medical journal.
India has a network of free government hospitals and around 37,000 primary health care centers across the country, but they are crowded, badly equipped and inadequately staffed. Yet patients who turn to expensive private clinics may be subjected to unnecessary medical tests, scans or even surgery, with the referring doctor getting a commission for the work.
Dr. David Berger, an Australian who worked as a volunteer physician in a small hospital in India, created an uproar when he described the practice of referrals and kickbacks in an article published in the British Medical Journal in May. He wrote that when doctors accept kickbacks, it “poisons their integrity and destroys any chance of a trusting relationship with their patients.”
Dr. Bobby John, a physician with the organization Global Health Advocates, said Berger’s article was not really news to the medical community: “It’s just that everyone had turned a blind eye to what was going on.”
Doctors in private hospitals are “incentivized to generate business for their employers by over-investigation and overtreatment of patients who are at their mercy both medically and financially,” said Dr. Samiran Nundy, a well-known gastroenterologist in New Delhi.
The practice is so common that in July, doctors at India’s best-known teaching hospital, the All India Institute of Medical Sciences in New Delhi, formed a group to counter it: the Society for Less Investigative Medicine.
Dr. Balram Bhargava, a cardiologist, said the group plans to establish guidelines on diagnostic tests and increase awareness about excessive and unnecessary tests, which he said “shatter the trust that should exist between the doctor and his patients.”
Doctors say the seeds of corruption in the profession are sown early. Since seats in prestigious government-run medical schools are limited, students opt for private medical schools where they get admission by paying a mandatory donation of up to 30 million rupees ($500,000) for a postgraduate medical degree.
Once they start working, “there is pressure on doctors from the management of private hospitals to recover as much money as possible, and therefore they are not only encouraged, but even pressurized, to do more procedures for which they can charge,” said Dr. K. Srinath Reddy, president of the Public Health Foundation of India, a non-governmental organization.
Dr. Harsh Vardhan, an ear, nose and throat surgeon, who became India’s health minister in May, has vowed to make cleaning up the health service his priority.
“I am more aware than anybody else of the corruption that is eating into the entrails of every aspect of governance, including the health system,” Vardhan told reporters recently. “We have to root it out.”
Vardhan has been unusually blunt in criticizing health care regulatory bodies that are widely viewed as corrupt. He referred to the drug standards body that oversees clinical trials as a “snake pit of vested interests,” and the council that oversees medical education as a “corrupt body.”
Late last month, Vardhan announced in Parliament that he was placing all government-run hospitals under review, but gave few details. Nor has he outlined what he plans to do to curb corruption in private hospitals.
According to the World Bank, India currently spends less than 1.3 percent of its gross domestic product on health, among the lowest in the world. The existing health care system faces an acute shortage of doctors and specialists. The situation is compounded by ill-equipped and decrepit hospitals and health clinics and inadequate supplies of lifesaving drugs.
India’s economic boom has seen the proliferation of hundreds of shiny new private hospitals, mostly in urban areas, but less than 20 percent of Indians can afford to use them.
According to government figures, around 40 percent of doctors at government-run health clinics are absent on any given day. With the low pay and abysmal facilities, they make up by moonlighting at private hospitals for higher salaries.
Any faith that Rawat and his family once had in the state-run health system was shattered long ago. Rawat has suffered from his leg ailment for 14 years, but doctors have been unable to diagnose it.
He walks with a pronounced limp and cannot stand for any length of time; he can’t even sit on a chair, because he cannot bend his knees. He dropped out of school years ago and has been unable to work.
His mother, a maid, once had a tiny plot of land in New Delhi, but she had to sell it to pay Rawat’s medical bills.
“When I see the long hours my mother works, I feel helpless,” he said. “But what can I do? I have no hope of a cure. We have nowhere to go.”