Correspondence

ww.sciencedirect.com c u r r e n t m e d i c i n e r e s e a r c h and p r a c t i c e 4 ( 2 0 1 4 ) 1 4 1e1 4 7 Available online at w ScienceDirect journal homepage: www.elsevier .com/locate/cmrp Correspondence Dear Editor-in-Chief, That corruption of varying kinds exists in Indian medical practice and the health care sector is quietly spoken about and silently admitted. At the same time we all know that there is an honest stream, where individuals and institutions do an exemplary job,andadishoneststreamthatbringsdiscredit to theprofession. I amfortunateandblessedthatmymedical friends are all in the honest stream.What you bring to our notice is that the balance has swung too far the other way, and you ask for action.Once again, the great issue of Romanadministration arises, ‘Quis custodiet ipsos custodes’, ‘whowill guard the guardians?’ Myanswer is, the guardians themselves. I put forward just one simple ideawhichmayhelp the issue,which is to be debated both inessenceanddetail. Let therebeaPEERREVIEWandrankingofall sectorsof themedicalfielddonebyDoctors themselves. For a layman like me incompetence and incorrect medication, and unnecessary medical investigations and surgical procedures are the really dangerous aspects of the practice. Incompetence and the gamut of corruption start already at the ‘so-called’ medical schools. Unfortunate students who wish to learn are fed-up with third-rate medical colleges. They graduate as incompetents, and that is theworst possible feeling, and this often leads themon to corruption. Here is a chance to nip the problem in the bud. If they knew that a certain College was rotten, then they would not waste their time or their money, or start off their lives on the wrong foot. So let us inform them in advance. This prior knowledge could be the KEY, and is the basis of the idea.We could here strike at the root of the problem. By doing a peer review create an accepted body of knowledge that would reward the excellent, support the good, dissuade the bad, and punish the terrible. It is enough. In every city, in every town, in every state throughout India, amongst the medical fraternity, the good honest stream generally knows which is less than honest stream. There are atleast 100,000 or more doctors in India in the honest stream. That is a large number ofmen andwomen.My suggestion ise that like there is a Shanghai ranking for the top Universities in the world, done quietly on fixed criteria, and generally accepted worldwide, and like there is a Michelin ranking of the best restaurants in France with stars, let the same be done for all the Medical Schools in India, then for hospitals and nursing homes, then radiology, pathology, and other Diagnostic Laboratories. And finally, for Doctors and their clinics, but this last to be done very very carefully and with much greater circumspection. Start slowly, systematically, silently and perhaps anonymously. It is a total secret forever as to who the Michelin restaurant inspector is. Publish under a general name. Publish for the Metros first, then the State capitals, then the smaller cities, then the smaller towns and so on down to the District level. This practice is already in place for hotels, etc., thenwhy not for themedical profession and field. And done by the good honest Doctors on the spot, who are from that State, and from that District. The good local doctor stream knows most things. The net should bewide and all institutions and facilities should be rated from the very best to the sub-standard. This is different from the Shanghai andMichelin, who rate only the best. It would be difficult to rate individual doctors, but it might also be possible. Publish the ratings in the local language for that State and also in English, in Manuals and on the internet, andmobile phone. Consult a good lawyer so you can't be sued if you give a low rating to someone, or no rating at all. Enrol the press and particularly the TV, not to bring out horror stories, not to do ranking by journalists or surveys, but to informpeople that a top class ranking is available, done by gooddoctors, so that people can learn and knowbetterwhat to do. This is a PEER REVIEW of themost direct kind, and it will be done honestly, and quietly, perhaps anonymously, and could carry enormous force. It should be such that the ‘good doctor stream’ and the ‘good Institution stream’wish to be part of it. It will be necessary to think out extremely carefully what the criteria should be, and how to carry this out. Mainly the criteria of competence and of ethics. With a will andwithmodern computers and a little organisation, and a small sum ofmoney, this is not too difficult to do. And it could have some effect for the good. Thank you for your kindness for asking me to write. Aditya Nehru New Delhi 9th June 2014 http://dx.doi.org/10.1016/j.cmrp.2014.06.008 2352-0817 www.sciencedirect.com/science/journal/23520817 www.elsevier.com/locate/cmrp http://dx.doi.org/10.1016/j.cmrp.2014.06.008 http://dx.doi.org/10.1016/j.cmrp.2014.06.008 http://dx.doi.org/10.1016/j.cmrp.2014.06.008 Dear Dr. Samiran, Thanks for sharing your article, which I much enjoyed reading. The pervasiveness of corruption is unfortunate, but very real in the health sector today. Your piece provides a good overview of the reasons for the same, and what may be done to tackle the problem. I wonder if you may consider responding to Berger's article on bmj.com with some of your recom- mendations, possibly a brief with a link to your editorial, once published. It would help to take the discussion further.We are keen to explore ways in which we may uncover corruption in the health sector, even globally. And it's important to keep these discussions going. We may also explore a feature on the private medical education system in India, and the political clout that may be driving it. It would be good to have your inputs. There is a lot of optimism with Modi coming to power e let's hope it translates to real change on the ground, with corruption sure to be a target. Anita Jain India Editor The BMJ Email: [email protected] Wow! Age has not cooled your fire. Has this article clarified who are your friends and who are your enemies? Unfortunately, your remedies, while necessary, probably have no great strength behind them. Is there a structure or organization in India that focuses onmedical corruption? In the United Stateswe have found that when a cause that is being ignored by government is picked up by a group of private individuals who publicize the issue broadly, government may be forced to take some action. Dr. Bert Pepper, Consulting Psychiatrist Hudson Valley, New York, USA Email: [email protected] Corruption in India's Medical Sector e A Comment Very sadly and unfortunately, I cannot but agree with the young Australian doctor's assessment of the all pervasive corruption eating into the doctorepatient relationships in India. In the health sector, some amount of ‘corruption’ is bound to exist on account of the asymmetry of information with the doctor always having more information over what ails the patient and the patient having no option but to trust the doctors' judgement. In such an inherently unequal relationship, some amount of ‘exploitation’ is to be expected, particularly if the doctor's aspirations depend on the amount of money and material wealth he is able to acquire during his lifetime and to the extent that societal respect depends on such show of wealth and prosperity. But what hurts is the scale and the poor quality of services rendered for the exorbitant fees charged. While corruption is for reasons indicated above, present in all such countries where the ideology of market funda- mentalism pervades and health is a commercially traded good or service, the difference betweenmany countries and India is the extent of fraud and cheating that is there in the system at every step. It is not as if Indians are genetically predis- positioned to corruption; it is just that, unlike in other countries that enforce rules and regulations making corruption high risk, the incentives in India to be corrupt and get away are high, since the state is soft, incapacitated and has shown neither capability nor willingness to govern. It was with some difficulty that in 2010, the bureaucracy was able to get the political executive and the Parliament to legislate a mild form of regulation. The medical associations and lobby groups have sabotaged the effective implementation of even this mild regulation, making it clear that along with government, so are the professionals equally culpable for promoting corruption and fraud. As Edmund Burke said “Nothing turns out to be so oppressive and unjust as a feeble government”. Corruption starts with getting admission into a private medical college on management quota. The recent incident in Andhra Pradesh where the entrance examination for admission to post graduate courses was manipulated by leaking out the question papers is one such example of fraud. India is the only country that, by official policy, permits the private owners of colleges to auction medical seats to the highest bidders. The huge capitation fees for admission into private medical (continued on next page) c u r r e n t m e d i c i n e r e s e a r c h and p r a c t i c e 4 ( 2 0 1 4 ) 1 4 1e1 4 7142 http://bmj.com mailto:[email protected] mailto:[email protected] http://dx.doi.org/10.1016/j.cmrp.2014.06.008 http://dx.doi.org/10.1016/j.cmrp.2014.06.008 colleges are paid by the affluent who either have their parents owning nursing homes and hospitals, or those wanting the degree for future business interests as a medical entrepreneur, or for social prestige. Unlike Japan where only doctors can invest in medical colleges, there is no such bar in India. And thus we have businessmen, liquor magnates, contractors and politicians directly or in partnership owning medical colleges. For such persons what matters is return on investment. Medical and nursing education is considered lucrative as earnings not only through the high capitation fees but also a weak regulatory system that does not enforce adherence to any standards or quality. For according permission to establish such colleges, politicians no longer take a bribe only but instead, have a few seats in the colleges earmarked for the candidates recommended by them. There are also colleges that reportedly take a huge fee upfront in return for a guaranteed degree. It is for this reason that all private colleges got together in opposing the government's move to have an entry examination for admission into colleges and government's inability to institute an exit examination for getting the licence to practice. The cycle is completed with the poorly trained ‘licensed’ doctors following the ‘kick back’ culture of medical practice. Incapable of diagnosing the ailment, they order a battery of tests that are interpreted by the laboratory for the doctor who then prescribe medicines based on the recommendation of the pharma company agents. In referring for tests to the lab- oratory as well as choice of drugs prescribed, the doctor gets commissions. Corruption is common in public and private e the scale differs as per the incentives. While in the public sector, cor- ruption in hospital is for admissions, early treatment, or purchase of drugs/consumables from the shops as suggested by the doctor, while in government departments, corruption is in procurement, transfers and appointments of doctors. In the private sector, mainly corporate hospitals, doctors continuance in employment depends on the amount of “business” he generates for the hospitals by way of expensive tests prescribed or surgeries performed. Thus on account of perverse incentives, the absence of oversight or regulation and the near collapse of values and pride left in the profession which is party to this situation, corruption thrives handsomely. The way out is for the state to govern. Considering the elections of 2014 have been fought on the plank of providing good governance, it is hoped that the medical profession will be regulated. For ensuring swift redressal of grievances and pun- ishment of corrupt doctors, government should consider instituting an independent health regulator rather than depend on the existing wheels of justice to turn. Besides, the Parliament needs to function and pass the desperately needed laws to make the private sector more accountable by making their pricing schedules open to public scrutiny and restructuring the Medical and Nursing Councils. These bodies urgently need a revamping by starting with making their membership more open to lay people and themode of selection through open and transparent processes of nomination than an election that is prone to manipulation by vested lobbies. But then in a field like medicine that is governed by trust, laws and regulations and punishments are limited in their impact and cannot achievemuch.What is urgently needed is soul searching by professionals whomust agree to self govern and ostracise those indulging in crass corruption, by hospital managements refusing to appoint any doctor from mis- managed colleges, media bringing out cases of corruption to shame the colleges/doctors/hospitals and the tax authorities tightening their vigil and scrutiny in flushing out black money. Only social awareness, social pressure and professional ostracism will discipline this profession and reduce this unsustainable level of corruption and greed that seems to have gripped this ‘noble’ profession. Ms. Sujatha Rao Former Secretary of the Ministry of Health & Family Welfare of India Email: [email protected] Dear Dr Nundy, The important point in David Berger's recent BMJ article is not simply that there aremany corrupting agencies within the ecosystem that the doctor occupies but that the doctor is easily liable to be corrupted. The question we should be asking therefore is how we prepare a better quality of doctor who is better equipped to tackle a corrupt ecosystem. One clear requirement is a much larger number of Government medical colleges. There is a general sense that Gov- ernment colleges produce better doctors if only because they see more patients. This is because patients in a Government college/hospital do not pay for the services they receive while they would have to pay if they were going to a private college/ hospital. State Governments might be able to provide land but not necessarily the financial resources. The Central Gov- ernment has to invest on land provided by the States. A good first step has been taken in the establishment of the additional 6 AIIMS. A second requirement is a completely new legislation which redefines the nature of medical education and establishes norms of conduct. The IndianMedical Council Act, 1956 and the IndianNursing Act, 1947 both need to be set aside. Such new legislation could separate the three functions (standard setting, accreditation and practice of the profession) which the present Councils do.Whichever residuary body dealswith standard setting needs to re-write curricula.Whichever residuary body deals with the practice of the profession should pattern itself on the UK GMC. This new legislation could also cover the allied health professionals, currently completely unregulated. It could also firmly establish the notion of a public health (continued) (continued on next page) c u r r e n t m e d i c i n e r e s e a r c h and p r a c t i c e 4 ( 2 0 1 4 ) 1 4 1e1 4 7 143 mailto:[email protected] http://dx.doi.org/10.1016/j.cmrp.2014.06.008 http://dx.doi.org/10.1016/j.cmrp.2014.06.008 cadre at the level of the State Governments and possibly also at the Centre. It should also reinforce the notion of medial ethics. A starting point could be the National Commission on Human Resources in Health Bill, 2012, which was rejected by the Parliamentary Standing Committee, and which can be rewritten. Yours sincerely, Keshav Desiraju Secretary, Department of Consumer Affairs, Government of India Dear Samiran, All of us arewell aware of the corruption and I am sure articles like yours are needed. However, I ampessimistic about the solutions you suggest. A silent minority can become a vocal minority, but we cannot get anyone to do anything about it. My own complaint to theMedical Council of India1with evidence of cutbacks resulted in no actionwhatsoever. TheMCI decided that since this happened in Chennai the Tamil Nadu Council should deal with it, but the TN Council just ignoredmy letters. The same happenedwhen I raised the issue of corruption in permitting transplants fromunrelated donors. I even tried to get a lawyer (well known for PILs) to take up the case, but he was not prepared as he felt there was no chance of getting action taken against a Government Committee. I believe things will settle down only when the public feel they should insist on honesty. Today, they are happy with the state of affairs, and just learn how to work the system, but at some time themajority will join in the fight against corruption in all fields. Not in our lifetime. References: 1. MANI MK: Our watchdog sleeps, and will not be awakened. Issues in Medical Ethics 4: 105e107, 1996 Dr MK Mani Email: [email protected] (continued) c u r r e n t m e d i c i n e r e s e a r c h and p r a c t i c e 4 ( 2 0 1 4 ) 1 4 1e1 4 7144 WE NEED TO DIG DEEPER TO ROOT OUT CORRUPTION Corruption is a significant problem in the health field and it is certainly amajor issue in India. Corruption destroys trust in the doctorepatient relationship and in the long term the poor andmost vulnerable persons bear the brunt of this.1,2 The fact that a large amount of public and private funds go into the maintenance of health, and that those approaching the health system are usually extremely vulnerable and seldom aware of, or in a position to demand, their rights, makes the health system particularly vulnerable to corruption.3 However recognizing that there would be multiple drivers of corruption in different situations, and the fact that, “different interventions will have quite different outcomes in both the short and long term”, a paper describing the protocol of an ongoing Cochrane review of, “Interventions to reduce corruption in the health sector”, points out that, “Awide range of strategies to reduce corruption has been described in the literature, but these have uncertain impacts, may have adverse effects, and may require substantial investments of resources. Although these in- terventions have been reviewed previously,4 there are no systematic reviews of the effects of alternative strategies or of case studies of efforts to reduce corruption”.5 However my contention is that if we want to root out corruption, we have to have a much deeper approach than what is suggested somewhat patronizingly by Berger6 and a broader one than what Nundy suggests in his editorial response.7 A lot depends on how you perceive corruption. One can see it as an 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 ap- proaches 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 reinforcement and regulation. Such approaches suggest the need to take a more nuanced view. The suggestions that one comes up with then have to be multi-level, iterative and evolve from experience in each situation. I would like to draw attention to two issues that represent these systemic contexts. One is the increasing commodifi- cation of more and more facets of our life, and the other is all pervasive inequity in society. Withmore andmore commodification of services like health and education, and increasing acceptability that they can be legitimate routes for extracting profit and accumulating capital, these services are increasingly being marketised, that is, bought and sold by the highest bidder. In such a system, where extracting more and more profit out of every episode of suffering becomes the bottom-line (whether directly or indirectly). Every opportunity is grabbed for using ones position in the system (and your debt financed education and life style) to extract thatmuchmore benefit (again a legitimate enterprise in the market). Such systems dehumanizes both the provider as well as the consumer (in the eyes of the provider). The (continued on next page) mailto:[email protected] http://dx.doi.org/10.1016/j.cmrp.2014.06.008 http://dx.doi.org/10.1016/j.cmrp.2014.06.008 Pharmaco-industrial complex in its turn has succeeded in inducing ever increasing usage of diagnostics and therapeutics.8 Thus turning us into paranoid and fickle consumers only temporarily assuaged by computer printouts we don't understand. In a system where inequities are accepted as collateral damage, and where one does not have the confidence or the security that just effort will be rewarded justly, one is groping for every opportunity to build up reserves of security to fall back on those random crises and disasters. Those who have reached the level of gatekeepers find their “success” and “security” defined by the ability to feed the system, and thosewho do not have the resources to reach there use every chance they have to desperately survive. In corruption studies there is also the term “survival corruption” where the corruption of desperately poor service providers like teachers and nurses, who in many cases have not got their salary in months, or whose salaries can't realisticallymake endsmeet, charge extra fees.9 Thus in away systems require corruption to keep them going, and to keep the inequities alive. The reason for alluding to these issues (amongmany possible ones) ismerely to draw attention to the fact that corruption cannot be tackled simplistically. Individual interventions like international pressure, stricter rules, electronic records, and manymore that are listed in the literature are certainly important steps in the process, andwill definitely help. My personal opinion is that unless these various interventions are allied with efforts of communities to reclaim their lives from further commodification andmarketisation, and efforts towardsmore democratization of the institutions that govern us and thus a redistribution of power, they are unlikely to have an impact. Given the complex nature of the problem, we need to actively look at local models/local experiences, learn from them, link with them and expand them. Simultaneously we need to democratize systems atmultiple levels, and loosen the grips of various professions and experts on our daily lives. Till we are ready for that as a profession, we cannot hope for deliverance fromwithin… it will be communities and patientswhowill get together, organize and mobilize, and form allies within the system to root out the evil of corruption. Rakhal Gaitonde Department of Public Health and Clinical Medicine, Umea University, Umea, Sweden Department of Humanities and Sciences, Indian Institute of Technology-Madras (IIT-M), Chennai, India r e f e r e n c e s 1. Falkingham J. Poverty, out-of-pocket payments and access to health care: evidence from Tajikistan. Soc Sci Med. 2004;58:247 e258. 2. Szende A, Culyer A. The inequity of informal payments for health care: the case of Hungary. Health Policy. 2006;75:262e271. 3. Savedoff W. The Causes of Corruption in the Health Sector: A Focus on Health Care Systems. Glob. Corrupt. Rep. 2006 Spec. Focus Corrupt. Heal. Transparen. London: Pluto Press; 2006. 4. Vian T. Review of corruption in the health sector: theory, methods and interventions. Health Policy Plan. 2008;23:83e94. 5. Gaitonde R, Bjorndal A, Oxman A, Okebukola P, Ongolo-Zogo P. Interventions to reduce corruption in the health sector. Cochrane Database Syst Rev. 2010;11. 6. Berger D. Corruption ruins the doctor-patient relationships in India. BMJ. 2014;348:g3169. 7. Sahm S. On markets and morals e (re-) establishing independent decision making in healthcare: a reply to Joao Calinas-Correia. Med Health Care Philos. 2013;16:311e315. 8. Nundy S. Corruption in Indian Medicine. Curr Med Res Prac. 2014;4. 9. U4 Anti-Corruption Resource Centre. Corruption in the Health Sector. U4. 2006;1:1e52. (continued) c u r r e n t m e d i c i n e r e s e a r c h and p r a c t i c e 4 ( 2 0 1 4 ) 1 4 1e1 4 7 145 Here is some info on the cut practice case before the Maharashtra Medical Council 1. Dr. Bawaskars case; Summary prepared by Dr. SV Nadkarni who is helping him has been covered in the local press. Dr. Bawaskar practises at Mahad, dist.raigad. He is a physician-MD and has a hospital. He spends lot of his money on research and has done research on scorpion and snake bites as also on water pollution causing fluorosis. He sent one patient Sunita Veer for CT Scan-did notmention any specific center. They got CT done in Pune at NMMedical center in Feb, 2013. In March the center asked for his address and sent a cheque of Rs. 1200 (CT charges are Rs. 4000). He was surprised and askedwhy the cheque to him and promptly received e-mail detailing the patient and the CT scan andwas told that these are “professional charges”. He strongly objected, wrote a letter and returned the cheque. Now the company changed the stance and said that it was a refund to the patient/a 302 concession as she had grumbled about the charges. The Center sent a cheque in the name of Sunita Veer and told Dr. Bawaskar to give it to her.But he officially complained to MMC that this is “Cut-practice” and MMC should take action. I was one of those who supported his battle, I was one of those who supported his battle. The company responded by a detailed explanation butmaintained thatMMChadNO JURISDICTION, asMMCcan take action only against the practitioners who are registered under it and NMM Center is a business company registered under “Company Act”. I found that Dr. (continued on next page) http://refhub.elsevier.com/S2352-0817(14)00070-1/sref1 http://refhub.elsevier.com/S2352-0817(14)00070-1/sref1 http://refhub.elsevier.com/S2352-0817(14)00070-1/sref2 http://refhub.elsevier.com/S2352-0817(14)00070-1/sref2 http://refhub.elsevier.com/S2352-0817(14)00070-1/sref3 http://refhub.elsevier.com/S2352-0817(14)00070-1/sref3 http://refhub.elsevier.com/S2352-0817(14)00070-1/sref4 http://refhub.elsevier.com/S2352-0817(14)00070-1/sref4 http://refhub.elsevier.com/S2352-0817(14)00070-1/sref5 http://refhub.elsevier.com/S2352-0817(14)00070-1/sref5 http://refhub.elsevier.com/S2352-0817(14)00070-1/sref6 http://refhub.elsevier.com/S2352-0817(14)00070-1/sref7 http://refhub.elsevier.com/S2352-0817(14)00070-1/sref7 http://refhub.elsevier.com/S2352-0817(14)00070-1/sref7 http://refhub.elsevier.com/S2352-0817(14)00070-1/sref7 http://refhub.elsevier.com/S2352-0817(14)00070-1/sref8 http://refhub.elsevier.com/S2352-0817(14)00070-1/sref9 http://refhub.elsevier.com/S2352-0817(14)00070-1/sref9 http://dx.doi.org/10.1016/j.cmrp.2014.06.008 http://dx.doi.org/10.1016/j.cmrp.2014.06.008 Bawaskar was unable to argue about this and so, I consulted Mrs. Nilima Sanglikar, got some valid points from her and drafted two detailed replies-one about the case that it is indeed a “cut-practice” and two that MMC has jurisdiction and can look into the case and take action. Dr. Bawaskar likedmy drafts and acceptedme to represent his casewhich I did whenever MMCmet.MMChas accepted our argument and dismissed the objectionse about jurisdiction and posted the case yesterday 4th Feb, NM Medical Center has filed a writ in High court e yesterday only e and got the hearing postponed for “atleast 2 weeks” pending the High-court order. However, the company has filed the case only against MMC and excluded us. So, Nilima Sanglikar will lodge a “court Summons” to plead that we will be allowed to join as respondents, as it is our case MMC is looking into. THIS ISWHERE THEMATTER STANDS TO-DAY. The hearing in the court is on 18th Feb. exactly after 14 days. To my knowledge the case is still in limbo. 2. The case against KD Ambani Hospital. Attaching 2 press cutting links but don't have further details. http://epaperbeta.timesofindia.com/Article.aspx?eid¼31804&articlexml¼Medical-council-to-fight-commissions- 14052014005071 http://epaperbeta.timesofindia.com/Article.aspx?eid¼31804&articlexml¼Med-Council-shoots-off-notice-to-hospital-over- 13052014005040 Sanjay Nagral Dept of Surgical Gastroenterology, Jaslok Hospital & Research Centre, Mumbai 400026 Tel 91 22 66573333, 91 22 66573338 (off) Head, Dept of Surgery, KB Bhabha Mun Gen Hospital Email: [email protected] Very good to hear from you and thank you for sending over the thoughtful and thought provoking editorial prompted by the Personal View that we published recently. While corruption in healthcare is, as you suggest, everywhere, I suspect the endemic problems in Indiamake it very high upon any ranking list of corrupt systems that might be drawn up. I don't doubt that having so many private medical schools in which its possible to “buy” a place and where inspection standards are not necessarily maintained is a core problem. This must surely not only effect standards but colour young students and doctors views aboutwhat is andwhat is not acceptable from the outset. I thought the Berger's Viewmade some good suggestions on how to tackle this which you have not included among the solutions you have put forward and it might be good to mention them. My view on the overall presentation of your piece is that I would devote a bit more space to discussing “the way forward” andmaybe invite readerse do you have rapid responses? I see you have a letter section, to write in suggesting what they see as priorities for action. It would also be good to provide some concrete examples, if you can of the scale of the kickbacks and facilitation charges, incentives to doctors to refer patients onto secondary and tertiary care centres etc. Howdo such sums comparewith average salaries? And is there not a literature on this to refer to drawing on information in Indianmedical journals and the press? Or is the topic largely kept under wraps? You might also mention that there is a conference coming upon “Integrity in health care practises and research 11e13 Dec 2014 at St Johns Medical College, Koramangala, Bengaluru”. Its the 5th National Bioethics Conference. Were you aware of this? Might it be good to discuss the issue with the people convening this? The organising secretaries are Ravindran G D and Thelma Naryan (I am sure you know her and Ravi?) and they have put out a call for abstracts at [email protected]. Maybe you should be speaking at the conference? Another thought is howmuch of this corruption is exposed and discussed in the Indiamedia? Is there a possibility of the Indian equivalent of Panoramamounting an investigation into privatemedical schools and airing the problems? Or has this been done? Clearly patient and public awareness of endemic corruption needs to grow for this might spur political action for transparency, not least around charges for tests, and incentives provided to doctors for carrying them out, and spur change. I think the point about patients, especially poor and disadvantage ones bearing the brunt of this is such an important one. In my new role as patient partnership editor its certainly a topic that I personally would like to further debate on in the BMJ. Are you aware of the US Choosing Wisely initiative? (and other countries efforts to replicate it) where patients and doctors are coming together to agree a rational approach to tests and treatment? Might an initiative like that be good in India? We recently had an in house discussion ofwhether the BMJ should adopt corruption in healthcare as a campaign after the publication of the Berger article but I think the idea was put on hold. I will share your editorial with our Indian editor Anita Jain and Richard Hurley who handled the Berger article, and suggest that the editorial team revisits this decision. Maybe one thing we could agree to do is a series of articles or a formal investigation of some sort. (continued) (continued on next page) c u r r e n t m e d i c i n e r e s e a r c h and p r a c t i c e 4 ( 2 0 1 4 ) 1 4 1e1 4 7146 http://epaperbeta.timesofindia.com/Article.aspx?eid=31804%26articlexml=Medical-council-to-fight-commissions-14052014005071 http://epaperbeta.timesofindia.com/Article.aspx?eid=31804%26articlexml=Medical-council-to-fight-commissions-14052014005071 http://epaperbeta.timesofindia.com/Article.aspx?eid=31804%26articlexml=Medical-council-to-fight-commissions-14052014005071 http://epaperbeta.timesofindia.com/Article.aspx?eid=31804%26articlexml=Medical-council-to-fight-commissions-14052014005071 http://epaperbeta.timesofindia.com/Article.aspx?eid=31804%26articlexml=Medical-council-to-fight-commissions-14052014005071 http://epaperbeta.timesofindia.com/Article.aspx?eid=31804%26articlexml=Med-Council-shoots-off-notice-to-hospital-over-13052014005040 http://epaperbeta.timesofindia.com/Article.aspx?eid=31804%26articlexml=Med-Council-shoots-off-notice-to-hospital-over-13052014005040 http://epaperbeta.timesofindia.com/Article.aspx?eid=31804%26articlexml=Med-Council-shoots-off-notice-to-hospital-over-13052014005040 http://epaperbeta.timesofindia.com/Article.aspx?eid=31804%26articlexml=Med-Council-shoots-off-notice-to-hospital-over-13052014005040 http://epaperbeta.timesofindia.com/Article.aspx?eid=31804%26articlexml=Med-Council-shoots-off-notice-to-hospital-over-13052014005040 mailto:[email protected] mailto:[email protected] http://dx.doi.org/10.1016/j.cmrp.2014.06.008 http://dx.doi.org/10.1016/j.cmrp.2014.06.008 Plenty of food for thought here Samiran. I'll keep you posted of thoughts/ideas from this end and would be happy to discuss things further. Tessa Richards Assistant Editor BMJ Editorial BMA House Tavistock Square London WC1H 9JR Email: [email protected] Dear Dr Nundy, You perhaps have space constraints, but could add something the following areas. 1. The bystander role of medical councils & medical associations in India 2. The impact of a large private sector with intense market competition & saturation on creating a fertile ground for corrupt practices Sanjay Dept of Surgical Gastroenterology Jaslok Hospital & Research Centre, Mumbai 400026 Have you seen this Economist article about the scale of fraud in healthcare. In the US? http://www.economist.com/node/21603026?fsrc¼nlw%7Chig%7C30-05-2014%7C5356c353899249e1ccb063a0%7C It is indeed a universal problem. Might oneway forward for India, given the concerns around privatemedical schools, would be to putmore investment In health including more public medical schools with high transparent standards? Tessa Richards BMJ Email: [email protected] Dear Tessa, Yes, this is certainly an idea much talked about. But the problem is that higher education has become a viable means for the private sector extracting profit… this is a trend all over the world…the protests in UK a couple of years ago was part of that…unfortunately in today's policy making “good ideas” have to battle influential “regimes” and given the present disposition where the state and the corporate interests are almost fused… this is highly unlikely though absolutely urgent… Rakhal (continued) c u r r e n t m e d i c i n e r e s e a r c h and p r a c t i c e 4 ( 2 0 1 4 ) 1 4 1e1 4 7 147 mailto:[email protected] http://www.economist.com/node/21603026?fsrc=nlw%7Chig%7C30-05-2014%7C5356c353899249e1ccb063a0%7C http://www.economist.com/node/21603026?fsrc=nlw%7Chig%7C30-05-2014%7C5356c353899249e1ccb063a0%7C mailto:[email protected] http://dx.doi.org/10.1016/j.cmrp.2014.06.008 http://dx.doi.org/10.1016/j.cmrp.2014.06.008 Outline placeholder References