1.        The health sector has been identified in many countries as being relatively more prone to corruption. In developing countries, this is often attributed to the fact that health services are in great demand, while the resources to provide adequate services are often inadequate, leading to a premium on their availability.

2.        Extent of Corruption in the Health Sector:

According to the India Corruption Study 2007 undertaken by Transparency International and the Centre for Media Studies, Health stands at the seventh position in terms of most corrupt services, out of 11 studied. (Above health comes, Police, Land Records/Registration, Housing, Water Supply Service NREGS. Forest and Electricity. Health ranks worse than PDS, Banking and School Education). The corruption in the sector is mostly to do with non-availability of medicines, getting admission into hospitals, consultation with doctors and availing of diagnostic services. In particular, the survey revealed the following particulars (Box 1):

3.        Types of Corruption in the Health Sector:

3.1.     As with most other sectors, corruption in the health sector can be classified into two categories, petty corruption and grand corruption. In addition, there could be another category, namely, the widespread prevalence of unethical and corrupt practices. Each is described below.

3.2.     Petty corruption refers to relatively small amounts paid in order to get services that are either free, or subsidised. While these amounts might be individually small, they amount to a big burden because they are usually demanded of poor people.

The typical petty corruption experiences of people are as follows:

• Bribes to gain access (to wards, to enter restricted areas such as labour wards)

• Bribes to jump queues, (out-patient department, laboratory sampling)

• Bribes to get free services (for X-**********, medicines, diet supplements)

• Bribes to get admission, discharge and release bodies from the mortuary.

• Bribes to obtain certificates on medical condition, such as fitness certificates, disability certificates etc., which are required for various purposes such as foreign travel, professional recruitments etc.

Such bribes are usually picked up by the staff in medical institutions and doctors might not be directly involved (except in the case of the issue of medical certificates). However, the passing on of cuts to doctors might not be ruled out.

3.3.     Grand Corruption relates to large volume corruption, often involving a team of officials, doctors, private sector agents and politicians. Instances of grand corruption in the health sector are:

• Procurement corruption (to win tenders for supply of pharmaceuticals, medical equipment and hospital supplies, civil construction or repair contracts). This can result in over-invoicing, supply of substandard equipment, supplies etc., sometimes having shorter life span or shelf life in case of medicines, over-supply of some items in excess of requirements. This might also result in excessive preference shown for one of the other brand of a drug, when cheaper generic (and equally effective) products are available.

• Corruption for postings and transfers of doctors and other staff to ‘lucrative’ positions, (where they have access to better private practice, more openings for diversion of medicines, cultivation of influence).

• Corruption in certification of facilities and the provision of mandatory recognition of departments and medical colleges, following inspection.

• Corruption in admissions, examination marking and passing students in medical colleges, particularly in respect of specialty and super-specialty post-graduation courses.

3.4.     An even more serious phenomenon is when grand corruption snowballs into increased petty corruption, because of artificial shortages, or more expensive medicines and other supplies, leading to a more bribes being paid for these at the customer interface level. Grand Corruption can also be integrated with petty corruption. Typically, this happens when profits from bribes taken at lower levels is shared up the ladder, through ‘pre-paid’ arrangements – a lump sum payment to secure a lucrative posting and regular monthly payments, collected from below, channelized upwards with a cut for everybody involved.

3.5.     Unethical and Corrupt practices:

Apart from the usually adopted classification of corruption into petty and grand corruption, there is another category of corruption prevalent, which is in the nature of corrupt practices arising from the breach of the very same internal code of ethics that give doctors their credibility and status. Some of the practices that are typically seen are as follows:

• Accepting percentages or gifts from other doctors, hospitals, laboratories, imaging centres, pharmacies, pharmaceutical companies and medical equipment companies for referring patients to them or using their products.

• Suggesting unnecessary laboratory tests.

• Undertaking unnecessary treatments, such as Caesarians, when normal deliveries are possible.

3.6.     Unethical and monopolistic practices in the Pharmaceutical business:

The pharmaceutical profession generates a large portion of the grand corruption seen in the health sector, largely because of extortionate and disproportional pricing of medicines beyond the raw material and production cost, in the name of covering R&D costs and IP protection and bribes in cash and kind paid to doctors for prescribing medicines.

4.        Causes of Corruption:

4.1.     The main causes of corruption in the health sector arise from the following:  

4.2.     Lack of Information to users:
In many health institutions, there is lack of information on what services are provided, where and when they are provided, who provides them and the procedures to be followed. This creates an environment for soliciting and paying bribes and also tempts many lower and middle level staff to turn into middlemen.

4.3.     Excessive Red Tape and Long Queues:

Some processes and procedures, even if they are necessary, can result in long queues if there are shortages and inefficiency. This again leads to speed money bribes for jumping queues.  

4.4.     Shortages:

Shortages of medicines and other medical supplies results in long waiting lists, including for elective services like surgical operations. Bribes are collected for jumping the queue. Sometimes, shortages can force hospitals to only perform emergency operations, leading to a higher premia for queue jumping. 

4.5.     Poor Salaries:
Comparative poor salaries might lead to health workers (including doctors) to take bribes. One way to overcome this is to allow doctors to engage in private medical practice after their official hours of service, so that they can increase their income even when retained in Government Service. However, this move has had some negative consequences, as follows:

• Doctors spending official hours in their private clinics, whilst absenting themselves from government hospitals, leaving patients there unattended.

• Doctors using government facilities and medical supplies to treat their private patients on priority basis,

• Doctors using public facilities as a conduit to channel clients to their private facilities.

• Doctors prescribing medicines that they know are not available in Government facilities and advising patients to procure them from their private facilities.

• Theft and pilferage of medicines, equipment and consumables from public health facilities.

4.6.     Poor Management and Supervision:
Poor management and inadequate supervision of health workers leaves them unchecked to do whatever they want to do. This leads to a breakdown of the management structure within a health institution. For example, the head of the institution may have less influence to take action against a junior staffer, who becomes more influential due to closeness to a powerful politician or bureaucrat (doctors who treat VIP patients are often treated leniently by their politically powerful patients). These become poor examples of good management for junior staff and more doctors attempting to build their influence through cultivating rich, famous and politically influential patients. 

4.7.     Treatments and procedures that disregard the Law:

Some kinds of corruption arise out of disregard of the law and/or its intentional breach. In many such cases, there is also collusion from the public and therefore, rarely do such instances come to light. Examples are as follows:

• Pre natal sex determination tests,

• Submission of false post mortem reports, or doctors looking the other way, when the police falsify dying declarations in the case of victims of dowry related offences,

• Trading in organs for transplantation,

• Undertaking tests of medicines on patients, without authorisation or their consent.

• Lack of price control mechanisms over anything but a narrow list of  essential drugs