Curbing Corruption in India’s Healthcare System

The Indian healthcare system is rife with corruption, and much of this corruption arises from the way that healthcare is regulated (or not). Because healthcare in India is inexpensive, at least by Western standards, private health insurance is relatively rare, and a sizeable majority of total health expenditures are made out-of-pocket. With little regulation, and without much meaningful price negotiation by either the government or private insurance companies, India’s healthcare system has become a vast “network of unregulated private sector hospitals.” This lack of regulation, coupled with intense competition, encourages doctors (who are often under substantial financial pressure) “to enter a happy axis of corruption where they routinely prescribe expensive investigations and perform operations which a patient might not need” in order to increase their profit margins. Doctors have also been known to take bribes from other healthcare entities in return for patient referrals, or to accept kickbacks from pharmaceutical companies disguised as “professional fees” in order to outcompete other private hospitals. As a recent WHO-Eurohealth publication concluded, health sector corruption in India includes not only “collusion, bribes and kickbacks in procurement which may result in overpayment for goods and contracted services” and doctors’ willingness to accept “payments in exchange for special privileges or treatment,” but also “distort[ions in] medical professionals’ prescribing practices.” 

Prime Minister Narendra Modi’s government has sought to address some of these concerns through a healthcare initiative known as PMJAY. The main objective of this program is to increase access to healthcare for the poorest 50% of the population—approximately 700 million people—who are given biometric government “smart cards” to purchase eligible inpatient healthcare services at both private and public hospitals. But while PMJAY is principally designed as a system for subsidizing healthcare for low-income people, it also serves as an anticorruption tool by bringing under government oversight millions of previously unregulated out-of-pocket healthcare transactions, requiring enrolled physicians to acquire digital pre-authorization before administering nonemergency services to PMJAY beneficiaries, and giving the government more power to negotiate with private hospitals participating in the program over healthcare rates. PMJAY’s computerized billing platform also serves a surprising secondary role as an AI-powered “comprehensive fraud analytics solution” for millions of transactions that were previously beyond the government’s reach. The program has already detected over 18,000 fraudulent insurance transactions, leading to penalties against hundreds of healthcare entities so far. The government has even made a list of “corrupt” hospitals available on the PMJAY website. Given PMJAY’s early successes, the government should expand the program. Not only would this increase healthcare access in general—a worthy aim in its own right—but it would further reduce corruption in the healthcare system. This is more easily said than done, however, in light of several practical obstacles to further expansions.

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Guest Post: Measures To Counter Corruption in the Coronavirus Pandemic Response

Today’s guest post is from Sarah Steingrüber, an independent global health expert and Global Health Lead for CurbingCorruption.

The coronavirus pandemic is a global health challenge the likes of which has not been seen in over a century. The outbreak demands swift and bold action not only in the direct response to the pandemic, but also in ensuring that monies are correctly spent, that companies do not profit unfairly from misfortune, and that power is not abused by our leaders.

Two weeks ago, I published a commentary on this blog that identified some of the critical corruption risks associated with the response to the coronavirus pandemic. In today’s post, I turn from a diagnosis of the risks to some possible solutions. In particular, I want to highlight four types of measures that will help to mitigate some of the corruption risks that were identified in my previous post. Continue reading

Fighting Healthcare Corruption with Smiles and Stickers

Compared to other EU countries, petty bribery in Lithuanian healthcare is quite common (see here and here). Though extortion seems rare, Lithuanians frequently make informal (and illegal) payments to doctors either to get better/faster treatment or as an expression of gratitude. When describing this practice, Lithuanians use the language of “giving a gift” or “giving a little envelope,” euphemisms that imply that these payments have come to be perceived as acceptable expressions of gratitude rather than bribes, despite the fact that the Criminal Code prohibits bribery and the Civil Code prohibits giving doctors any sort of gifts outside their private lives. Though formally bribery, giving money to a doctor in Lithuania seems to have developed a different social meaning—rather than implying that you are a dishonest or corrupt person, giving extra money to your doctor has come to be understood as something that reasonable people do in recognition that doctors work hard, are underpaid, and deserve gratitude. Offering gifts or money to a doctor has also become a way to express how much you care about the health of your loved ones who are unwell. So, in Lithuania, the practice of making illegal payments to doctors seems to have become a “social norm” – a shared understanding that such behavior is permitted or even obligatory. It has become a norm both in the descriptive sense (people make these payments because they think that everyone else does so) and in the injunctive sense (making an extra payment to your doctor is an appropriate expression of gratitude). That doesn’t mean it’s good, or something we should ignore or tolerate. But it’s something we need to take into account when thinking about how to combat this form of corruption.

Once we recognize that petty bribery has become a social norm, we should ask what tools could be used to disrupt that norm. Because the problem is so extensive and multifaceted, many of the solutions will require significant institutional reforms, changes in management style, budget reallocations, and the like. Without minimizing the importance of those more fundamental changes, it’s also possible that seemingly small, inexpensive, and non-coercive interventions might help disrupt this dysfunctional social norm. Back in 2011, when I was working for Transparency International Lithuania (TI Lithuania), we piloted one such initiative in collaboration with the Lithuanian Medical Students Association. Our objective was to disrupt social norms surrounding informal healthcare payments—not through loud or aggressive actions, but with stickers and smiles. Continue reading