New Delhi: Irrational prescriptions, bribes for referrals and unnecessary investigations are the most common forms of corruption in India’s health sector, the British Medical Journal (BMJ) reported.

On 24 February, BMJ published three papers on medical malpractice, regulations and whistleblower protection in India, raising serious concerns over healthcare fraud in the country. In a series of interviews, Arun Gadre, a Pune-based gynaecologist and health activist, recorded statements of 78 doctors from Bengaluru, Chennai, Delhi, Kolkata, Mumbai and Pune. Of them, 64 were private practitioners, five were from government institutes and nine from charitable hospitals.

Each doctor was asked to give examples of malpractices. The shocking answers ranged from “a general practitioner in Maharashtra, who said that doctors get 30,000-40,000 for referring patients for angioplasty" or a gynaecologist “performing sonography without indications in pregnant women, then fabricating false reports of cervical abnormalities and advising the women to have cervical stitches, with the pretext of preventing miscarriage".

The article states that the system was perpetuated as “few patients request a second opinion, and the doctor does not give them any documents to avoid being found out".

On the other hand, the BMJ report states, “wealthy patients are admitted directly to intensive care and several thousand rupees are pocketed by the doctors". Gadre sums up the investigation saying, “These interviews underscore one fact—paying money does not guarantee good healthcare. The private healthcare system largely treats patients as revenue generators, without rationality or medical logic."

BMJ also addresses the complete lack of regulation of private players. Health is one of the least transparent and worst regulated sectors in India. A 2005 study by Transparency International concluded that the Indian healthcare sector is the second most corrupt sector, after the police.

Corruption, kickbacks and the nexus between doctors and pharmaceutical firms are so rampant that BMJ, in June 2014, launched a campaign called Corruption in Medicine, specific to India, stating in an editorial that corrupt practices had “steadily eroded the trust and respect with which doctors were previously regarded".

In another paper, author Sunil Nandraj, a public health policy expert, writes that the “current regulatory and accountability mechanisms are not sufficient to ensure quality and prevent negligence. Patients’ interests are not adequately protected. India’s plans for universal healthcare coverage through the private health sector, the National Health Assurance Mission, will be stymied without appropriate regulation."

As of now, Nandraj points out, private health services in many states—including Assam, Goa, Gujarat, Kerala, Meghalaya, Punjab and Tamil Nadu—don’t have appropriate legislation to regulate private clinical establishments. The states that do have regulation find the laws outdated and enforcement “near absent".

The Bombay Nursing Home Registration Act dates from 1949, the West Bengal Clinical Establishments Act from 1950 and the Delhi Nursing Home Registration Act from 1953, the article points out.

The Clinical Establishments (Registration and Regulation) Act 2010 (CEA), the law that is currently used to regulate the private sector in healthcare, prescribes minimum standards for personnel and gives standard operating protocols. But it is in force only in Arunachal Pradesh, Bihar, Himachal Pradesh, Jharkhand, Mizoram, Rajasthan, Sikkim, Uttar Pradesh and Uttarakhand and all union territories. Other states may choose to adopt the CEA or introduce their own legislation.

Nandraj writes that even when implemented effectively, the CEA is a toothless law. “There is no inspection; after registration is applied for a decision has to be made within 45 days, and there are provisions for appeal if registration is denied. The act has no provision for imprisonment, only monetary penalties, because the intention is to seek compliance rather than to take punitive action."

Health experts said the papers highlighted the need for regulation.

“The survey may be small but is reflective on the general situation of healthcare in India. Everyone knows about the malpractice, kickbacks and doctor-pharma co-nexus but little regulatory oversight and/or citizen engagement is happening to address these issues," said Amit Sengupta, member of the advocacy group Jan Swasthya Abhiyan.

“In the case of CEA, one must understand that it might have been adopted by states but it is not implemented anywhere, as of now. This is because the rules are yet to be notified. At central level rules are being drawn up, the process is ongoing," he added.

The interviews by Gadre are compiled in a Marathi book, titled Kaifiyat - Pramanik Doctoranchi (Reflections By Sincere Doctors), which was released in September 2014.

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