Our optimism is derived not from theory but from our day-to-day work, which ranges from health policy leadership roles to the management of an academic integrated delivery system to hands-on patient care. From this work, we have a frontline view of the good that an organization can produce, but also the inefficiency, missed opportunities, confusion, and occasional harm that cycles the working of a health care organization .
While working for a long year within a government organization in the country of India, I came across many wrongs that I could lay account for, which are quite evidently the root cause for poor healthcare within India. Corruption the taboo that infests Indian mainstream medicine, from the physicians to the lowly staff fall prey to this unethical practice. Her life and death expectancy are not measured through the seriousness of the patients health but the way in which he can satisfy the insatiable corruption around.
The biggest killer in India today is not the mosquito, population, poverty, not tobacco, and certainly not the polio bacterium despite the disproportionate effort spent on eradicating it, it is corruption. To make it sound more technical and acceptable to the medical profession perhaps we need to label it.’ Coruptionoma’, which may in the future lead to a global epidemic threat .
Today in India where scientist claim to have sent men to the moon polio is still common in existence, somewhere a child dies every minute of every day from diarrhea or due to lack of basic care and every 6 minutes a woman dies from pregnancy related causes (official GoI figures). Infant female feticide is increasingly observed in wealthier districts with high literacy rates. Road traffic accidents in Delhi and Mumbai alone are of epidemic proportions.
It is a myth that high technology and costly medicine are the best ways to treat a patient and bring health reforms, it is easily achievable through age old ways readily available then why are the above problems not catered to and still spreading at an alarming rate? It is the disease of corruption that makes managing a health practice impossible.
2. CORRUPTION in Health Care
While working as a resident medical officer at a government hospital in India I faced innumerous issues in the management but the issue that was commonly causing chaos is corruption. Corruption comes evident in various forms and puts the whole effort of providing good service or trying to salvage the oath taken in service of our patients.
“The things I have personally experienced working in an Indian public hospital for over a period of one year is that the life expectancy of a person depends on the financial background of the person.”
The fact that women in labor die due to late arrival of ambulances and un operational equipments
Adulterated drugs proliferate because high level politicians who encourage or protect the people who sell them.
Doctors don’t attend place of work despite drawing a wage from the Government.
Large amount of medicine wasting before reaching the point of use.
Unwillingness amongst underpaid staff who either sit on months of strike for their appraisals or either find under table ways of moving their files.
Unavailability of clean water and hygienic environments resulting in filthy hospitals due to lack of accountability and supervision.
Issuing of licenses to service providers and manufacturers who are incapable but willing to pay high bribes.
Negligence in documentations in departments and usage of illegal means to alter information for self benefit.
Power breakdowns compromise the safety of hospitals due to surging charges and lack of government help.
Officials elected for the purpose of recuperating the health conditions neglect their sole purpose are busy catering to their political scandals and filling their pockets by the power of their seat.
Unnecessary drug prescribing by doctors making practice a means of advertisement for scrupulous pharmaceutical companies.
Under the desk payments demanded from patients by everyone for the watchman to the doctor.
Buildings constructed at inappropriate sites to please politicians and others, discouraging proper use.
Staff wanting to make their private practices look more efficient than the public sector caters to theft and sabotage of instruments.
Favoritism and relational influences give opportunities to the undeserving candidates for higher post and even educational sponsorships.
Loved ones are made to pay bribes to provide loved ones with immediate medical care due to unethical working standards.
[, edited based on true personal experience]
Corruption In Its Various Forms
3. FINANCIAL Management Corruption
Corruption is seen in every aspect of healthcare mainly financial management of the organization. In a recent report in an Indian daily — “Indians pay bribes worth Rs 2,728 cr” (equivalent to approximately US$570m annually), the report finds that the public sectors surveyed the health and education sectors were the most corrupt .
Factors contributing to financial corruption:
Low Wages for Public servants
Low Wages, Poor patterns of incentives and bad working environment relates to the capacity of an organization to attract and retain honest, skilled and motivated staff in a long term similarly, low wages in the public sector are likely to attract less qualified, poorly motivated and potentially disloyal staff, resulting in an opaque, inefficient and potentially corrupt staff. “Informal fees” Of course, like unofficial fees, are not official nevertheless, developed like more of a “practice.” The underpaid officials and underlying poverty influence the practitioners to fill their pockets by unofficial fees .
In my experience Low wages is a greater public tolerance for corrupt practices when the worker incomes are insufficient for living the working environment is intolerable with bleak chances of improvement due to the already existent corruption at the political and higher regions . The existent salaries perceived as unfair in comparison to private sector salaries. Thus subsistence strategy or survival technique that compensate for inequitable working conditions and hardships faced economically make the demanding of under counter money or accepting bribes for poorly paid staff.
Illiteracy amongst masses
The common story amongst people of developing nations is the lack of knowledge and self righteousness. Though the government acts in favor of free medical camps and health coverage the poor due to their lack of awareness fall prey to corruption where they pay for the rights freely available to them at public hospitals.
Free vaccinations for polio, medical camps in rural areas and treatments for HIV/AIDS, tuberculoses, cancer and movements to eradicate malaria have been readily undertaken by the government, but illiteracy amongst the rural and lower sectors (i.e. working class) leads to corruption and future diminishing health conditions.
Lack of funds
The public hospitals rely on government funds or fund raising events which hardly keep pace with the fast growing health sector. The increase in technology has levied a burden on the feeless hospital where the promised care cannot be delivered due to aging population and increasing diseases.
The only way in which the organization avoids complete shutdown is by compromising in the health care by using obsolete technology and unmaintained hospitals with inexperienced staff working in unhygienic conditions. Leading to lesser scope of modernization or remodeling facilities to provide better health care.
This situation also provokes the organizations to remove their staff for balancing their financial need causing a setback in the prosperity of the nation.
4. How can the financial management corruption be dealt with?
Changes in accounting systems
Health systems require clear and simple accounting and procurement standards based on legal framework that encourages transparency participation and due timeliness. An effective supervision and auditing systems is essential in improving the over sightedness that is the root cause to loop holes in an organization and ensure effective enforcement of rules that punish misconduct.
Transparency accounts for practices and expenditures to be open to public and legislative involving scrutiny and that civil society at all stages of budget formulation, execution and reporting . Budget transparency requires an information system that produces timely, reliable and accurate information in order to hold public officials accountable for the use of allocated resources.
Decentralization is a favored strategy with a view to enabling broader public participation and improves technical as well as allocation efficiency, involving public in the decision marketing process and enhancing the responsiveness of the health system. Research indicates that in poorer countries, higher fiscal decentralization is associated with lower mortality rates and improved health outcomes even in high corruption environments .
Privatization in health sector
The lack of accountability arises when institutions are weak public funds is low, privatization of health services can be seen as an alternative method of improving the quality and effectiveness of health services. Privatization limits the powers of the public officials and thus their opportunities of influencing bribery and corruption. Monitoring the quality, reliability and cost-effectiveness of private care and treatments, ensures access to quality health services to the needy and also prevents abuse of the resources. Managing the rates of medicines in private by the displaced informal payments would make a mere difference in public and private care.
Tracking the supply demand chain and eliminating the middle men who add to the price of medicines and also influence illegal bribery. Encouraging the tracking the level of stock and recording the expiry of medicines which may harm the patient’s health. Keeping distributions flow constant and eliminating the unused and outdated stock rather than black marketing supplies for personal gain.
5. Drug Management Corruption
The corruption in drug management affects the price, availability and quality of drugs, undermining safe and affordable access to essential medicine in many developing countries mainly India. Due to the complexity, in the opaque system of health services influenced by large flows of money involved, forge fraud and corruption at all points of the organizational chain, from the registration at hospitals to the admissions and selection of medical treatment and distribution to the promotion of medicines. This is likely to have a long term impact on health and economic outcomes especially the health census of a developing nation .
The factors influencing drug corruption
The drug procurement and pharmaceutical expenditure constitute a large part of the health care budget after salary expenditure. More than 20 to 50 % of the funds are promised for making drug available at affordable prices and thus indicating a growth in health care standards. 
Corruption in procurement and distribution of pharmaceutical and medical supplies reduces access to essential medicines; doctors prescribe medicines on basis of the cut they are offered by the pharmaceuticals. The vulnerable groups thus fall victim to shortage of the facilities and healthcare. Inadequate provision of drug and medical supplies has a direct bearing on the performance of the organization.
Registrations and legalities
The market approval of the production and distribution sector is highly influenced on the bribes that the companies offer to pay than the adequacy neither capability of the company nor the potency of the drug. It is a regulatory decision of the political bodies concerning the health sector to allow a medicine to be marketed in a given country.
Compliance with regulations elongates the period of drug licensing, accreditation and approvals can prove costly for pharmaceutical companies wanting to launch a new product. Some of them may try to bribe or influence the regulator simply to speed up the approval process.
The middle chain of distribution elongates and also becomes costlier by the amount of unofficial money associated with the drug release of drug release or distribution this can also affect the setting of user fees for drug registration, which are often set well below true cost .
Pharmacies and drug stores also require due registration and licensing. The process of licensing pharmacies for operation is corrupted by bribes, favoring kin or political contacts of government agents, geographic inequities, and facilities that do not follow government regulations. As with the registration process the responsible national experts receive compensation from pharmaceutical companies that influence their statistics and thus influencing wrong judgments.
The selection of essential medicines in a given country needs to use defined criteria and consultative and transparent process. The inclusion of any pharmaceutical on the list of nation’s essential medicines is influenced by means of bribery gain due to the opacity in the selection process . Interested parties may also bribe the committee responsible for deciding which products are reimbursed through government social insurance programs.
Procurement and lack of skill
Providing health facilities with drug and medical supplies is a very complex process. This involves a large variety of members interacting between the private and public sectors. Government’s health officials lack the managerial skills required to specify technical details, supervise bidding and monitoring the already active contracts and trail their legal fulfillment. Corruption can occur at any stage of the process influence decisions on the model of procurement rather than competitive bidding, on the type and volume of procured supplies rather than the demand enlisted, and on specifications and selection criteria hence compromising access to essential medicines and hampering their quality endangering lives of the poor who are the most vulnerable victims to corruption.
In a context where quality controls are difficult to exercise, an increasing lack of funds results in corruption where officials sell low quality, expired, counterfeit and harmful drugs at cheaper prices. Corrupt procurement officers also purchase sub-standard drugs in place of quality medicines pocketing the difference.
Unmonitored systems and lack of official records
Falling short of finance the systems are obsolete and poorly monitored, record-keeping is ineffective hence the accounting mechanisms make it an easy opportunity for the corrupt, theft of large quantities of drugs and medical supplies depositories and medical facilities, sale of samples for personal gain in private practices or on the black market .
Puppets or patients
A Strategy to supplement their meager salaries doctors working for government has been increasingly allowed to open private practices Resulting to which doctors spend official time in public facilities treating private patients, or merely channeling patients to their private practice.Due to the lack of punishment the doctors are either absent or not concerned with their low salary jobs playing with the lives of their patients.
6. How can the drug management corruption be dealt with?
Tracking Registration process
Authorities need to ensure transparency and accountability. A formal committee responsible for registration of medicines needs to be established where the basis of selection remain technical and competitive with easily accessible terms and conditions and fixed payable fees. Training should be provided for the officials who are responsible managing records and performing registration activities.
To limit corruption in the process of drug selection practical involvement and fair practice is a must where adopting lists of essential medicines that are based on standard evidence-based treatment guidelines at national and sub-national levels. Government officials need to ensure that the selection of these essential medicines is based on transparent process with expert committee responsible for this exercise operating according to published terms of reference, whose members will be selected based on expertise, and whose decisions will be influenced by current state of scientific evidence.
Improving access to medicine
In order to tackle this complex problem the causes and manifestations of corruption and the ongoing in the region are too be evaluated to prevent it. Agreements to establish a working group with the industry and NGOs in order to promote transparency in the health sector based on various health standards.
The prerequisite for curtailing corruption in the procurement process consists of defining rules and guidelines that reduce discretionary powers where they are likely to be abused and to increase the probability for corrupt practices to be detected and sanctioned. Promoting transparency in the procurement process can be achieved by offering clear documentation and public access to bidding results, if possible using an electronic bidding system where interference is not possible, and involving civil society at all stages of the process. Technical assistance and to manage competitive bidding training for procurement officers can also improve standards of the government .
To reduce illegal practices at the distribution stage of medical supplies include establishing controlled inventory systems, improving record keeping providing security against robbery in repositories. Providing tools for improving drug distribution systems, including guidelines for forecasting, supply chain management and managing process flow in the distribution system.
Other possible measures include banning practices of gift and sponsorship, following WHO ethical guidelines on medicines promotion , and promoting codes of ethics in marketing through trade and professional organizations. The practitioners should be educated against the promotional propaganda of the pharmaceutical companies.
Addressing the issue of rising health care costs is critical to the economic health of our country, and the physical health of its residents. In this situation when corruption enters the developing nations mainstream it soils the whole system from the lower working class to the managerial level. They participate in the malpractice of endangering the lives of their patients, rather than making medical supply and health services readily available?
National health officials are interested in pocketing the differences they earn by under counter money and unofficial fees for items termed as free. Financial management faces corruption due to its poor accountability and inadequate supervision. The Lack of trained officials leads to unmaintained records, wastage of medical supplies and unavailability of required medicines.
As a resident official in one of the busiest hospitals I observed the lack of enthusiasm amongst the working staff and also the practitioners this attitude is mainly influenced by the lack of funds, insufficient salaries and unhygienic working environments. The only alternative to satisfy their mere day to day needs , officials are forced to accept bribes and get involved in illegal activities.
The drugs not for sale are robbed and distributed at private institutes or also black marketed during times of high demand. The supply is irrespective of demand. Competition in the pharmaceuticals has lead to influencing of doctors in prescribing high cost medicines for their personal benefits and gifts. The respect of human life and the oath of serving our nation with honesty has long been forgotten especially in the Indian sub continent.
Lots of ways have been prescribed in books of many volumes but corruption as a disease may blame politicians, poverty and many other uncontrollable traits but the only virus for this disease is human nature and the lack of self control and honesty. The selections of political power is always in the hands of the masses then blaming our leaders and giving them opportunities is like blaming ourselves for the condition we find ourselves in.
As an Indian belonging to the middle class I too have observed the corruption in our country, not done much to prevent or stop it but have done enough to encourage and kindle its existence.
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