Corruption and health services

The India Corruption Study has classified Indian states into high, medium and low performance, based on the UNDP composite health indicator. Kerala, Karnataka, Tamil Nadu, Gujarat and Maharashtra, with low levels of corruption have better health indicators and fall in the first category. Andhra Pradesh, Haryana, Punjab, Assam, Himachal Pradesh and Orissa belong to the medium performance category, while West Bengal, Bihar, Uttar Pradesh, Madhya Pradesh and Rajasthan have the worst health indicators and belong to the last category.

Key findings – snapshot

Total monetary value of petty corruption put at Rs 2,017 crore a year
59% of rural and 51% of urban households sought services of government hospitals. All India figure: 55% (11.3 crore) households

Of those who interact with government hospitals, 26.5% (3 crore households) paid bribes – 19% in rural areas, 49% in urban; average bribe paid per household: Rs 663
Irregularities like non-availability of medicines and unethical practices by doctors are much lower in southern parts of the country

43% of respondents felt quality of service in government hospitals was poor. In low performance states, 53% felt service was poor.

67% felt corruption was widespread in government hospitals.

45% said hospital staff frequently demanded bribes

Use of services
Location of Households using Government hospitals
Urban- 51%
Rural -59%
Overall- 57%

In Himachal Pradesh and West Bengal, a significantly higher percentage of people was availing the services of government hospitals. In Bihar, considerably lower number of people were availing the services of government hospitals.

Is There Harassment?
In low performance states, only 38% of the respondents received treatment or consultation compared to 66% in the high performance states. Overall 23% said they did not receive any treatment or consultation during a visit to a government hospital

Reasons for repeated visits
Doctor not available in previous visit-39%
Failed to get appointment -21%
Admission to ward not available-14%
Operation theatre was not free-13%
Diagnostic lab failed to take sample -12%

Perceptions about Government Hospitals
Service: Perception about quality of services
Very Poor-13%
Poor-30%
Neither Poor/ Nor Good-26%
Good-28%
Very Good -3%

Prevalence of Corruption
There is widespread corruption in hospitals

Strongly Disagree- 6%
Disagree Somewhat- 9%
Neither Agree Nor Disagree- 18%
Agree Somewhat- 38%
Strongly Agree- 29%

In the high performance states, 62% felt that there was corruption in government hospitals, against 77% in the low performance states.

Common Irregularities
Medicines unavailable- 52%
Doctors suggest a visit to their private clinic -37%
Doctors refer to private diagnostic centers-31%
Over-prescription of medicines-24%
Bribes demanded by staff-20%
Diagnostic tests are done even when unnecessary-18%
Doctors are absent-13%

In low performance states, 66% said medicines were never available in government, against 29% in the high performance states. Possible reasons: genuine shortage, diversion of medicines to private medical shops, doctors deliberately prescribing medicines which were not available in the dispensary. Long waiting time for getting consultation or treatment is might basically be due to low capacity of the hospitals, but creates an opportunity for corruption by giving hospital staff the power to provide required service out-of-turn, and for doctors to ask patients to get diagnostic tests from a particular private laboratory, which pays them referral commission.

One study says: overall, 63.33% of the prescriptions were found to be irrational (i.e. flouting established norms of treatment). This figure was the highest for prescriptions from unqualified sources (81.8%) like registered medical practitioners, and lowest (44.44%) for public sector hospitals. In southern states of Andhra Pradesh, Tamil Nadu, Kerala and Karnataka, these irregularities exist at a much lower scale

Experience of Interaction with Hospitals
Ways to bypass normal process
By paying bribes -54%
By using influence- 42%
Middlemen- 5%
Reasons for Using Alternative Process
Save time- 38%
Could just not get work done in normal way- 23%
To get better care and treatment- 39%

30% of respondents had to take recourse to “alternative methods” like paying bribe or using influence, to get faster (out of turn) treatment and for better care (like consultation with senior doctor, not juniors, clean bed-sheets and better food for in-patients).

Though the system is largely free of middlemen, there were cases of people going to middlemen (mostly hospital staff or ex-staff or their relatives). In the low performance states, the prevalence of bribery is higher than in the high performance states.

What do people pay bribe for?
To get medicines- 29%
To get admission- 22%
For consultation or treatment -17%
To avail diagnostic services -13%
For operation- 11%
For blood- 7%
Getting proper food- 1%
Who Gets the Bribe?
Doctor-18%
Other hospital staff- 75%
Middlemen- 7%

Service Providers’ Perspective

Pressure on infrastructure: Despite capacity constraints Govt hospitals are forced to admit patients because of pressure from co-doctors or local politicians. So, the hospital is almost always working beyond capacity, resulting in low quality of service.

Lack of resources: Lack of resources/funds often means diagnostic instruments are not in working condition, forcing doctors to ask patients to get tests done from private laboratories.
High workload: Acute shortage of manpower hence, they are not able to attend to all the patients, resulting in long queues and delays

False charges of negligence: People come to the government hospital as a last resort, after trying to get treatment in local nursing homes or doctors, by which time, in most cases, the patient’s condition is critical. Any adverse eventuality is blamed as negligence on the part of the hospital.

RKS model of Madhya Pradesh: appears to be sound.

Suggestions to reduce corruption
Users’ Committees should be constituted to take up citizens’ grievances.
Provision of diagnostic services: The diagnostic services can be outsourced to private players, where they receive payment from government on per-patient basis. This is already being conducted to some extent in some hospitals in Delhi.

Medicine supply: Patients often fail to get medicines from government dispensaries, either due to actual shortage or diversion of supplies. To check for the second possibility government dispensaries should display the drugs received every month and furnish daily stock position.