When it comes to health providers duping patients to fatten their wallets, Dr. Arun Gadre, a gynaecologist-turned-health activist in India, has heard it all, and then some.
Last year he interviewed 78 doctors from across India about the professional malpractice they'd encountered during their careers. His findings, while shocking to outsiders, were less of a surprise to Gadre.
"I was a private gynaecologist in a small town in Maharashtra in India for more than 20 years," he told Reuters Health. "It was actually what I saw all around me."
Details from the interviews appeared online on 24 February 2014 in the BMJ, a leading British medical journal, alongside two other papers on the lack of effective regulation and whistleblower protection in India's chaotic health sector.
Most experts agree that healthcare fraud is rampant in the world's largest democracy, with recent corruption scandals engulfing everyone from doctors to drug companies and health regulators.
Gadre's work suggests that three types of malpractice are particularly common: kickbacks for referrals, irrational drug prescribing and unnecessary interventions.
One interviewee told Gadre that doctors typically get 30 000 to 40 000 Indian rupees (R5 500 - R7 300) for referring patients for angioplasty, a procedure to open blocked arteries. For perspective, many Indian health providers make less than R100 000 a year.
To put it in perspective, a physician doctor in general practice in Johannesburg earns an average salary of about R500 000 per year.
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The medical 'mafia' racket
Gadre said that when he started practicing, physicians referred patients to him without expecting a cut. But that changed, and he began to lose business when he refused to pay up.
"As the medical sector became more and more commercialised, the same doctors started asking for commission and the number of patients who came to my hospital started to drop," he says.
While kickbacks are illegal in India, they are nearly impossible to avoid, health providers say. Young doctors in particular, many with towering student debts, find it hard to survive without them.
Some doctors have to rely on this practice to get started, said Dr. Anita Jain, the BMJ's India editor, adding that ultimately patients are footing the bill.
"There is the economic burden, which is very challenging in a country like India," she said. "But also it leads to unnecessary procedures and unnecessary investigations."
The health sector in India is largely private, and most people pay out of pocket. A 2011 study in The Lancet found that 39 million Indians fall into poverty yearly from medical expenses.
Another theme in Gadre's interviews is irrational drug use. He tells of a girl who received steroids for red eyes from a homeopathic health provider. She later developed cataracts, a known side effect from prolonged use, and needed surgery.
Alternative practitioners such as homeopaths and Ayurvedic healers are common in India, and many people prefer them over doctors with a diploma in modern medicine. While not allowed to use modern drugs, in practice they do so with impunity, often encouraged by drug company sales representatives.
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The rise of medical scams
Medical scams intended to wring money from patients also emerged as a major topic in the interviews.
In the so-called "sink test", the doctor orders lab tests despite not suspecting any medical problems.
"Only a few of the tests are performed, and the extra blood collected is dumped in the sink," Gadre writes. "Fabricated results are given in the normal range for all tests that were not performed. The patient pays a large sum, which is shared by the referring doctor and the pathologist."
Other examples include unwarranted C-sections and hysterectomies, he said, or cervical stitches based on false reports suggesting a pregnant woman might miscarry.
Although India's public health centres are known to be understaffed and dysfunctional, Gadre and many public health experts believe privatisation of medical services and education is at the root of the problems.
But so far, he thinks, the medical community has been in denial. "Unless we accept that we are ill, we will not seek treatment," he said of his profession.
The Indian Medical Association's Secretary General Dr. Krishan Kumar Aggarwal largely dismissed the concerns over profit-driven tests and procedures as a "perception", saying corruption is less widespread than the media would have it appear.
"The medical profession is noble and will remain noble," he told Reuters Health. "There are people who are corrupt, they are facing charges and they are being punished."
Others argue that only the tip of the iceberg has emerged, as people who blow the whistle on corruption risk being fired or harassed.
"It has been challenging for doctors to speak up about it, and many have been victimised for doing so," said Jain of the BMJ, who is also a family physician in Mumbai.
Last year, India enacted a whistle blowers protection act. But according to one of the new BMJ reports, the law has yet to be enforced and "offers no protection to those who wish to raise concerns about private sector healthcare".
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The problem is, there is not enough accountability and legislation
In a second BMJ report, Sunil Nandraj, a public health expert and adviser to the Indian government, says many Indian states lack appropriate laws to regulate hospitals, diagnostic centres and other healthcare facilities in the private sector.
"Right now, anybody can start up anything," Nandraj told Reuters Health. "You can charge whatever, there is no legislation."
The resulting free-for-all has been devastating for the country, he argues, and murky pricing has allowed kickback schemes to thrive.
While Nandraj is pushing for more and better legislation, Gadre and the organization he works for – Support for Advocacy and Training to Health Initiatives, or SATHI – have chosen a different path toward accountability.
As part of a government-supported program to improve rural health, SATHI is coordinating community-based monitoring of public health services in hamlets across Maharashtra.
Villagers fill out report cards on the services, which are then displayed at the health centres, and also meet with health officials and other stakeholders at public hearings to discuss problems such as over-charging or staff absenteeism.
"Community monitoring is the only remedy for improving public services in general," Gadre said.
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Sources: http://bmj.co/1BOrei8, http://bmj.co/1LAktQU and http://bmj.co/1w8Jrjh BMJ, online February 24, 2015.
Image: Ironic. Medical students strike in protest against exorbitant fee increase of 100% by the state municipality run medical school on September 02, 2012 in Ahmedabad, India Apurva Madia / Shutterstock.com