How patients can help to heal a sick healthcare system

1. BMJ 2014;349:g5156 doi: 10.1136/bmj.g5156 (Published 14 August 2014) Page 1 of 2
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Use patient power to tackle medical corruption in India
Educated and empowered patients make it much harder for corrupt practices to occur in the health
system, writes Aniruddha Malpani
Aniruddha Malpani medical director, Health Education Library for People, Ashish, Tardeo, Mumbai
400 034, India
Corruption (the abuse of power for private gain) seems to be a
problem that afflicts healthcare systems the world over. A recent
article in The BMJ described some of the problems in India.1
It’s true that the Indian healthcare system is ailing. We have too
many patients and not enough doctors to provide personalised
care. The result is that patients see themselves as helpless, and
some doctors and officials exploit this power imbalance to make
money by unfair means.
Traditional solutions have not worked. Regulation is doomed
to fail because the regulators themselves are often corrupt.2
Exhorting doctors to become more ethical is not helpful—good
doctors don’t need to be told, and bad doctors will not improve
because we preach to them.3
Contributing to the stalemate is that we continue to consider
the number of patients in India as a problem. Actually, they are
part of the solution: patients are the largest untapped healthcare
resource.
Healthcare needs to learn from the revolution that has occurred
in microfinancing.4 When given money and the freedom to use
it as they see fit, even very poor people have come up with
remarkably innovative ideas that could never have been planned,
designed, or anticipated by bankers—the traditional experts. If
we treat patients as experts, they may suggest far cleverer
solutions to fix their healthcare problems than doctors have been
able to.
The present situation is made worse by the intermediaries who
contaminate the doctor-patient relationship. This means that
instead of doctors being free to act in the patient’s best interests,
they have multiple masters. For example, the family physician
who takes a kickback to refer a patient to a specialist will often
demand that the specialist perform surgery because it is more
profitable. It’s an open secret that to earn more money
laboratories and imaging centres offer financial incentives for
referrals; and the drug industry compounds the problem by
bribing doctors to prescribe their brands.5
One way to fix the problem is to cut out the intermediaries and
create direct relationships between doctors and patients based
on trust. Healing this relationship will allow doctors to act as
the fiduciaries they are supposed to be. Thanks to the internet
it has become much easier to do this. Patients are now online,
and when doctors are too there will be no need for them to offer
cuts to referring doctors—patients will be able to reach out to
them directly. If every doctor had his or her own website, this
would force them to become open, which is a powerful antidote
to the poison of corruption.
We now have a new generation of healthcare entrepreneurs,
who are developing clever online solutions that allow doctors
to engage directly with their patients. When a doctor’s medical
practice is flourishing thanks to loyal and satisfied patients then
there is no longer any need to engage in underhanded financial
deals.
This may also lead to a virtuous circle. Doctors will compete
to be seen to offer more value to patients. This digital leverage
would encourage doctors to become more available, affordable,
and accessible.
Doctors will always be busy and will never have enough time
to educate their patients face to face. This is why they need to
invest in creating online educational tools that patients can use
to become well informed. These can be cost effective to develop
because they are created once and then used multiple times. We
need to apply the “flipped classroom model”6 to healthcare so
that patients can have more productive consultations (in the
clinic and online) with their doctor. When patients are armed
with accurate information about their illness, they can form an
intelligent partnership with their doctor—this in turn will help
to reduce corrupt practices.
We also need to involve other patients.7 Peer to peer education
is effective. Expert patients are much more empathetic because
they have “been there, done that.” They speak the regional
language without medical jargon, and they know how to make
the best use of the locally available resources. These expert
patients inspire trust because other patients know that the advice
being offered is free of vested financial interests. Online
platforms where patients act as health coaches for other patients
are valuable. Many Indians believe in karma and understand
that the best way to help themselves is to help others.
info@drmalpani.com
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2. BMJ 2014;349:g5156 doi: 10.1136/bmj.g5156 (Published 14 August 2014) Page 2 of 2
Information can be delivered widely and inexpensively, thanks
to the internet and the proliferation of smart phones. It’s
important that patients trust their doctors, but this trust needs
to be earned. Patients can be taught to do their own homework,
so they can independently verify that their doctor is giving them
sound advice. This will help to keep doctors honest too.
To empower patients, the government needs to provide quality
information for the right person at the right time. Ideally, every
clinic, hospital, pharmacy, and diagnostic centre should have a
patient education resource centre, where people can find
information on their health problems. Illiteracy can be a
bottleneck, but using video is possible.
This is a huge opportunity for the Indian government. While
patients are hungry for information, they are not sure if online
information is reliable or not. If the Indian government provided
this information, not only would it be trusted, it would also
allow the government to show that it was spending its funds
sensibly to improve the health of its citizens. It is farcical that
the United Kingdom’s NHS provides more high quality health
information in Indian languages such as Gujarati than the Indian
healthcare system does.
The other big players in the healthcare system also have an
important role. Drug companies have damaged their reputations
in pursuit of short term profits. By providing reliable information
about their drugs, companies can help to improve their image
and restore public trust. Health insurers also need to provide
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information to control the epidemic of overmedicalisation. This
will allow them to improve the quality of services they provide,
because this would reduce their losses.
Finally, good doctors would be happy—it’s much easier and
less time consuming to talk to a well informed patient. Ethical
doctors would much rather treat a well informed patient who
has realistic expectations of the outcome of treatment. A good
doctor and a well informed patient can form a partnership that
will ensure that patients get the best possible medical care.
Competing interests: I have read and understood BMJ policy on
declaration of interests and declare the following interests: I am the
medical director of HELP, a non-governmental organisation that
promotes “information therapy” in India.
Provenance and peer review: Not commissioned; not externally peer
reviewed.
1 Berger D. Corruption ruins the doctor-patient relationship in India. BMJ 2014;348:g3169
2 President signs ordinance on MCI. The Hindu 2010 May 15. www.thehindu.com/news/
national/article430812.ece
3 Chattopadhyay S. Corruption in healthcare and medicine: why should physicians and
bioethicists care and what should they do? IJME 2013;X:153-9.
4 Yunus M. Banker to the poor: the story of the Grameen Bank. Aurum Press, 2003.
5 Sachan D. Tackling corruption in Indian medicine. Lancet 2013; 382:e23-e24.
6 Flip teaching. http://en.wikipedia.org/wiki/Flip_teaching
7 deBronkart D. Let patients help! CreateSpace Independent Publishing Platform, 2013.
Cite this as: BMJ 2014;349:g5156
© BMJ Publishing Group Ltd 2014
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