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Interviews | Dr David Berger, director of the British Medical Journal group and a general physician practising in Australia, speaks to Rema Nagarajan
Dr David Berger, director of the British Medical Journal group and a general physician practising in Australia, speaks to Rema Nagarajan

Dr David Berger, director of the British Medical Journal group and a general physician practising in Australia, speaks to Rema Nagarajan

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published Published on Oct 4, 2015   modified Modified on Oct 4, 2015
-The Times of India

Dr David Berger, director of the British Medical Journal group and a general physician practising in Australia, is better known in India for an article he wrote in the BMJ in May last year titled 'Corruption ruins the doctor-patient relationship in India' based on his experiences of working in India. The article sparked a public debate on the widespread corruption in India's healthcare sector. Here now on a personal trip, Dr Berger spoke to Rema Nagarajan about how doctors could be ethical and what drives corruption in the sector.

* How difficult is it for a doctor to be ethical?

It is not that hard. You just try and do everything in the best interest of the patient. I have worked all over the world in medicine and I have found that patients are the same everywhere. What ordinary patients want is that you do whatever is best for them. There is no difference in this between a hill person in Garhwal, somebody in London or Australia or wherever.

* Is a highly privatised healthcare part of the problem in India?

There is an inherent contradiction in fee-for-service medicine, whether it is in the state run system or a privately run system. I think medical establishments around the world are guilty of a high degree of wilful blindness with respect to fee-for-service medicine and the inherent contradiction that implies. If we want a highly ethical medical establishment, we need to look at salaried service, and it could be a good salary even a very high salary. And you could reward quality with financial payments. But once you incentivise throughputs, then you have a very severe conflict of interest.

* In government hospitals doctors are salaried. That has not stopped corruption or taking of cuts on procedures like angioplasties. Why?

You mean, like getting a kickback from the stent suppliers? That's just grossly corrupt and that is an enforcement issue. That's an important issue exacerbated by, I suspect, relatively low level of government salary. Once you have a big disparity between state sector salaries and private sector salaries, it sets the scene for corruption in the state sector. You cannot attract the best people to the state sector and the people who are there, will inevitably start taking cuts. There is no question that a highly privatised under-regulated medical system is ripe for corruption. When it comes to the private sector the key is official regulation and oversight, in terms of government oversight, and that certainly seems to be lacking. So one has to hope that some of the private medical groups would see that an open and transparent, evidence-based approach to medicine and a true commitment to honesty and acting in the best interest of the patient could be a competitive advantage in a crowded field. If all you are doing is competing on price and pictures of the high quality meals that you offer, that's quite a sterile competition. It is a highly competitive field and you hope there would be medical groups that would want to compete on an ethical basis. We know there is a huge unmet need for ethical medicine. And surely the business imperative is to service an unmet need. Or maybe, I am really naive.

* In India, with a huge unmet need for healthcare services and little competition from the public sector, even unethical healthcare businesses thrive. So where is the need to turn ethical?

That's a problem. But after 25 years of medicine, I am still naive enough to believe that there are actually a lot of doctors whose primary reason for getting up in the morning is to do something meaningful with their lives and to deliver the best possible care they can to their patients, not to scam them. I know those doctors are out there because I am one of them and there are plenty. And I do think that it provides a competitive advantage. Whether it will provide profits of the same order as ordering large number of unnecessary investigations and procedures, well I guess not.

* In India, with a huge unmet need for healthcare services and little competition from the public sector, even unethical healthcare businesses thrive. So where is the need to turn ethical?

That's a problem. But after 25 years of medicine, I am still naive enough to believe that there are actually a lot of doctors whose primary reason for getting up in the morning is to do something meaningful with their lives and to deliver the best possible care they can to their patients, not to scam them. I know those doctors are out there because I am one of them and there are plenty. And I do think that it provides a competitive advantage. Whether it will provide profits of the same order as ordering large number of unnecessary investigations and procedures, well I guess not.

* You wrote in your article about private medical education contributing to corruption. But is there a direct connection? Does studying in a publicly funded institution keep doctors from being corrupt?

If you come out of medical school with a debt in crores of rupees you got to earn that money back. And you haven't got the luxury of necessarily practising in an ethical way on a lower income and so it is a further impediment. I don't think per se it is an inevitable correlation but you got to wonder. And the very fact of having had to make a very corrupt payment, however unwillingly, also means you have been corrupt yourself. You have entered that corruption process. It's a sort of slippery slope. Then you start to be enticed and you take a fatal bite of the apple.

* The students are just 18 and it is the parents who make the payment to get them a seat in a private medical college. Would it still corrupt the students?

It is institutionalised. It is an indoctrination. They are indoctrinated into believing that this is the way the world works, that you have to make a substantial under-the-counter payment to do anything. So it is not even something they would question. It's just a given. So in that way institutionalised corruption perpetuates itself, generation after generation and that is the danger of rising trend of privatised medical education in the last 20 years. I don't have an objection per se to private medical education but certainly the way it has occurred in India with very high overinvestment in the private sector and underinvestment in the government sector is problematic. And you can see how this problem is ratcheting out of control. In some ways it is heading for a dysfunctional medical system.

* Do you feel India is going the US way rather than the UK's NHS (National Health Service) way of state-provided healthcare?

India is not going the NHS way at all. The Indian and the US situations are very similar. If anything, it has not been highlighted that the situation here is somewhat worse because most of the hospitals here are for profit whereas in the US, most are not for profit. Less than 20% are for-profit hospitals. Yet, when you talk to people in the US their biggest concern is their medical care, their insurance, what they will pay for, what they won't pay for. It's a huge concern when somebody gets ill. It's the same here; it is the biggest cost that could hit you at any time. It is a question of individual health and wellbeing. I think there has to be a better way for India. In India, it does seem quite an extreme system for some of the poorest people in the world and the amount of pain that people go through is just huge.

* How do you see the opening up of the health insurance sector to private players playing out in India?

It will, perhaps in a limited sense, create a bureaucratic labyrinth that actually very few people will be able to navigate effectively. When you make an insurance claim for anything, the first thing an insurance company does is to see in what ways the claim could be disallowed. So in terms of reducing anxiety and helping people cut health costs it is not at all certain that that's going to help. I think that kind of unregulated private health insurance system is probably among the worst. You just look at the numbers in the US. They spend 17% of their GDP on healthcare and they have the worst outcomes in the developed world. It is a crazy labyrinthine system.
 

The Times of India, 4 October, 2015, http://timesofindia.indiatimes.com/india/Unregulated-private-insurance-wont-help-people-cut-health-costs-Dr-David-Berger/articleshow/49212374.cms?from=mdr


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