People's Democracy

Institutionalising Corruption: The MCI Story

Amit Sen Gupta

IN April 2011, Dr Ketan Desai, the president of the Medical Council of India was arrested by the CBI. The charges against Dr Desai were grave – he was accused of having received a bribe of Rs Two crores to give permission to Gyan Sagar Medical College at Patiala to induct a fresh batch of students without the college having requisite infrastructure. While Dr Desai’s arrest was extensively carried and commented upon in the media, the news did not come as a surprise to many in the medical fraternity. For long, the Medical Council of India, which oversees the regulation of medical education and the conduct of ethics in the medical profession, has been widely known as one of the most corrupt institutions in the country. While an assertion such as this might shock the lay public, Dr Desai has been on the radar of the CBI for a very long time. In 2001, Ketan Desai was arrested for taking a bribe of Rs 65 lakh, but the case was closed in 2009 when investigating agencies claimed that what Desai had received was “goodwill money”!

As recent events have shown, corrupt officials abound in positions of power and influence in the country. The Ketan Desai case is, however, of particular significance because it involved a person who was supposed to be instrumental in overseeing an area that people still regard as sacrosanct. Unfortunately, the medical profession today is anything but sacrosanct. The Ketan Desai case is significant also because it is virtually impossible to accept that people in the corridors of power have not known about the sorry state of affairs that have existed for long in the MCI. Ketan Desai was just a symptom of the much larger malaise that afflicts the entire medical profession, and especially medical education and medical ethics. It is beyond belief that Ketan Desai and his cohorts were able to run the MCI as their personal fiefdom, and able to amass huge amounts by giving recognition to colleges with rudimentary facilities, without people in the government having been aware of it. It is beyond belief that Ketan Desai on his own could have run such a huge racket without many others in the MCI and the health bureaucracy across the country being willing accomplices.

A STRUCTURALLY

CORRUPT SYSTEM

Ketan Desai and his MCI were part of a system that had become structurally corrupt over a period of time. The sordid saga of the MCI is a part of a larger sordid saga – that of the almost complete commercialisation of medical education. There was a time when the best minds in the country competed to gain entry into medical colleges. A different day and age, when the profession was referred to as the ‘noble’ profession. Welcome to the age of scams and corruption, when the same profession is one of the most tainted; an age when parents with the deepest pockets vie with each other to ensure that their wards gain admission to medical colleges. They do so, in order to pave the way for the future doctors of tomorrow to pursue the new mantra of this age – the pursuit of huge pots of money at all costs, without the semblance of scruples of any kind. Health care is big business today and doctors, to be seen to ‘succeed’, have to conform to the ‘ethics’ of big business – profits at any cost, even at the cost of human lives.

The structural corruption that has crept into the medical profession encompasses both the health system in the country and the system of medical education. Privatised health care is a principal source of systemic corruption in the health system. For private medical care to reap super profits, all norms of medical ethics and rational practice of medicine have to be abandoned. That is exactly what we are starting to see in India.

PRIVATISED

HEALTH CARE

India has had one of the most privatised health systems in the world for decades. In percent GDP terms, public expenditure on health care has stagnated at just 1 per cent of GDP, over the last two decades. This has resulted in huge out-of-pocket expenditures being incurred to access health care costs. Estimates indicate that over 70 per cent of health care costs are paid for through private means. Catastrophic expenditures on health care have been indicted for 39 million people being pushed below the poverty line in a year.

As a consequence of grossly inadequate public expenditure on health care, the private sector has grown enormously. In spite of some sporadic attempts, the private sector is largely unregulated. Costs in the private sector have also grown enormously over time (at current prices, out-of-pocket expenses on medical care has grown two and half times between 1993-94 and 2004-2005), with little attention having been paid to the standardisation of the quality of care. The private sector is undergoing a transformation, with large corporate run hospital chains forming an increasingly important segment of private care – especially in urban areas. While public systems remain under resourced, the private sector (especially the large and organised corporate controlled private sector) benefits from indirect subsidies it receives from the government in the form of tax breaks, land made available at almost no cost and a pool of human resources trained in public funded institutions.

The transformation of the health care system – from a system that provided care to one that is designed to generate profits – is clearly visible all around us. Gone are the days when public hospitals attracted the best and the most dedicated talent in the country. The apex public institution in the country – the All India Institute of Medical Sciences in Delhi – is perennially plagued today with the problem of a large section of its senior faculty migrating to the private sector. The deliberate neglect of public institutions has paved the way for private institutions to emerge and flourish. These institutions thrive on money that the elite in this country have accumulated in the era of neoliberal reforms. The poster boys of liberalising India, today, make a beeline for corporate run five star resorts that incidentally happen to be called hospitals. Business is booming and the elite among the medical profession never had it so good! So what, if the India today lags behind Bangladesh and Nepal in many indicators of health. That is an India that is best forgotten and consigned to the realm of poverty statistics.

The private medical system has changed enormously as well – from a sector whose first priority was healthcare to one where board rooms and share holders call the shots. In many big cities the friendly neighborhood General Physician (or GP as he was known as) is a vanishing breed. In metropolitan cities, the earlier generation of nursing homes, run by honest and hard working medical professionals, are being muscled out. They are being squeezed out of the emerging market for health care by corporate chains and their franchises. The nomenclature is no different from that in vogue when describing supermarket chains and designer stores.

This is the current world of health care – a world where profit reins supreme and corrupts all those who come in contact with it. This is the systemic corruption that breeds individual corruption.

TRANSFORMATION OF

MEDICAL EDUCATION

How does medical education fit into this changed system? For a fairly long time there was an asynchrony. While medical care in the country has had a large private element since long (this pre dates the liberalisation of the Indian economy and goes back right to the time of independence), medical education was the domain of the public sector. Most medical colleges were publicly funded and the best medical professionals studied in these institutions. The prominent private institutions were not set up with the motive of making profits, but rather to genuinely produce professionals who would best serve the nation. Prominent among them were some set up by Christian Missionary institutions – Christian Medical Colleges in Ludhiana and Vellore, St John’s Medical College, etc. to name a few.

This idyllic world, however, where medical education would be relatively free of the corrupting influence of commercialisation, was bound to face the real world of commercialised medical care. The transformation started in the 1980s and accelerated in the decade of the 1990s. It was provided impetus, by the slowing down of public investment in medical education. As the mantra of liberalisation gained ground, so did the prescription that the government need not ‘waste’ money on building new medical colleges – the benevolent private sector was willing to lend a hand! Thus we had the spectacle of the mushrooming of private medical colleges, with many states vying with each other to grant permission to private colleges in a breakneck race to the bottom, a race to the bottom that, in many instances, creates doctors of mediocre merit and dubious morals. The products are lapped up by a system that no longer puts a premium on integrity of the medical profession.

The accompanying Table provides details of the rate at which medical education ahs been privatised in recent years.

Table: Privatisation of Medical Education

Source: Computed from data on MCI website

The cycle is now complete! The medical education system is now in synchrony with the world of privatised medical care. Ketan Desai and his ilk, in an earlier era, would not have had the opportunity to amass obscene amounts of wealth by striking surreptitious deals with the managements of private colleges. In fact, they would probably have had no interest in being part of an institution such as the MCI.

REFORMING MCI:

PRIVATE SECTOR TAKEOVER

Let us complete the story by examining the response of the government to the Ketan Desai episode. On the face of it the government acted with remarkable speed. Within weeks the previous MCI was disbanded and replaced by a team of selected individuals (who, by all accounts were people of integrity). But clearly, the intent was not to change the broken system, but rather to perpetuate it. No attempt was made to cleanse the institution of the MCI by building it from below again. State Medical Councils were stripped of their powers to intervene, and the government appointed adhoc body was conferred with all the powers. No roadmap was worked out to restore the democratic functioning of the MCI. Nor was the systemic corruption inherent in privatised medical care and medical education touched. We were given to believe that Ketan Desai was an aberration that could be wished away.

Unfortunately for the government, fissures appeared soon. The government appointed members pressed for a common system of medical entrance examination for the entire country. This went against the whole enterprise of capitation fee medical colleges – they would lose their autonomy over admissions and thus their ability to generate super profits. Many state governments were in the forefront of opposing the MCI’s move, and the government challenged the proposal in court. The Supreme Court in the beginning of this year struck down the government’s objections. The government reacted in a most startling manner by disbanding the MCI, composed of its own handpicked members, and nominated a fresh set of five members.

Lest we think this is mere madness, there is a clear method in the madness. All the previously appointed members have been sacked (without any reasons being assigned) and the MCI has now been packed with people who largely represent the interests of the private sector. Barring one, the other four members have little or no experience of medical education or teaching. Such experience is critical to the nature of work of the MCI.  Further, three of the five board members are from private sector hospitals and their appointment constitutes severe conflict of interest as the MCI is not only in charge of medical education but also deals with cases of medical negligence. One of the members, associated with a private hospital, has been accused in the past of conducting unethical clinical trials. Another member is from a deemed university that does not even award medical degrees. A third member is associated with one of the largest private sector chains in the country – a hospital chain, furthermore against whom charges of medical negligence are pending before the MCI! (Mail Today, May 17, 2011).

The circle is now truly complete, and so is the private sector take over of medical education and the governance of the medical profession. The ethos of the private, over the public, is to be exercised, not just de facto, but de jure as well. The transition is in line with the transformation that is taking place in many public institutions. The age of individually corrupt officials like Ketan Desai is being replaced by systems that are institutionally geared to nurture the corrupt system. This does not, by any means, mean that individual corruption shall wither away. Only, it will work now in a system that is transparently biased – as neoliberal ideology matures in the country even the façade of impartiality and public accountability can be dispensed with.

The MCI and the Ketan Desai story has larger lessons for us – how public institutions are corrupted when the system gets corrupted. Perhaps these are lessons that the present, entirely laudable, campaigns against corruption need to imbibe. It is not enough (though extremely important!) to go after the individuals who become the symbols of corruption. It is necessary, as well (and more important) to understand and oppose a system that is creating people like Ketan Desai.