Tessa Richards: Patients combat corruption in healthcare

Tessa_richardsCorruption in health systems has been described as “one of the biggest open sores in medicine.” It occurs in many guises and all countries. Patients may be unaware of the price they pay for corrupt procurement processes, manipulation of drug trial data, and conflicts of interest, but they are well aware if they need to make “informal” payments to doctors to get the care they seek. This situation has recently led a Lithuanian patient organization to play a leading role in demanding more effective government action to combat corruption in the health sector.

POLA is a non-governmental coalition of cancer patient organisations. Last month in cooperation with Transparency International and The European Healthcare Fraud and Corruption Network it organized a meeting in the Lithuanian Parliament aiming to draw public attention to the many sided problem of corruption in healthcare. The meeting, attended by over 260 healthcare professionals, patients, patient advocates, and policy makers, attracted extensive media coverage and a pledge by the newly appointed Lithuanian health minister to make tackling corruption a priority.

The Global Corruption Barometer 2016, produced by Transparency International showed that Lithuania has the second highest reported level of bribery in healthcare institutions in the EU. It found that one in four people who visited a healthcare institution over a 12 month period  admitted to having given a bribe.

Paul Vincke, a member of the European Healthcare Fraud and Corruption Network presented 2013 data on the frequency and scale of informal payments to health professionals and hospitals in Poland, Bulgaria, Lithuania, Romania, and Hungary. This showed that the demand for informal paymentsor patient’s perception that they must make an “additional payment” to get good care, is not uncommon in all of these countries. The same holds for most countries in Central Asia too.

Prior to the meeting POLA sought the views of around 600 junior doctors. “We reached out to junior doctors deliberately,” said Šarūnas Narbutas, President of POLA, for they appear to share the patient community’s concern about informal payments in a way that senior doctors do not. Of those surveyed half agreed that informal payments were unacceptable, yet half of respondents said they were unavoidable given the low salaries doctors receive in public hospitals. Furthermore, another small poll completed by patients, revealed that one third had given bribes to family doctors and one in two cancer patients reported that they had to bribe oncologists to receive high quality care.” 

While legal action for bribery has been taken against some healthcare professionals in Lithuania, Narbutas argues that action is needed on many other fronts.”The Ministry of Health has listed 88 measures to tackle inefficiency, waste, and fraud in the health system, but they are complex, and not well implemented,” he says. Vice president of POLA Gediminas Žižys has highlighted that “there must be greater transparency around prices of public tendering, comprehensive declaration of conflicts of interest by healthcare professionals, and a better way to report the occurrence of  informal payments.”

Patients and health professionals have a legal obligation to report activities which they judge to be  corrupt “but they often don’t,” says Narbutas, “Revealing personal details is seen as risky and patients are calling for legal initiatives to protect them as ‘whistleblowers’ for they perceive that anonymous reporting fails to deliver any tangible results.”

tessa_vitamin_labOne promising initiative aired at the meeting was presented by Sergejus Muravjovas, Executive Director of Transparency International Lithuania who described how “we turned the Lazdynai Outpatient Clinic in Vilnius into an anti-corruption lab. The health professionals decided to be explicit about the nature and quality of the services they were providing and make it clear that treatment would be provided equitably. The patients were asked for their views about the service they got. The opportunity to provide instant feedback at a so-called Vitamin Lab reduced the willingness of participating patients to give bribes and changed their overall perception of bribery in the clinic. It also pointed the way to how better dialogue between patients and health professionals can reduce the use of bribes.

Although the minister of health in Lithuania has yet to announce further plans to step up or change existing anti-corruption measures Muravjovas is cautiously optimistic. “The fact that patient organisations have taken the lead on tackling the problem and brought it to wide public attention is good. Formerly, people in high places were reluctant to acknowledge the problem. Now they have and this is the first step towards combating it effectively.”

Tessa Richards is senior editor/patient partnership, The BMJ.

  • How can patients influence healthcare systems in the UK? I have become very alarmed to discover that UK GP guidelines are leading, I believe, to a very alarming rise in disability caused by inappropriate prescribing of antidepressants (in particular) leading to serious functional/somatic problems which are misdiagnosed as ‘Medically Unexplained Symptoms’. My article describing this was published last week on the Mad In America website: https://www.madinamerica.com/2016/12/outsiders-observation/

    If the guidelines are misleading the doctors, effectively abusing and exploiting the essential basis of trust in the doctor/patient relationship, this seems to be a particularly cruel outcome of corruption within our own UK healthcare systems.

  • An announcement by the BMA Board of Science in October, recognises that patients are experiencing terrible problems with medicines commonly prescribed for anxiety and depression. Patients have been trying to get these issues raised for many years, and have been repeatedly brushed off or ignored. At the same time there is a rising problem of patients experiencing ‘Medically Unexplained Symptoms’ resulting in huge costs to the NHS, Apart from very cursory references, the current GP guidelines skim over these medications as potential causes of MUS. It appears that GPs and patients are actually being misled, and the all-important doctor/patient trust relationship cruelly abused and exploited. This seems to be a result of corruption within our own UK NHS and political systems. How indeed can patients combat this?

  • Tamas Bereczky

    The situation in Central Europe is both different and similar, and I can completely relate to the issue and Narbutas’ description in particular.
    In Hungary and other CE countries, the doctor will often not even speak to you if you don’t pay under the table. This is horrible on the one hand, however, they are also left very little choice with the salary of a young doctor being around 400 EUR a month. What else can you do if you want to earn a living? This is also the reason why so many of young doctors will go abroad, they leave the country almost immediately after graduation. Or they maintain double employments at home an abroad.
    So you go to the doctor and you pay extra. People will bring gifts like food and home distilled spirits, even live hens in the countryside, but the most common form is the “lined envelope”. The system is so much built on corruption that the tax authority in Hungary once issued guidelines for doctors on how to include grey and black payments in their tax returns, should they wish to do so… And then there is the issue of manipulating waiting lists for operations and expensive treatments.
    I agree that the definition of corruption is perhaps not entirely clear, but the very point about corruption is that it is grey, vague and shady. It has been one of the biggest ailments of healthcare systems in my region.

  • susanne stevens

    The situation is more stark in some countries yet the issue of ‘bribery’ is not a million miles away from the situation in the UK. A person who has actually paid into the National Health Service may be denied treatments or kept for so long on a waiting list they become more unwell. People who can manage to pay and those who can ‘beg and borrow’ the money can see the same Dr who was unable to treat them in the NHS – privately. Most people cannot afford the fees they charge privately. The NHS in UK is so fragmented that for example NHS treatment can be obtained in one part of the country and not in others – people sometimes move house to get treatment in a catchment area which provides what they need.. It is not a system which provides an ethical service to all regardless of income, status or knowledge .

  • Dr. Amy Price

    Thank you for a thoughtful and heart wrenching article. It is wonderful to hear about the progress and awareness this group has raised. It is true medical fraud hurts us all and can block the entry of good medical care and innovation.

    I address the plight of the individual patient with no one behind them who has something to report. It is difficult for patients to be heard, they are looked at with suspicion and they are ostracized for reporting. This is not a responsibility that should be put on
    patients, it is not their duty, it is the duty of the providers to provide
    ethical care.

    It is crucial to highlight the cost patients will pay to report medical fraud or unethical practice and how difficult it is to see results. Survival strategies are needed because an individual can be sued civilly for libel or slander in some countries. When there are no
    grounds and the case and all appeals are dismissed the patient will still be responsible for legal representation, costs of appearing, accommodation, flights and more.

    This can easily run to hundreds of thousands of dollars or pounds
    and four to eight years of their lives and that of their family. Every aspect of their life will be exposed and there is no law against the perpetrators making public any deposition or posting false reports.

    I reported to the FDA and other governing bodies three cases, one where a young man had stem cells directly injected into his brain and was later hospitalized with infection, another where elderly persons
    were charged several thousand pounds for a miracle injection to “cure” stroke. In this case the individual had already lost a medical license and was still practicing but nothing was done in either case. In the third example, something I reported earlier was ignored until two lives were lost from the “Treatment”. This individual did have their credentials revoked however no reasonable restitution was ordered and the “doctor” did not serve one day in jail.

    My recommendation learned through experience is to quietly report wrongdoing (after verifying that there is wrongdoing) to all authorities and follow this up with emails to your political representatives. Wait for them to do their jobs, it will be slow. Send a personal letter as it is much more effective than a petition although when possible it is good to do both.

    Lastly when a patient speaks Truth to Power against corruption they are likely to be slandered and maligned. Fellow citizens let us protect and encourage them and stay on their side even if the media turns against them and they initially are not considered credible.

    They will be hurt to the core and will not be at their best because in addition to fighting when they need to heal, they will live with betrayal, shame and broken trust, they may be bitter. They will need to grieve, be a friend, deliver comfort and reassurance, give them time. Remind them of who they are and support them.