I recently came to know that it is not government offices or police stations that have the widest prevalence of corruption. That distinction surprisingly belongs to government hospitals, the larger referral centers. And unlike corruption in other establishments, this one is deeply entrenched and not easily resolved. Here is why.
The patient is normally greeted at the registration counter itself with attendants offering a swifter route to access the doctor in return for some "speed-money". And the ordeal continues till they approach the medicine issue counter, where a "fee" is demanded for provision of medicines. In between, the patient is forced to pay bribes at every location he/she visits for a diagnostic service - laboratory, X-ray center, dressing center, injection room etc.
For the in-patient, the experience follows an even more elaborate work-flow. Apart from all the aforementioned, "user rents" are extracted from them by the sanitation workers (sweepers and cleaners), nurses, food contractor, and so on. The single biggest payout is reserved for the operation theatre attendants. Their extortionary power gets amplified by the psychological vulnerability of a patient bound for the operation table.
Here are a few features of this hospital rent-seeking network
1. There are multiple rent-seeking interfaces within a hospital. Each bribe-taker serves an independent rent-center within the hospital. It is not possible to offer a one-time bribe and then pass through the entire chain of services unrestricted.
2. The psychological vulnerability of a patient visiting a doctor makes them easy prey to the extortionary impulses of the bribe-takers. The demands are likely to be met without much resistance and there is little likelihood of anyone openly complaining. No where is this more evident than patients being taken to the operation theater. In fact, atleast some of them pay up as an insurance against life-threatening negligence during the operation.
3. Most worryingly, hospital rent-seeking is completely institutionalized. Almost every staff member is partakes of the spoils. In fact, it has become so closely enmeshed into the work culture that at least some of them rationalize it without any remorse and view it as normal. In other words, the intrinsic deterrent against this practice has severely diminished.
4. The bribe transactions are between two individuals, neither with an incentive to make it public, and take place in relative privacy. Further, the odds-stacked against the patient are so formidable that there is little chance of him complaining. Adding to the challenge is the rapid flow of these transactions within the system.
5. There is an important supply-side willingness to pay dimension that makes the task of controlling hospital corruption even harder. For example, it is almost a cultural norm to gift the nurse delivering the new-born baby. Similarly, patients coming out of a successful operation reward their attendants as a token of appreciation and expression of their happiness.
Regulatory strategies, by way of improved supervisory systems while important, are not likely to make much head-way. A near universal and deeply institutionalized phenomenon cannot be satisfactorily tackled with supervisory oversight. How can we punish everyone? When everyone breaks the law, it no longer remains a crime, atleast in the popular psyche!
The deterrent effect of punishments on individuals caught indulging in taking bribes is not likely to remain for too long. Soon the positive feed-back generating (it collectively emboldens everyone) environmental effect arising from everybody taking bribes will prevail and the deterrent fear will fade out.
In view of all the aforementioned, how do we control corrupt practices in our referral hospitals? In general, how do we control a form of corruption which has become so pervasive as to be the norm and not the exception?