When Dr. Nuwa Masinde Muliro, a senior surgeon in Kampala, referred his patient to what he believed to be a reputable Health Centre in India, he did not expect anything except a consultation report and, hopefully, news of a good outcome. Instead the first communication Dr. Muliro (not his real name) received from the lead consultant in an Indian hospital was an e-mail requesting his banking details.
“When I enquired why they needed my bank details,” Dr. Muliro wrote last week, “the Indian consultant informed me that they often paid ‘consultation fees/benefits’ to the referring doctor.”
Dr. Muliro was incensed by the offer and told the Indian doctor that such dealings were unethical. “I have never sent any more patients to that institution,” he wrote.
The Indian consultant was probably surprised by Dr. Muliro’s refusal to participate in a lucrative, multimillion-dollar scam that has enriched many doctors in Uganda and India. It is a scam that is an international version of India’s vast domestic corruption in the medical services, where kickbacks to referring doctors is normal practice. They call it “Cut-practice.”
Many Indian medical specialists and hospitals offer cash incentives to Indian primary care doctors to send them referrals. This cut-practice is so competitive that commissions are reported to be as high as 40-60 percent of the consultation fee. (Other literature reports lower commissions in the 10-15 percent range.) There are reports of Indian specialists literally going to primary care doctors’ clinics, cash stuffed envelopes in hand, to solicit referrals.
The international version of the scam is orchestrated by Indian business coordinators, the vast majority of whom are not medically trained. Over the years, several of them have set up health tourism companies in Kampala and have established unethical partnerships with Ugandan doctors to operate a rather straight forward scam.
The Indian businessmen, together with their Ugandan partners, network with Ugandan doctors, offering them promises of commissions on each patient referred.
Patients that could be effectively and successfully treated or operated on in Kampala get referred to India. Whereas patients and their relatives often initiate the request for referral, the doctor in the scam does not try to persuade the patient to get the treatment locally. He is very happy to facilitate a trip to India.
The doctor prepares a referral letter that he sends by e-mail to the Indian business coordinator – usually a non-medical person. The latter forwards the mail to a doctor in India, a member of a given chain of hospitals. The patient is accepted, the Kampala doctor is advised, and he relays the news to his patient.
The patient, armed with a letter by her doctor, seeks a visa from the Indian High Commission. The diplomats are very happy to assist and a visa is granted. An Emirates air ticket is purchased and the patient, together with a relative, travel to India. She pays her fees on admission, a percentage of which is immediately sent to her Ugandan doctor’s bank account. She then receives the same treatment that was available back home.
Even more tragic are the cases of patients with very advanced diseases, such as terminal stage, inoperable cancers. After review and investigation in Uganda, a patient is informed that she has, say, pancreatic cancer that has spread all over the body. This is one of the most aggressive cancers, with poor outcome even in the best centres in the world.
Like most human beings, the patient wants “everything done.” The Bakiga-Banyankore call it okutaaga (pulling at straws.) Money is mobilised, and her doctor activates the Cut-Practice system.
When the terminally ill patient arrives in India, her Ugandan doctor gets his big kick-back from the fees. The patient embarks on chemotherapy. Her condition deteriorates. She dies within two weeks of arrival in India. Her family is devastated, but they are comforted by the knowledge that “everything was done.” The cost of returning the body is five times that of a living person’s air travel.
A Ugandan doctor, whose word I trust, told me last week: “I know a so-called senior doctor who has sent ‘rich’ patients to India for sham treatment. On getting there, they go through all the investigations, then they are told to go back to Uganda because they are fine!”
This Indian Cut-Practice is most definitely unethical. It has attracted the attention of the international medical community, with very many publications in peer-reviewed journals, including a long editorial in the November 16, 2013 issue of The Lancet, a leading medical journal.
The scam is so lucrative for all in the chain – the referring doctor, Indian middleman, Indian Hospital and doctor(s), the broader Indian economy – that it is very difficult to arrest. In Uganda, of course, the chain is joined by government officials and others who are involved in approving funding for politicians and other public servants.
Whereas the Code of Ethics of the Uganda Medical and Dental Practitioners Council is vague about receipt of commissions for referring patients, a careful reading of Rule 17(e) suggests that it prohibits this practice. The similar Code of Ethics Regulations of the Medical Council of India more explicitly prohibits giving or receiving such commissions. This is consistent with the international standard for medical ethics.
The conduct of these doctors also violates the cardinal principle of medical and surgical practice, namely, Primum, non nocere – Above all, do no harm. The practice harms patients by impoverishing them to enrich greedy doctors. (The Ugandan doctors are paid hundreds, even thousands of dollars per patient!)
The Indian profiteers direct the patients to their partner institutions, not necessarily to the best doctors or surgeons. The practice sometimes offers hope where none exists, knowingly subjecting patients to unnecessary and expensive investigations and ineffective treatments. The profit motive becomes the driving force, not the patient’s interests.
One Kampala doctor wrote last week that some terminally ill patients are duped into thinking that their conditions are curable. They are told to “go to India, get fixed and live on.” They are not told about the outcomes, life after surgery, gross complications, risks of death and so on.
This doctor has seen patients return from India in their last few days “disillusioned and impoverished following a referral for ‘cure’ of terminal cancer, stem cell transplant therapy, cardiac surgery and so on. The theme has been the same: they are not told the truth and, if any truth, half truths.”
So, what is the solution to this serious problem? We shall share some thoughts on this next week.
muniini@mulerasfireplace.com