Customs that have become crimes

The Serbian Ministry of Health decided in 2000 on a novel idea to help stop patients from drowning doctors with unethical tips and bribes for favored treatment.

Under the banner ‘Thanks But No Thanks’ the ministry invited medical workers to join the campaign to renew ethical standards in the medical profession by returning all ‘tips’ they had received from patients in the last two days.

Among the items returned to patients were more than 6,000 envelopes with 149,500 German marks, 11,000 American dollars and 800 dinars; 396 pigs (96 living and 301 roasted), 8,000 pieces of poultry (processed and unprocessed), 14,217 boxes of chocolates, and 79 cases of Scotch.

Similarly, BiH patients have been saying ‘thanks’ with increasingly large sums of cash but their doctors have not been saying ‘no thanks’ according to health officials and social experts. The result is that BiH is facing a moral collapse that is helping to destroy what is left of a nearly bankrupt health care system.

Patients desperate to get better health care in an economically starved system with falling standards are pushing increasing sums into the hands of their doctors. At the same time their low-paid doctors have gone beyond the temptation of accepting fatter ‘blue envelopes’ to the extreme of demanding them, which is a criminal act of racketeering or extortion. Doctors are now also bold enough to use their public clinic jobs to feed patients to private clinics they own or where the doctors have a second job.

The criminal behavior is the final corruption of age-old customs that began by giving the doctor an apple for good service, said University of Sarajevo sociology professor Salih Fočo, who specializes in Bosnian customs and taboos.

‘Today, a bribe, the phenomenon of collecting money, has developed from such a cultural custom’ Fočo said. ‘It has become distorted due to social circumstances and because the doctor’s financial status in the country is bad.’

The custom has also gotten quite expensive.

The average bribe to doctors currently amounts to 250 KM, which is a 25 percent increase over 2002, according to a report by Transparency International (TI), an international NGO specializing in fighting corruption.

The causes of this problem, the TI report continues, lie primarily in the bad financial situation of the health care sector, which has resulted in low salaries, outdated equipment and a lack of medications, sanitary equipment and food at the hospitals.

The first victims are the patients, who, faced with dissatisfied employees and shortages of supplies, have to decide how much their health is worth above what they have already paid in health insurance.

Dana Dulić remembers making that decision for her mother, who needed to have gall bladder surgery. As she and her mother entered the Banja Luka Clinical Center, she worried about how to bribe a doctor, something she had never done or thought of doing before.

While her mother was calmly talking to the doctor, Dulić suddenly stretched out her hand with an envelope containing her mother’s health value, 300 KM.

‘Thank you’ the doctor said, and without even looking at the envelope, he put it in the drawer of his desk.

Dulić said she had been advised by her friends to offer the money as a second insurance policy to make sure the doctor would give her mother good care.

‘Well, everybody does it’ Dulić said. ‘By doing this, I expect them to pay attention to my mother.’

Professor Fočo believes that patients are to be blamed for the atmosphere of moral decay when they make small desperate decisions like Dulić’s.

‘(The breakdown of morality) is verbally transferred from one patient to another and it develops as an ideology’ Fočo said. ‘Doctors, whether they want it or not, receive an abundance of gifts and it becomes normal.’

Dr. Aleksandar Lazarević, head of the RS Medical Association, agrees that low salaries and desperate patients are putting doctors in a difficult position. He points out that a doctor’s salary will not even pay for a subscription to a single professional journal he needs to maintain his skill level.

‘Doctors are embarrassed because the society has put them in such a position’ Lazarević said.

Such circumstances lead some doctors to a moral abyss and crime, because they engage in racketeering or extortion. Such doctors, who ride roughshod over ethical principles, ask for the money from the patients in advance in order to operate on them. They send a clear message: If you pay, you will be accepted immediately and with gratitude; if not, you have to wait.

The methods of requesting the money from the patients are different, but they are rarely direct. According to TI’s findings, a common method is for a doctor to tell the patient that the operation is urgent, but that there is no available room in the hospital.

‘It means that they let the patients decide, and the conclusion is already known’ said Srđan Blagovčanin, a TI spokesman, summing up the report’s findings.

Despite the temptations brought on by low salaries, demanding money is still a serious crime. But it has rarely been treated as such by prosecutors. Since the war, not one doctor has been sentenced for accepting bribes or other ethical lapses.

Recently, however, several investigations of doctors for bribery have surfaced, alleging some of the methods used to ‘let the patients decide.’

Dr. Mladen Stojnić, from Prijedor, allegedly asked for 200 KM from a patient, explaining it was needed to pay for surgical thread, according to Vukašin Kondić, a Prijedor prosecutor. Police said a patient made a complaint and they used marked KM notes as evidence that Stojnić had accepted the money. Stojnić, who was indicted and will go to trial, denied the charges, and said he was set up by police for what was only miscommunication between himself and the patient.

In a Sarajevo case, police recently sent charges to the prosecutor alleging that Dr. Zijad Lagumdžija, of the University Clinical Center (UCC) Koševo, acted as a mediator to convince the best doctors to operate on a patient. Elvis Demirović alleged that Lagumdžija asked him for 2,000 KM to find a doctor for his wife’s pregnancy complication. Lagumdžija denied the charges and said he was only explaining that there would be a legal extra charge for a complicated procedure.

The two cases were both brought because of allegations made by patients to the authorities. But patients willing to take an ethical stand are rare, according to police and medical administrators.

Dr. Dragan Kostić, director of the Banja Luka Clinical Center, admitted that he knows that bribery, ‘the worst form of crime’ does goes on at the Banja Luka hospital, but it is hard to prove without a credible witness.

‘The patients complain, but they refuse to sign the statement, because of fear, I guess’ Kostić said.

In that case all he can do, Kostić added, was to warn that particular doctor that he will publicize his or her name if it is once again mentioned in such context.

Many doctors either do not want to talk about the subject of ‘favors’ or they negate its importance and scope, and say that those are only the stories the patients tell.

Some doctors see a broader picture relating to the customs of gift-giving. They believe they are allowed to take everything given ‘voluntarily’ by the patients.

‘If you are satisfied with a waiter’s service, will you leave half a mark for him? It is in our tradition to be grateful’ said Marin Kvaternik, the RS minister of health. ‘But the problem is when a certain amount of money becomes a precondition for the operation. It definitely is a problem.’

Others attach importance to the amount of money and not the act of bribery.

In an interview, an angry Dr. Stojnić pointed out that, although he is innocent, he will be on trial in Prijedor for allegedly taking 200 KM for colon cancer surgery, when he has heard that doctors are asking for 2,500 KM in Banja Luka.

Even Dr. Lazarević from the RS Medical Association, which deals with the ethics of the profession, believes that with the current level of corruption in all areas of society too much significance is being attached to small bribes.

‘Millions of marks are missing, or are stolen and nobody asks about them’ Lazarević said. ‘And a doctor is on trial because of 200 KM.’

Apparently the liberal attitude toward ‘gifts’ is not only found in BiH.

Croatians spend 250 million euros per year for the gifts, expressions of gratitude and ‘blue envelopes’ according to data from Adenda, a private insurance company. International financial institutions estimate that the health systems in most central and southeastern European countries receive 15 percent of their annual health sector budget in bribes and gifts.

If such estimates are correct, then the citizens of Bosnia-Herzegovina would be spending 120 million KM a year for such purposes.

Most of the bribery cases in BiH, according to the reports of citizens to TI, mostly relate to the UCC Koševo and Banja Luka Clinical Center, particularly to the surgical wards.

‘Obtaining money from the patients by extortion is a criminal offense’ UCC Koševo director Dr. Faris Gavrankapetanović said. ‘And should that be the case, I will always file a complaint against a doctor.’

Gavrankapetanović said he knows of none of the bribery complaints that the TI report claims to have had from the center’s patients.

But one of the doctors in charge of a Koševo ward said that bribery is a big enough problem in the clinic that he has prohibited patients from giving and the staff from accepting money from patients.

‘The FBiH provides all patients with free medical treatment. If someone asks for the money, then it is blackmail’ said Dr. Haris Vila. ‘Since there have been cases of doctors who accept money, I wanted to prevent them at my ward. I am not interested in what happens in the halls of other wards.’

In the country’s private clinics, blackmail and bribery are all but unknown. At Banja Luka’s Jelena private clinic there are no gifts, according to manager Dr. Mirjana Nikić.

‘In the private sector, there is order, work and discipline’ Nikić said. ‘The patients are informed about the prices, and if somebody really wants to show gratitude, it can be shown in the form of flowers.’

But private clinics have also become the home of moonlighting doctors from public clinics and hospitals. These doctors draw patients away from the public system, often to their own clinics, but still depend on public facilities to provide expensive patient services.

Due to low salaries, doctors have tried to earn money on the side in private clinics, but very frequently they do it on the working hours which should be spent in hospitals.

‘Our doctors have private practices and every test they charge the patients for is done at public institutions’ said Dr. Aida Čemerlić, deputy director of the FBiH Public Health Institute, which analyzes statistical data on the health system. ‘It is chaos paid by both the patients and public health.’

Doctors need to choose either a public or a private job, Čemerlić added.

In neighboring Croatia, dual practice is prohibited, meaning that if a doctor chooses private practice, he or she has to leave the public health institution.

But many BiH doctors disagree with a complete ban on the practice.

‘Under the Law on Labor, it is not allowed to prohibit somebody from working on the side if the state has not provided them with a decent salary’ said Dr. Lazarević from the RS medical association.

He agrees that a person should not own a private practice and be a public institution employee at the same time. But that is not the same as simply having a day job and a night job.

‘If you work the whole day, you sacrifice your family life to provide your family with a normal life’ Lazarević said. ‘There is no conflict of interest.’

But moonlighting can cause bigger problems, as Dr. Kostić, the manager of the Banja Luka center, found out.

Kostić terminated dual practice in the Banja Luka center, because he found that doctors were working at private clinics when they were supposed to be at the public clinic. He also discovered that one group of doctors were recruiting public patients for the doctors’ private clinics.

When Kostić began to compare public and private clinic costs he found some suspicious facts. One of the public clinic’s drug suppliers said they had not sold a single anesthetic to private clinics in two years, even though most of them perform surgeries, Kostić said.

‘It is assumed that drug ampoules and other medical equipment find themselves in the pockets of the doctors in dual practice’ Kostić said.

Kostić then developed a records system that enabled him to monitor the delivery of the medications to the Clinical Center and their distribution out of the Clinical Center.

Health care administrators like Kostić who are trying even small reforms are risking the anger of their profession, because it is not in doctors’ interest to have somebody limit their earnings.

Dr. Zoran Riđanović, director of the FBiH Health Institutions Quality Assessment Agency, got a similar reaction when he proposed a solution as simple as Serbia’s ‘No Thanks’ program to end the distorted gift custom.

He suggested a sign at the entrance of every hospital and clinic: ‘The staff of this hospital will not take any money or expensive gifts. If you want to support the hospital pay some funds to its bank account.’

Even though he said he would exempt small gifts of boxes of chocolate it still seemed like it was going to be a hard sell in the current Bosnian health care system.

‘One of my friends, a hospital manager, after hearing about my proposition, said that it would not be popular, because he would lose his influence over his staff’ he said.