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Read the whole health sector review or jump to any section using the headings on the sidebar. Or download this sector review as a pdf document to read separately. Whoever you are – a health professional, a health Minister, a health company executive, a patient association – we hope that this review will give you ideas.
Health Sector review as at 7-10-2018
Health corruption is a major issue worldwide, in both developed and developing countries. Within the EU, for example, the European Commission has been active in scoping the scale of the problem. In the EU 2017 report on corruption in the healthcare sector they say: ‘The health sector is one of the areas that is particularly vulnerable to corruption, but relatively little is known about this subject… Countries where patients have the most frequent experiences of paying for privileged treatment are Slovakia (41%), Slovenia (38%) and Germany, Spain, France and Sweden (all 29%), while the EU average stands at 19%. … They then add some cause for optimism: Prosecution of physicians for bribery in medical service delivery has, over the last few years, become more common. Also, it appears that the younger generation – both physicians and patients – tend to no longer accept bribery in medical service delivery as common practice.’
AUTHORS AND CONTRIBUTORS
The originating author of this health sector review is Mark Pyman, who is the founder of CurbingCorruption. Additional contributions have been made by Sarah Steingrüber, Rich Feely and Taryn Vian. Sarah Steingrüber is the global health lead for CurbingCorruption.
FOCUS on the specific corruption issues - Guidance summary
The corruption challenge needs first to be focused – disaggregated – into specific issues. Our experience is that there are 20-40 different issues in each sector, recognisable to those working in it. They can then be organised into an easily comprehensible format – a typology. The reforming group uses the one-page typology as the starting point for discussion and for analysing them: their scale, importance, context, avoidability and solubility. You can use this as the basis for building a shared understanding of the impact of the corruption.
Start by disaggregating the different corruption types that you are faced with. You can do this in the following way:
You can read more guidance on FOCUS here.
In tackling corruption in a national sector as large as health, where is it best to start? We suggest that you start by considering your health sector as a ’system’ of six building blocks, as defined by the World Health Organisation (WHO) and USAID: Service delivery, Human resources for health, Medical products, vaccines and technologies, Health Information Systems, Health financing and Leadership and governance. This conceptual framework draws from the efforts of the past two decades to define and understand health system functions and performance and has its basis in systems thinking. The building blocks are shown schematically in the diagram below:
Our typology identifies 48 different types of corruption in health. We categorise them according to the six WHO building blocks. Some corruption types are generic, like favouritism in the appointment and promotion of staff, but most are specific to the health system, such as bribes to advance on the surgery waiting list, or unnecessary operations, or collusion in the pricing of medicines. Some corruption types are specific to just a few countries, for example health insurance, which is a huge issue in the USA (See Rose-Ackerman and Palifka, 2016). Collectively, this list is called a ‘corruption typology’.
Here is the tabular list of the health typology
Health Corruption types
2. Unnecessary or expensive interventions
3. Informal payments or bribes in medical and surgical interventions
4. Informal payments or bribes in medical and surgical waiting lists
5. Prescribing of over-costly or unnecessary medicines
7. Other cases of illegal contact of health professionals in the public health sector: pre-selection of patients, directed prescription of drugs, issuing of false documents, private use of equipment, etc
8. Inappropriate prescribing of prescriptions and misuse of the electronic prescription system.
9. Over-treatment due to incentivising the application of diagnostic procedures and treatments
11. Inappropriate care strategies to suit special interests
12. Dereliction of duty by permitting fraud, lax controls, deliberately allowing control and clinical audit agencies to remain weak, etc
14. Inappropriate absenteeism
15. Nepotism in restrictive expert groups such as doctors
16. Inappropriate professional accreditation
17. Expert-bias in complaints and disciplinary procedures,
18. Acceptance of improper inducements for conferences, research, product placement
19. Accepting reimbursement through fake workshops and fake per diem schemes
20. Human rights and related discrimination against certain groups,
21. Conflicts of interest
22. Fake reimbursement claims
24. Inappropriate approval of products
25. Inappropriate product quality and inspection
26. Private sector collusion on medicines and technologies
27. Corruption in the research and development of new products
28. Companies ‘gaming’ the system to keep medicine pricing as high as possible
29. Theft and diversion of products
30. Re-packaging of non-sterile and expired products
31. Legal parallel trade in drugs for export that corrupts the system
32. Overly high pricing of non-medical products (gloves, stents, drips, etc)
33. Inadequate control of non-intervention studies and lack of transparency in clinical research
34. Improper benefits offered by medical companies accepted by health professionals, such as participation at conferences, sponsored medical education and other hospitality
35. Improper acceptance of donated medical devices
36. Improper research, trial and marketing practices by health companies
38. Corruption in procurement
39. Complex and opaque tendering procedures: complexity makes them vulnerable to corruption
40. Highly decentralised procurement, where purchasing is separately implemented in each hospital and agency, allows for both inefficiency and corruption.
41. Donor collusion in corruption
42. Corrupt invoicing by suppliers, sometimes in response to government delayed payments.
Alternative corruption typologies in health. There is no magic to the above typology: The purpose is to start you off with a sound template that you can modify in line with your own particular context. Here are some alternative corruption typologies in health
Transparency International’s Pharmaceuticals and Healthcare programme (ti-health.org) lists 37 different corruption issues across pharmaceuticals and healthcare, as shown opposite.
There are also other ways you can categorise the corruption types. For example, you could categorise them by the categories of people involved in corruption:
Or you can categorise the issues using a ‘value chain’ perspective. This was done by Savedoff and Grepin (2012), for example, in application to the health system in Ethiopia. See opposite:
Aggregate, comparative data: You may want, or need, to present specific corruption data on your health system. Such information comes usually from national and sub-national surveys, which you may be able to use, or to piggy-back on. Groups like Transparency International, World Bank and OECD also do larger surveys across many countries, which can also be surprisingly detailed about the individual countries.
The OECD has done several analyses of corruption in health. Opposite is data from an OECD 2015 analysis, showing the 10 ‘worst’ countries for health corruption, and making comparisons between them. Or you can commission your own – many countries do this, as the EU 2017 example at the beginning of this review showed.
Local national or sub-national data on health corruption. Your health system may have its own data on fraud, corruption and patient complaints, some of which will be about corruption. If you can use these, do. NGOs and patient associations may also be well informed. Local anti-corruption NGOs may be prepared to carry out a survey or analysis for you, or you can commission an external analysis.
Ask around or looking for local data yourself. Nowadays there is a lot of research and surveys in corruption, and it may be that others can point you towards it. For example, recent re-analysis by researchers of global data from Transparency International’s Global Corruption Barometer is showing up country specific and sector specific trends in corruption. You may not know about such analyses yourself, but if you ask around in the sector, or ask us at CurbingCorruption, you may find more useful material.
Example: Data showing reduction of corruption in the health sector in Uganda
According to a recent re-analysis of Transparency International’s Global Corruption Barometer (GCB), the bribery rate for health services had halved for service users between 2010 and 2015. Such a stark reduction in the health sector’s bribery rate was statistically improbable.
This analysis was done by Peiffer et al (2018) at the Leadership Development Program.
The reduction would seem to be the work of the relatively new Health Monitoring Unit (HMU). A highly visible institution with an exceptional degree of support and direction from the president, the HMU developed a strategy to improve accountability in the sector. This included high profile raids. Through highly visible investigations, the HMU seems to have been effective in making health workers in the country significantly more cautious, reducing their willingness to request bribes. Requests for bribes for health services appear to have decreased as a likely consequence of the HMU’s efforts. However, though there have been bribery reductions, the naming and shaming approach has also led to reduced morale among health, because of perceptions that the HMU had unduly harassed many innocent health professionals.
The above list of specific health corruption issues may be sufficient for your purposes. Alternatively, you may like to make your own list of corruption types relevant to your operations. You will want to consider whether to pick out the most serious, and/or the most common, or the most distressing for patients, or the costliest, or the ones that should be easiest to solve.
Doing this analysis can be a two-hour exercise or it can be a six month one. The quick way is always attractive. Your own staff are usually well aware of the corruption issues. Health professionals are among the most committed people in the world, with extensive experience of working in large, complex, bureaucratic environments. Hence, they are likely to be the best informed about what the corruption problems are, which ones can be tackled, and which ones need to be left for later.
Give them the typology of health corruption types above and ask a group of them to analyse which are the more relevant ones and their relative importance. This simple approach has the advantage that you can quickly capture the ‘top of mind’ knowledge of your senior professionals. It has some disadvantages, notably that it is likely to focus on the more immediate issues. In the mid-range, you may have specialist groups with extra knowledge, like internal audit groups and clinical audit groups. Together with external groups like community health groups, patient communities and civil society, you can get a more inclusive analysis done, still quite quickly. It has the same disadvantages as above.
At the most thorough end of the spectrum, you can get a detailed analysis done by groups with professional anti-corruption knowledge, if possible combined with health expertise. These groups might sit within universities, or civil society, or think tanks. You can consult our list of sources of expertise in Reading & Bibliography, that can give you some guidance. Such analyses are likely to take from two months to six months. In large initiatives, there are several analytical techniques you can consider, such as Vulnerability to Corruption Analysis (VCA), Public expenditure tracking surveys (PETS) and Quantitative Service Delivery Surveys (QSDS). Read more about techniques for analysing corruption vulnerability in our Guidance Step 1 – Analyse the specific corruption types.
There is also an obvious and often sizeable political advantage to having a thorough, independent analysis done of the corruption issues and risks. If you have time and funds, we recommend that you do a thorough analysis.
Example: Ethiopia commissioning a first analysis of health corruption types
In 2012, Ethiopia was starting to open itself up to external scrutiny about the levels of corruption in the country. This was stimulated by their poor standing in the Transparency International Corruption Perceptions Index of that year. They commissioned analyses by external experts on each of several sectors (construction, telecoms, health, etc.). The health analysis, not surprisingly, pointed out a range of problems (Savedoff and Grepin, 2012).
They provided a typology of the problems that could be used by the Ethiopians: Procurement (poorly functioning reporting systems and weak oversight); Pharmaceutical management ( Concerns on the licensing, selection, and sale of medicines; pharmacists’ opportunities to exploit patients; and a growing black market for pharmaceuticals); Regulation (The inspectors who enforce the health regulations are poorly paid and vulnerable to requesting and accepting bribes); Unequal patient treatment (Although illegal payments did not appear to be a major issue in Ethiopia’s front-line service delivery, many interviewees reported complaints that providers give preferential services to friends and colleagues); Rising foreign and other donor aid (the influx of funds outside of the public system and the sheer size of these new funds have also increased the risk of corruption).
Specific Reform Measures - guidance summary
Reform measures will always be specific to the particular circumstances. Nonetheless, in order to get ideas and insights, it helps to learn about reforms employed elsewhere and to have a mental model of the type of what sorts of reforms are possible. We recommend you consider each of these eight categories of specific reform approaches:
Talking through with colleagues and stakeholders how each of them might work in your environment enables you to ‘circle around’ the problem, looking at different ways and combinations to tackle it. One feasible option might, for example, consist of some institutional improvement projects, plus strengthening integrity among staff, plus strengthened sanctions and discipline.
You can read more guidance on Specific Reform Measures here.
There are fewer examples of health corruption reforms than we would like to see. We think this is because corruption within the health sector is less talked about than you might expect. In high income countries like the EU, as we quoted in the introduction to this review: ‘The health sector (in the EU) is one of the areas that is particularly vulnerable to corruption, but relatively little is known about this subject.’ (EU 2017).
In developing countries, a good guide is from USAID, who have systematically reviewed their experience of anti-corruption programmes, including in health. Although most were aimed at health system strengthening and health governance, not corruption, these initiatives did serve to strengthen the anti-corruption environment and prevent fraud and waste while establishing transparency in the sector. Several common reforms were identified: Developing health information systems – these are perhaps the most powerful for exposing areas vulnerable to corruption; Institutional strengthening through improving protocols and standard operating procedures; Creating performance-improvement mechanisms that strengthen the Anti-Corruption environment; Strengthening healthcare policies and the healthcare regulatory environment; Building capacity and effectively engaging non-state actors; Innovative communication approaches to enhance hospital-community relations; Improving monitoring and oversight; and integrity and ethics reforms USAID (2014)
This is a large category, including organisational reform, service delivery and other clinical reforms, reforms to non-clinical processes, reforms to management information systems, and technological reforms. There are usually more reform measures in this category than you can possibly accommodate. The question is one of prioritising, using criteria such as relative impact, political opposition, or the risk of slow implementation.
Functional reform measures you can consider:
This is where the anti-corruption work will be most clinically facing. There are likely to be multiple initiatives and reforms going on at any one time to improve service delivery in a national health system. Such work to improve patient outcomes is the core business of any health system, and the corruption aspect will only be one element of this. The way that clinical protocols and pathways operate is very closely linked to the corruption opportunities that they throw up, whether this be for unnecessary procedures, or overtly expensive ones, or pathways that favour one medical group over another, and so on. This is as true in developed country environments as in developing country situations.
Example1: Preventing informal payments in Armenia through a child certification programme. The Health system in Armenia is complex but underfunded, and much of the payment for services comes directly from citizens, of which about 70% are for ‘informal payments’, rather than for official services or payment for medicines. This reform initiative focused on informal payments for child health, and a ‘Child Health State Certification Program’ was designed and implemented. USAID reported as follows: ‘The findings of the quantitative assessment clearly demonstrated that the Child Health State Certificate Program significantly reduced informal payments for paediatric inpatient care for children 0-7 years of age and increased accessibility of care for those who could not afford it previous to the program’ (USAID, 2011).
Example2: Reform of clinical pathways and payment system in Vietnam. ‘Researchers from Vietnamese Health Economics Association, a civil society organisation with support from AusAID (Australia), are developing a case-based reimbursement methodology, which they believe can help improve transparency and reduce perverse incentives in the health care delivery process. Case-based payments, established prospectively based on estimated resource needs for standard care, replace fee-for-service reimbursement. Under this kind of payment system, providers no longer have the incentive to use many diagnostic tests or potentially ineffective treatments to maximise revenue. Working in four pilot hospitals, the research team collaborated with facility personnel to develop care pathways for the treatment of three types of cases: pneumonia (medical), normal delivery (obstetrics) and appendicitis (surgery). For each of these cases, the researchers developed criteria for admission and discharge, indications for standard mandatory and other diagnostic tests and imaging, guidance for selection of drugs and criteria for other interventions.’ (Vian, 2012).
Examples3 of bribes for service delivery: There are many more analyses from other countries of the small bribes paid to navigate national health systems, and the ways in which the authorities tackled this common problem. There are further examples described by Vian et al (2015), Stepurko et al (2010), Bjorkman and Svensson (2009), Liarapoulos et al (2008), Rispel et al. (2016).
Improving the way that the multiple systems and processes of the health system works is a natural way to reduce corruption: by reducing procedural complexities, streamlining budgeting, automating cumbersome procedures, improving controls, improving the range and reliability of performance indicators, etc., etc. However, be cautious. It is tempting for officials to focus on these types of improvements, because they are technical, can be defined precisely, and are usually relatively non-political. However, there are two problems. First, they can tend to take time to put in place, easily 12-24 months. This is a real issue – the timeline to results will be longer than what you would want to show progress to citizens. Second, there is also a more cynical aspect: the fact that the work takes time allows progress to be proclaimed until sometime after the momentum for change has dissipated. Those opposed to corruption reform can therefore safely support such initiatives, anticipating that they can be slowed down again in 12 months’ time.
Example4: Health procurement corruption reform in Ukraine using ProZorro. Ukraine has made excellent cost savings in the health sector (and in other sectors as well) through procurement anti-corruption and transparency reforms. See “Everyone sees everything; the overhauling Ukraine’s corrupt contracting sector”.
Example5: The Open Contracting Partnership. OCP is an excellent multi-country reform initiative measure that is being used by a wide range of countries, from the UK to Mexico to Afghanistan. It starts at the planning stage, and covers tenders, awarding, and implementation of public contracts, including in health.
Improved Health Management Information Systems (HMIS) are one of the most crucial technical levers for reducing corruption. This happens both by direct changes, such as by better medicine stock management, and indirectly, by providing reliable data on the performance and relative performance of all parts of the health system. This is at least as much an issue for developed countries as for developing ones, because they are often working with large, cumbersome systems that are too expensive and sometimes too complex to replace. In such cases, simple web-based solutions alongside the old systems to get over some of the worst efficiency and corruption problems may be as much a corruption reform as an efficiency reform.
Example6: Greece, for example, has made great progress with a Business Information’ portal for health that has been able to circumvent their huge problems with inflexible, complex old systems. Note that the same cautions apply as with the non-clinical improvements already discussed: It is tempting for officials to focus on these types of improvements, because they are technical and tend to take time to put in place, e.g. 12-24 months.
Examples7: MIS strengthening in Albania, Moldova, Cambodia, Palestine West Bank. USAID has done such improvements, for example, in Albania, Moldova, Cambodia and Palestine West Bank. These systems improved management, administration, and operational efficiencies of hospital and health actors, leading to greater transparency and access to information within the sector. As the USAID 2014 evaluators put it for the Albania project: ‘The systems contribute to anti-corruption by creating greater control over critical data and information and, thus, reducing the opportunity for committing medical fraud’. And for the Cambodia project: ‘The project-supported health informatics team works closely with the hospital improvement program to improve data collection methods, data quality and data use via HIS. Improved data quality reduces the likelihood of corruption by diminishing the ability of individuals to manipulate or falsify records and information.’
There are multiplying numbers of reforms using new technologies, mobile apps and social media that may also reduce corruption. A recent review identified 15 distinct ways of using technology for good governance activities in LMIC health care. These use cases clustered into four conceptual categories: 1) gathering and verifying information on services to improve transparency and auditability 2) aggregating and visualizing data to aid communication and decision making 3) mobilizing citizens in reporting poor practices to improve accountability and quality and 4) automating and auditing processes to prevent fraud. From Holeman et al (2016). For a review of data mining processes to reduce fraud in health, see Joudaki et al (2015).
Ministries can easily become corrupted. If the problem is deep rooted, you need to consider also whether changing the mandate and/or structure of the Ministry and/or the health system organisation might reduce the problem more fundamentally.
Example8: Health ministry structure in Afghanistan. The health system is fundamentally structured to be operated by international NGOs (like Save the Children and the Aga Khan Foundation), rather than by government. The Ministry is therefore less operational and more geared towards policy and financial control. They still have major corruption problems (See Pyman 2018 Tackling health sector corruption: five lessons from Afghanistan), but they no longer have the larger corruption problems that arising in a post-conflict government bureaucracy
Example9: Benefits of Public-Private partnerships in Lesotho, Southern Africa. Lesotho has explored the use of Public Private Partnerships (PPP) to improve health governance and the corruption impact of such reform seems to be beneficial. An independent assessment concluded that ‘Corrupt practices that were described at the government-run hospital (theft, absenteeism, and shirking) were absent in the PPP hospital. In the PPP hospital, anticorruption mechanisms (controls on discretion, transparency, accountability, and detection and enforcement) were described in four management subsystems: human resources, facility and equipment management, drug supply, and security. … The PPP hospital appeared to reduce corruption by controlling discretion and increasing accountability, transparency, and detection and enforcement. Changes imposed new norms that supported personal responsibility and minimized opportunities, incentives, and pressures to engage in corrupt practices. By implementing private-sector management practices, a PPP model for hospital governance and management may curb corruption.’ Vian et al (2017).
People-centred measures you can consider, with examples
Being clear that your team can and will make a difference – can change the organisation’s culture to one with a much lower tolerance of misbehaviour. This sounds so straightforward as to be hardly worth a Chapter heading. But it is important because tackling corruption is not a ‘normal’ thing to be talking about or doing. Being clear that your team can and will make a difference can change the organisation’s culture to one with a much lower tolerance of misbehaviour can inspire people to work with you and to put in much more than ‘normal’ effort.
Most people in most organisations hate corruption but feel trapped and disempowered by it. Building a team of officials across the ministry and related agencies who share the vision of what can be achieved with less corruption is therefore a key place to start. Ask someone to open up these discussions across the organisation.
Example1: Using a questionnaire to tease out peoples’ opinions. You could use a questionnaire to bring out peoples’ opinions. Here is one example opposite for local government employees from UN Habitat 2006, but it could easily be adapted for health. For each of the ten statements, there are four choices, to register whether you agree (score 1) or disagree (score 4) with the statement, and how strongly. The results indicate to the respondent and to you how big a barrier there may be to tackling corruption and is one way to start the conversation.
This author has been present at such discussions in numerous professional leadership groups, from global companies to health leadership teams, from clean Scandinavian countries to conflict countries. Each of them was initially reluctant to engage in open discussion about corruption. This changes quickly once you make it clear that this is not a taboo subject, and that your purpose in tackling it is not punitive but is constructive, because it will actively improve access and service for your patients. You can do this in round table conversations.
Example2: Convening quarterly senior public official discussions in Afghanistan on corruption reform progress, including on health. See this report from MEC 2017
Set up one or more forums where people can come and demonstrate their commitment to your plans. Sometimes people – public officials, citizens, whoever – are ready to help but don’t have a forum around which to congregate. Patients groups and Community groups can provide a powerful voice not only on which corruption issues hurt them most, but also what the solutions can be.
Focus your efforts on building a coalition across multiple stakeholders.
Example3: Coalitions, politics and success in health reform: the ‘Sin tax’ in the Philippines. A diverse range of partners, including doctors and health-related organisations, led reform against tobacco, via the so-called ‘Sin tax’. This was a classic coalition of parties with different interests and one in which companies were also involved as ‘allies of convenience’, notably British America Tobacco and San Miguel Corporation. The reform coalition included other diverse components, namely:
Read more on the process that led to the Sin Tax
This analysis of the role of developmental leadership in the passage into law in December of excise tax reform which significantly raised taxes on cigarettes and alcohol – generally referred to as the Sin Tax Reform’ is taken from Sidel (2014) Achieving reform in oligarchical democracies: the role of leadership and coalitions in the Philippines.It is also quoted in Development Leadership Programme (2018) Inside the black box of political will.
A broader form of developmental leadership was critical to their passage into legislation and their subsequent implementation, comprising reform coalitions that incorporated elements of government, the legislature, and civil society. While these coalitions were diverse and flexible in their form and composition, their core strength came from established advocacy groups and experienced activists. These groups and activists used highly labour-intensive, specialized and complex forms of mobilisation. Plus there were also ‘allies of convenience’: The reform coalition found itself in alignment with British American Tobacco (BAT), which openly sought to ‘reform’ a tiered tax classification scheme which greatly inhibited the entry of its products into a market monopolised by others.
The success of these reform coalitions has implications for economic and governance reform in the developing world, particularly in systems characterised by oligarchical democracy, where competition for elected office is closely linked to the entrenched interests of business and industry.
In the event, the passage of the bill secured billions of pesos in annual new tax revenue for the government and contributed to growing investor confidence in the Philippines. The Sin Tax Reforms had significant health implications as well. The passage of the bill also demonstrated that it is possible for reform legislation to overcome resistance from powerful special interests, thus emboldening reformist elements within the administration and beyond. The passage of the bill has also helped to strengthen the political capacities, knowledge, and connections among a network of ‘reform entrepreneurs’ within the administration, in Congress, and in civil society.
See Section 2.8 later in this section.
To some in the health sector, it may seem perverse to suggest working with the health companies on corruption. Aren’t they the cause of much of it? Indeed, often they are. But they also have the energy and the means to do something about it and in the last ten years, encouraged by tougher anti-corruption laws, larger companies have moved towards active efforts to make sure that they are ‘compliant’ by not being involved in corruption. This shift is not universal: there are many countries of the world where almost none of the national health companies have a meaningful compliance programme. Nonetheless, this shift is welcome news for tackling corruption because solving corruption requires constructive inputs from multiple groups, one of which is the private sector. Here are six things you can consider doing:
There may be a more fundamental issue than simply pressing health companies to engage and do better, which you may or may not be able to address. The issue may be that the structure of the health industry in the country incentivises corruption. There are often hundreds, or thousands, of local manufacturers of drugs who have to sell into the grey market of hospital purchases. Besides often being poorly regulated, this also makes it harder for the larger multinational companies to avoid bribery. China has been a major example of this problem (e.g. leading to the prosecution and punishment of GlaxoSmith Kline), but also of solutions:
Example4: The Government of China has moved to cut off the licenses of offending local producers (See for example The Economist (2018) China is sprucing up its pharma sector and Cockcroft 2012 pp 33-35).
Independent scrutiny is key to reducing corruption. Sometimes, for exactly this reason, independent scrutiny bodies are under-resourced, or populated with low-grade staff, or denied access to key people and records, bribed or threatened, and otherwise marginalised. Finding ways to get multiple forms of independent scrutiny into effect is a core part of anti-corruption strategies. There are multiple mechanisms you can use and/or strengthen. Here are actions and examples that you can consider.
8 Monitoring reform measures you can consider, with 11 examples:
Monitoring by outside groups is an important part of control against corruption. Patient groups, Community groups round a hospital, specialist health forums, all can be used both as a source of knowledge about the corruption issues and as a good location to seek local solutions. In some countries these are easy to set up, in other countries the opposite is true. Some countries, especially in Latin America, have a very active tradition of citizen engagement, and they are likely to be already active on anti-corruption scrutiny. In other countries, you will need to encourage them, or find ways to support them.
Regulatory agencies and oversight agencies are vital parts of the control framework of a health system. However, it is easy for their standards to deteriorate, to become servants of government officials, or even for the agencies to become complicit in condoning corrupt practice. Examining how these independent agencies are functioning, the independence, competence and diversity of their members is important. The opposite problem is also common, that there may be too many such agencies. Their overlaps and organisational confusion simply enable the corruption.
Example1: Vietnam health system. The article calls for regulatory and service delivery functions to be split in the Vietnamese health system. There will be endemic corruption until the government realises that it cannot be both a ‘player’ and a ‘referee’ at the same time. Other countries have models similar to the Medical Council model, where a board independent of the Ministry of Health has disciplinary powers over professionals working in Ministry of Health facilities. The following options, based on the three approaches of Vietnam’s anti-corruption strategy, would help: Approach 1: Enhanced administrative oversight; Approach 2: Transparency, citizen monitoring and participation; and Approach 3: Structural policy reform to reduce incentives for corruption’ (Vian et al 2012).
Audits and reviews of corruption risks and issues are a powerful way of raising awareness of corruption and deterring wrongdoers. But these control mechanisms are not used in health systems as much as elsewhere. Internal audit has been a low-quality department in many health systems, and often subservient to health system management or to local management. In such situations, you would be better off using an independent group to do the audits.
In other countries and health systems the internal audit function is strong, and so can be used. They signal a change in the culture and show that certain areas of the health system are being targeted.
Example2: Health system monitoring in Colombia. In the Colombian health sector, there are currently eleven Internal Control Offices.…‘it is identified as a high-risk sector, as there are many potential entry points for poor service delivery, waste and malpractice, as well as corrupt schemes and conflicts of interest (state capture, public procurement, over-billing, doctor-patient extortion to jump the treatment queue, links between medical professionals and the pharmaceuticals industry, etc.), which makes a strong case for an effective internal audit function.’ (OECD 2017 Colombia report, p131.
Example3: Health fraud audit in Calabria, Italy. In Calabria, countless investigations in healthcare have corruption as both a crime and a conspiracy, including mafia infiltration. In his report to the Italian Parliament on 27 February 2009, Renato Brunetta, then Minister of Public Administration and Innovation, showed that Calabria was in first place for corruption in healthcare. Still, much corruption remains hidden; despite the Laws on Checks and Controls, healthcare organisations previously lacked a comprehensive system of control of both administrative and economic performance. (European Commission 2015). (Read more: More detail currently unavailable as at June 2021).
Example4: Internal audit leading transparency and corruption reform in Ukraine. In other sectors, internal audit has developed as the lead group in tackling corruption in that Ministry. One example is in the Defence Sector, where Ukraine has made progress led through the internal audit departments work. See, for example Barynina and Pyman (2012), and ‘The 3rdline of defence: how audits can help address defence corruption’. She leads that Department and her analysis is of 400 defence audits and reviews, all of which are publicly available.
Routine external audits have a surprisingly low success rate in detecting and exposing fraud; yet this is an expensive resource, and a potentially powerful one. Carrying out reviews of the quality of external audits is one way to tackle this issue (through broader than health sector alone). Where there is a specific health external audit and investigation agency, making this a priority element of the health anti-corruption initiative can be useful. Such agencies may have been marginalised in the past, and increased focus and resources can invigorate them.
Example5: Global Fund, GAVI both do regular reviews of the effectiveness of their audits. See for example GAVI (2020) Audits and Investigations Department: Independent quality assessment, Feb 2020; and Global Fund (2017b) OIG Report: Thematic Review of Fraud Reporting by Four International NGOs. Here
This is an established way of understanding the nature of corruption and fraud within a health system. In a review of case studies conducted in 33 organizations from six high income countries, concluded that the ‘percentage loss rate’ due to fraud and abuse in health care ranged between three to ten percent with an average of 5.6% of total health care costs (Rashidian et al 2012). However, the same study found that there are few health fraud audits being carried out in low income countries and even less attention is paid to fraud and abuse related to private insurance organizations.
Example6: Cameroon. External investigations have a vital role, and, if there is external donor aid, this is an area where the donors can actively assist. In Cameroon, the GAVI alliance initiated an investigation into massive fraud and misuse of drugs in a Cameroon project in 2009-2011 The result led to a stimulation of reform. Based on these findings, and in consultation with the Ministry of Public Health (MOPH), ‘The case study shows the benefits donor organizations can gain by adopting a transparency and accountability policy: Having a clear policy in place allowed GAVI to implement pre-defined procedures, including the FMA and follow-up investigations, which detected and responded to mismanagement and abuses. The policy was agreed upon beforehand and contained stepwise escalation procedures, which made response actions more transparent and understandable. Although the investigation revealed that government employees were involved in the fraud, which was undoubtedly an embarrassment for the Cameroonian government, they fully supported the investigation and were willing to act on its findings. In addition to providing guidance and support for the detection of misuse of funds, the TAP policy also helps to deter future violations by strengthening financial management support – not only detecting, but also preventing corruption’ (See U4 2013).
Clinical audit is an equally powerful and often under-utilised control mechanism. It is defined (Wikipedia) as “a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change“. Clinical audit only entered mainstream health care in the 1990s but is now a standard clinical control mechanism.
Sometimes it makes sense to press for a formal Commission of enquiry about the corruption, as a way to publicly address known but unexplored problems. This is a way of raising awareness of the corruption issues in a very visible public forum. It means that there will be huge attention to the health sector and may result in greater momentum for reform. Even if the follow up is subverted, such Commissions can be valuable.
A detailed analysis of the rationale and potential benefits of choosing such a reform measure in a country like Uganda has been made by Kirya (2011) in ‘Performing good governance: Commissions of Inquiry and the Fight against Corruption in Uganda’. Here is her overview: ‘The findings suggest that the global anti-corruption framework signified by the good governance agenda is hindered by various factors such as the self-interest of donors, the moral hazard inherent in aid and the illegitimacy of conditionality; all of which contribute to the weak enforcement of governance-related conditionalities.
This in turn causes aid-recipient countries such as Uganda to do only the minimum necessary to keep up appearances in implementing governance reforms. National anti-corruption is further hindered by the government tendency to undermine anti-corruption by selective or non-enforcement of the law, the rationale being to insulate the patronage networks that form the basis of its political support from being dismantled by the prosecution of key patrons involved in corruption. Ad hoc commissions of inquiry chaired by judges, which facilitate a highly publicised inquisitorial truth-finding process, therefore emerge as the ideal way of tackling corruption because they facilitate ―a trial in which no-one is sent to jail. …They also served to appease a public that was appalled by the various corruption scandals perpetrated by a regime that had claimed to introduce ―a fundamental change and not a mere change of guard in Ugandan politics.
Nevertheless, while they enabled the regime to consolidate power by appeasing donors and the public, they also constituted significant democratic moments in Ugandan history by allowing the public – acting through judges and the media – to participate in holding their leaders accountable for their actions in a manner hitherto unseen in a country whose history had been characterised by dictatorial rule.
Example8: South Africa Health Market Enquiry. An analysis of the private health care sector in South Africa ‘blew the lid off…. the Competition Commission revealed the results of a four-year investigation into competition within the private healthcare market. The inquiry found a lack of rigorous competition in sectors including pathology, hospital groups, as well as medical aids and administrators.’ For more information, read this article or the provisional report Competition Commission of South Africa 2018.
Example9: Queensland Health Payroll System Commission of Enquiry. A similar analysis, though it stated that they found ‘nothing to suggest any form of corruption’. (Queensland 2013, p86)
Example10: Uganda Commission of Enquiry. ‘The sum total of the enormous catalogue of flaws, shortcomings, errors, mistakes, and hiccups enumerated and detailed in all the above … adds up to a humongous picture of grand managerial inefficiency and incompetence. … The great losers in this sordid story were the people of Uganda; the international donor community; and, particularly so, the new experiment in Global Fund Public-Private Sector partnership’. The Commission that was very clear in its findings, but with little follow up. For more information, read this article by Cohen 2008 or a later analysis by Sekalalah and Kirya 2015.
Report Cards are a specific citizen-driven method used to generate information on the quality and efficiency of the public service as perceived by users.
Examples11: There are many examples of health report card use. To read more see Guidance for more details.
In low corruption environments, criminal investigation and prosecution of corruption is a normal, periodic part of professional life. Sadly, this is the exception rather than the norm. Nonetheless, even in environments where mainstream courts are slow and risky, speaking out and putting senior individuals under investigation can change the culture.
Equally, you can change the organisation dynamics if you make it clear that sanctions or disciplinary action will definitely be taken. Often such sanctions do exist but have fallen out of use or have been taken over by special interest groups. In this case you have first to reclaim the proper functioning of these disciplinary mechanism, but that is much easier than trying to engage with the judicial processes.
As the Icelandic and Norwegian Prime Ministers both said recently at the Plenary session of the OECD Integrity Forum, Paris, March 27th, 2018: ‘Naming and shaming is good. Other times, the best thing you can do is to make it possible – and safe – for citizens and officials to complain or to blow the whistle. Such actions and other forms of calling out the corruption are all ways to make it clear that corruption will not be tolerated and to change the climate of opinion; even if you know you may fail in implementing sanctions.
Justice and Rule of Law Measures you can consider, with examples:
Prosecution of corrupt health officials or company executives or politicians can jolt the system and show that there is a change of tolerance. Prosecution also responds to the demands of the public. However, prosecutions are high risk: they can be very slow, often many years, to come to court; they can be unpredictable, as powerful individuals find ways to escape prosecution or conviction. Worse, if the judiciary are corrupt, this tends to mean that corruption reform will take decades. Perhaps only Sicily, in Italy, has had success against corruption by a prosecution-led strategy. Whilst prosecution may be a tactical response to public pressure, it is unlikely to be a major part of the strategy.
Where prosecution may be too slow or too difficult, more active use of sanctioning, discipline or penalty procedures sends a strong signal of change, that corruption is no longer acquiesced to. Civil and administrative penalties often hold out more hope of impact than prosecution. Examine in detail what disciplining and sanctioning options you have, and how they might be strengthened, or adapted to prioritise corruption cases. Often, the priority is to move a corrupt person from their job – to allow that directorate to improve – and to sanction the individual so that he/she is not simply placed somewhere else in the bureaucracy.
Example1: The work of the Health Monitoring Unit (HMU) in Uganda. According to a recent re-analysis of Transparency International’s Global Corruption Barometer (GCB), the bribery rate for health services had halved for service users between 2010 and 2015. The reduction seems to be the effect of the Health Monitoring Unit (HMU). A highly visible institution with an exceptional degree of support and direction from the president, the HMU developed a strategy to improve accountability in the sector. This included high profile raids. Through highly visible investigations, the HMU seems to have been effective in making health workers in the country significantly more cautious, reducing their willingness to request bribes. Requests for bribes for health services appear to have decreased as a likely consequence of the HMU’s efforts (Peiffer et al 2018).
However, though there have been bribery reductions, the naming and shaming approach has also led to reduced morale among health, because of perceptions that the HMU had unduly harassed many innocent health professionals.
Example2: The Global Fund. After several corruption scandals, the Global Fund dramatically toughened up their control and investigation of corruption in the last five years. They have introduced claw-backs and penalties for countries allowing corruption in their grants. Here is their description of current practice: ‘The Global Fund actively manages risk, with embedded procedures including strict controls and monitoring. When a problem is identified by a country team at the Global Fund, it is referred to the Office of the Inspector General, who independently evaluates evidence and decides how to act on it. When an investigation identifies misspent funds, the Global Fund pursues recovery, so that no donor money is lost to fraud. Since 2012, the work of the Office of the Inspector General has been strengthened and expanded. Its staff has grown from 27 to 47 experienced professionals.’
In the 1990s, calling for new laws or new regulations against corruption was the first port of call for reformers. Now most countries have decent laws relating to corruption. Nonetheless, there will still be multiple areas where reform of law is vital and where gaps, overlaps and ambiguities allow the corrupt to escape justice. There will also continue to be new forms of corruption, some of which may start of being legal until pressure builds to criminalise them; and new ways in which the corrupt bend the current laws to their favour, which too will need regulation.
You may have many suggestions from officials on how the laws can be improved. This needs critical review, however. It is normally unwise to plan on making a large number of regulatory changes, as you are likely to get bogged down and thereby seen to be making no progress, so the changes that you will pursue need to be carefully prioritised for effectiveness. Involve outsiders in the review, not just Justice officials: also civil society, or non-government legal experts with knowledge of anti-corruption impacts.
Example3: Health law reform in Moldova. The results of a review in the Moldova health system, taken from USAID (214): ‘Creating integrity and ethics through (legal) reform. Working closely with the Moldovan Ministry of Health (MOH), USAID contractor MGTCP drafted laws, policy papers, and recommendations to improve healthcare services across the country.
Caution: Examine which changes in policy might disrupt corrupt dynamics. It has not been usual for policy to be made explicitly with anti-corruption in mind. This may therefore mean that there are some policy changes that you can make that would have a significant impact. Pay attention to policies that directly or indirectly allow corruption to persist. Policy can also be captured by corrupt interests, so the challenge is also to scrutinise misuse of current policy.
Along with independent review and monitoring, transparency is one of the central tools in reducing corruption. Corruption problems naturally thrive when the relevant data is not going to be made public. Transparency is an easy word to say – it is almost ‘motherhood’ – but if you find the right way to use it – or the right information that needs to be made transparent – and you can do it in a way that people recognise, then the impact can be great. A good example is to publish surgery waiting lists, when before they were held by the surgeon and used to extort bribes in order to rise up the waiting list. The beneficial effect for patients is out of all proportion to the generic statement of ‘making data more transparent’.
Transparency measures you can consider, with examples:
This is context and sector specific, so you need to brainstorm with colleagues on what data would most show up corruption or improper influence. It can be very simple, such as publishing hospital waiting lists for surgery or publishing how much of the primary school education budget is actually received by each school. The more resistance there is to publishing data, the more likely it is that there is some corruption reason behind it. Examples include Wait lists for surgery (with suitable measures being taken to prevent patient identity), Boards showing the Presence/Absence of clinical staff in the hospital, the Average unit costs of drugs in hospitals, regions or in the country. Also useful are comparisons with international public sources for cost of common drugs (from MSH, MSF, WHO, GFATM etc) so that someone can see if the country is paying above the world market. In all such data cases an important related question is which forum you use to present the data. Is it electronic, or via meetings, or in journals, or to patients’ organisations, or highly visibly, e.g. on boards at the front of the hospital, or in newspapers?
Example1: WHO Good Governance in Medicines initiative (GGM). The WHO has created process indicators for transparent and accountable drug promotion practices as part of the Good Governance in Medicines programme. The GGM approach to increasing transparency in public pharmaceutical systems includes three steps: risk assessment, development of a national framework for responding to identified needs and implementation of approaches such as procedures for disclosure and management of conflict of interest, web-based medicines registration and licensing systems, and other interventions. To date, 26 countries are participating in the GGM, including Cambodia, Malaysia, Mongolia and the Philippines.
Example2: Transparency measures in seven countries in the Medicines Transparency Alliance. The WHO Medicines Transparency Alliance (MeTA) fostered policy dialogue to bring together government, civil society and private company stakeholders concerned with access issues in health and to promote transparency. An analysis of the effect of this in seven countries (Ghana, Jordan, Kyrgyzstan, Peru, Philippines, Uganda, Zambia) found strong evidence that transparency was enhanced and some evidence to suggest that MeTA efforts contributed to new policies and civil society capacity strengthening, although the impact on government accountability is not clear From Vian et al (2017).
Good HMIS data is essential for tackling corruption. You need data on relative costs of procedures from one site to another, on stock levels, on costs per patient per diagnosis. Sometimes, getting this data is a ‘normal’ function of upgrading the HMIS to give you that functionality. Often though this is not the case: the official systems are often old, cumbersome and unsuited to any such intelligent query. In which case you have to decide if the problem is worth a separate management information system or application.
Example3: In one OECD country, Greece, the Health leadership had exactly this latter problem and, despite huge budget constraints, were able to produce an alternative HMIS that was dramatically more useful than the old, official system. As a result, they were able to scrutinise treatment costs between hospitals that led to a major improvement in performance and reduction in corruption.
Example4: Less corruption in the medicines system in Thailand. Thailand participated in a WHO Good Governance for Medicines programme, with a number of significant achievements, such as lower costs for medicines, and national pharmaceutical laws reviewed. Thailand’s Dr Tharathep offers this advice for other countries: “First of all, they should do a medicines situation analysis in their countries, then develop a good governance framework appropriate to their context and environment. The gap between the existing system and the framework should be identified and the strategy should aim to fill the gap…The transparency of the system is one of the crucial activities. For us, the pharmacy information centre has been the best tool for transparency. We have the pharmaceutical products prices from each company who sold their products to the Ministry of Public Health hospitals publicly accessible.”(Read more: More detail currently unavailable as at June 2021).
If public money is being used, then there should be a presumption that the interactions should be public. Examples include senior public officials having the whole of their daily agenda online (as in the European Commission), or new contracting and procurement that require all contracts, progress reports, tender submissions and so forth to be available online (see Open Contracting Partnership here, for example). The simple way to do this is for the electronic calendars of officials to be available online.
This is not yet the case in many countries. You need to see the Open Budget Survey to identify countries, here. This authoritative survey shows that even in an uncontroversial sector like health, such data is often not available. Citizens often want to know how much their government spends on a particular service and how that spending is changing over time. Answering this question is not as simple as it sounds. Besides the Ministry of Health, you probably need at least the “functional classification” that organises spending by functions or purposes, as well as spending by state corporations that support health services (such as public insurers or suppliers). If the health system is decentralized, funds to lower levels of government might not be captured under the central Ministry of Health budget or the functional classification of national spending and you would need quantitative and narrative information about such transfers.
Example5: The table below from the Open Budget survey provides a summary of the level of availability of these types of information. While two-thirds of countries surveyed have a basic functional classification, less than half provide any of the other types of information described above.
Are all external audit reports public? They should be, though many are not. One public analysis suggests that about 85% of external audit reports are made available publicly (Institute of Internal Auditors, 2012). Internal audit reports are more commonly not public: only 10-14% of public sector reports were made public according to the quoted study. There is sometimes justification for non-publication – it can lead to big problems being kept quiet rather than written in the report – but the opposite problem is usually bigger: if the report is not public, it can be buried, and marginalised. It is less difficult and restricting to make internal audit reports public than officials might imagine.
Example6: In Ukraine, internal audit reports are publicly available (Barynina and Pyman 2012).
Transparency may be good, but it is not a panacea. Often data and reports are made transparent, but the underlying corrupt behaviour still does not change, especially if the public and NGOs are disinterested in examining and acting on the data. What more do you need to do? The answer is often to encourage civil society to make more use of the newly transparent information. There may also be different understanding of transparency among staff, because transparency means different things to people depending on what level you are in the organisation.
Example7: Transparency in US health care means different things to different people. ‘Much research on transparency in global settings has focused on institutional design, such as online performance reports and external budget transparency. Yet, these avenues of research do not help to illuminate how change develops in an organization and the micro organizational social processes which influence policy implementation. Eliciting narratives of transparency in health care organizations can be a tool to gain insight into how to develop and nurture organizational cultures which are favourable to transparency, adapted to particular social, economic, and country contexts. The analysis of this small set of stories suggests potential areas where people may understand transparency differently depending on their organizational position and prior experience. … Narrative analysis focused on stories of transparent and non-transparent behaviour can help researchers gain insight into human conduct and relationships which affect organizational accountability. These insights can, in turn, help in the design of interventions which cultivate a transparency culture and promote good governance. Taken from Vian, 2012.
Reducing corruption is as much about establishing a strong integrity framework among public officials and the population as it is about directly addressing corruption. The norms of most societies and of all religions include acting with integrity. However much this may seem to be overly optimistic, it strikes a strong chord of emotion and pride in people. Building on this desire – such as through discussions across the organisation, in leadership fora, and in collaboration with other interested parties such as patients organisations – is fundamental to developing a high integrity organisation.
Creating and maintaining a culture of high integrity behaviour among health professionals and health officials should not be so hard; These are among the most caring groups of people in society. However, powerful social ‘systems’ can be more powerful in driving human behaviour. As quality engineering guru W. Edwards Deming once said: ‘A bad system will beat a good person every time.’ The OECD is increasingly active in working with countries to structure suitable ‘integrity frameworks’ for the nation’s public officials. Recently this has included work in Mexico, Colombia and Thailand, for example.
There are a multitude of ways to press for and to build a high integrity health culture:
There is a useful report Integrity in healthcare organisations from the Netherlands Health System (CEG 2016), which analyses integrity approaches to health care. They analyse five situations where the integrity is most tested in health care organisations: conflicting interests and expectations, dealing with errors, remuneration of administrators, perverse incentives within the system and peer pressure.
General anti-corruption education for officials and building the capability of oversight and regulatory bodies can also be a useful measure, especially if they reach a critical mass of people or officials, and in environments where it is hard or dangerous to have more direct impacts. This is one way to show that at least something is happening, however modest.
Example1: Professional integrity for health staff in Australia. Here is an example of the professional health staff code from Australia.
Example2: A structured approach to Integrity Codes in Colombia. Colombia has put considerable effort into developing integrity across its public administration. In relation to Integrity codes and codes of conduct, Colombia has a three-level model, from national, to at-risk positions, to specific Ministries and organisations. If your country has a similar structure, then you will want the health system codes to align with the national level ones. The OECD report on this effort is worth reading (OECD 2017, p67), as are the reports for Mexico and Chile.
Whistleblowing is now an accepted mechanism, and most large bureaucracies have mechanisms for complaints and or whistle-blowers. At the same time, these mechanisms are usually weak, may exist on paper only and the whistleblowers usually end up suffering. Yet these mechanisms are vital in identifying and calling out corruption: the challenge is to find a way in your context to make them effective, and to publicise this. This has been done in countries and companies, so it is quite possible.
Encourage complaints mechanisms. These mechanisms are vital in identifying and calling out corruption and the challenge is to find a way to make them effective. Civil society has often shown that it can be a more honest and independent way of checking performance and/or being a trusted place that complainants speak with. Today, many complaint systems are actually run by NGOs for this reason. Besides feeling confident to make the complaint to someone, the other half of the complaint system is assurance that there will be prompt and accountable complaint investigation. There needs to be a range of sanctions (fines, loss of contract renewal) which can be implemented without going to the judiciary. This second part of the system has worked badly in many public health systems. In some it is just because of budget pressure. But in others it is more corrupt, being driven by the interests of professional groups, such as doctors or health officials, to protect themselves by ensuring that complaints do not get concluded.
So, making an effective complaint system can be more about making changes to the power balances within the health system than about the technicalities. Sometimes, a solution has been for a top official to take the complaints directly and personally. For example, in another sector, the top official made himself personally available all day every Monday to hear complaints from citizens.
Be open and public about the depth of the corruption. Do not underestimate the effect that you and senior colleagues can have just by speaking openly and publicly about the corruption problems. When the head of the World Bank spoke about corruption in 1996, after years of silence, the effect was huge. Countries such as Estonia and Georgia have had considerable success. particularly in the earlier years of their reforms, they made it publicly clear that curbing corruption was the top mission of the government. It was clear that the government would stand or fall by their success in tackling corruption, and this gave them greater credibility with the public; though more recently, some of the progress is being undone in Georgia.
At local level, you have much opportunity to enlist citizens for change, or to be pushed forward by citizens who are determined to achieve change. The involvement of civil society can be unpredictable – they are of course not under your control – but for the same reason it gives your initiative more of an external reality. Some countries have a social tradition of very high levels of civic engagement. This can be harnessed to involve patients in reform against corruption – whether via consultation, policy participation, or active co-creation of some of the initiatives.
The table opposite, for example, presents the results of surveys reviewing the levels of civic engagement in nine Latin American and Caribbean countries. Some of the countries have very high levels of civic engagement, while others in the same region do not (OECD 2017, Chile report).
At local level, therefore, you may have good opportunities to enlist citizens for change, or to be pushed forward by citizens who are determined to achieve change. This may involve a ‘call to action’ for citizen involvement, or it may happen naturally. A successful approach involving citizens can have different formats, procedures, purposes, success factors and costs; it can yield better-quality policies, stronger legitimacy and prevent policy capture. However, ‘findings from the Bertelsmann Foundation indicate that national and local governments may struggle to actively involve citizens. A full 50% of the 20 health ministries surveyed registered similar.’ (From OECD 2017 Chile report, p23).
Collaboration with civil society organisations is a natural mechanism for reform on corruption. Many of them have a sizeable expertise on corruption, they have a much greater freedom to intervene when there is misbehaviour than official hierarchies do, and they can help in reaching out to the wider community to build trust.
Political & Tactical Approaches - Guidance summary
This is the political, judgemental, tactical part of the strategy formulation exercise. It starts with how to shape the overall approach. Would it be most effective to mainstream the anti-corruption improvements within a larger improvement initiative? Or to adopt an incremental approach, keeping the anti-corruption measures below the political radar? Or tackle just one vital aspect of the corruption problem so as to concentrate effort and have a visible result? Would the organisation’s output be better if the overall anti-corruption approach was framed as integrity-building, as confidence-building, or directly as confronting corruption? The actionable reform approach will be more political, more contextual and more time-bound than individual measures; how to build support, how to spread the benefits, how to bring opponents on board or how to outflank them.
We suggest that you – in collaboration with those who might also own the reforms with you – start out by examining these eight possible approaches: Broad approach; Narrow approach; Low-profile approach; Rapid & radical approach; Signature-issue approach; Bundling approach; Keeping-up-hope approach.
Issues to consider include:
You can read more guidance on Political & Tactical Approaches here.
The desired impact will usually be something tangible, such as lower drug prices, more free access to doctors, fair treatment of patients on waiting lists, rather than ‘reduced corruption’.
There are too many choices: Focus on large-scale changes or small changes? Prioritise fighting corruption or building integrity? Prioritise a preventive strategy or a prosecution-led one? Prioritise specific technical reforms or allow scope for diversity and improvisation? And so forth.
Example: High-income country draft health strategy. Here is a recent example of how one developed country drafted its health anti-corruption strategy. They decided it would be in two parts: 1) Structural reform and 2) Providing real information direct to citizens.
PART 1: IMPLEMENTING NECESSARY STRUCTURAL REFORM. The Ministry drafted seven structural reform priorities: Better information availability and transparency; More robust purchasing and stock management; Stronger controls over high pricing of medicines and materials; Stronger controls over corruption in medical practices; Strengthening control over semi-independent health agencies; Better auditing – admin and clinical – and better controls; Strengthening sanctions and discipline. The Ministry will also work more closely with the representatives of the health industry – because their active cooperation is essential – and so that they too sanction bad industry behaviour.
PART 2: GIVING CITIZENS REAL INFORMATION. The objective was to give citizens a more powerful voice, so they feel their complaints, especially about corruption, are being heard and acted upon, and to ensure that their feedback actually reached health leadership and health inspectors. The Ministry drafted three priority work areas: Public information on waiting lists and key facilities; Public information on hospital daily effectiveness; and Strengthening patients’ rights offices.
Example: a large-scale health reform strategy in Afghanistan. The government supported a major initial analysis of the corruption weaknesses in the Afghan health system, carried out by the Afghanistan Independent Anti-Corruption Committee (MEC) in 2016, despite knowing it would be highly critical. The principal parts of the reform strategy were: Expanding the role of the local Health communities (Shuras); Expanding Independent Oversight; Overhauled Auditing; Strengthening the Independent Council; Much closer liaison with the Attorney General to advance prosecutions; Independent oversight and monitoring of all senior health appointments; and Improving the quality of imported Pharmaceuticals via an overhauled regulatory body amalgamating several previous bodies.
A major feature of the reform strategy was that the Anti-Corruption Committee instituted an independent ‘Active quarterly follow up’ of the recommendations and the Ministry action plan. This is done by a team of two people, who spend one month every quarter vising hospital and Ministry sites to see what progress is being made. They write a detailed progress report which is discussed with the Minister and his health leadership team each quarter, and which is published and publicised in the media. These quarterly follow up reports are published by the Afghanistan independent Anti-Corruption Committee.
Corruption reforms usually involve several groups of stakeholders, whether the reform is small, like eliminating informal payments for child care, or large, like passing a bill to improve health outcomes in a country.
An anti-corruption initiative might be small, such as a single project, but many of them involve multiple projects, in different parts of the country, in different agencies, and will extend beyond the Health Ministry boundaries into other ministries and agencies. This requires a more formal ‘programme management’ approach so that they are each managed properly, there is a full-time person or team doing the coordination, proper tracking system in place, and there is regular reporting so that those in charge, or the Steering Committee, are kept up to date.
Unless your ministry is a beacon of integrity in an otherwise corrupt government, or your project is very small, you should expect your reforms to be an integral part of the broader reforms in your health system. Sometimes the action will be 90% the same as a reform that the ministry is already planning or undertaking, such as having a good HMIS, improving controls and improving HR practices. The ‘added-value’ of an anti-corruption angle is that you would not think about the corruption aspect if you were just thinking about effectiveness and good practice. Nevertheless, be explicit that you are tackling corruption. You may be tempted, and you may also hear expert opinion, to suggest that the ‘normal’ institutional reforms will in due course take care of the corruption problems; so that no separate emphasis on corruption will be required. We believe that you should not do this. Such advice often arises because people, especially experts and donors, feel uncomfortable talking explicitly about corruption. Such advice ‘permits’ them not to delve into this subject, which is obviously wrong. People who are the recipients of the health services – patients – will have no hesitation in recognising corruption, and they will rightly be suspicious of reforms that do not explicitly tackle it.
There are several other alignments also likely to be necessary: with the government’s anti-corruption strategy as a whole, with other government good-governance policies, and regional alignment.
Transnational initiatives - Guidance summary
Review what international sector efforts are active in tackling corruption in your sector. They may be sources of knowledge, ideas, support and assistance in the development of your initiative. Sector-specific organisations include:
Non-sector-specific organisations also have sector knowledge. These include:
Many health corruption issues can be addressed within the health sector of a single country, as we have been discussing here. However, other issues can only be properly solved through an international approach. Examples include medicine regulation, pharmaceutical authentication, medical company behaviour and other issues such as responses to pandemics.
Attention to these international health corruption issues also means that global expertise is increasing. As health corruption expert Taryn Vian, Clinical Professor of Global Health at Boston University School of Public Health says: ‘Fortunately, an emerging body of knowledge is helping to translate the findings of anticorruption research into operational anticorruption programs. While we still have much to learn, a number of general lessons from this field are already proving useful for designing and implementing anticorruption reforms’ (Vian, 2017).
The split between domestic health corruption issues and international or global health corruption issues is shown up nicely in the diagram below from Mackey and Liang (2012):
Experts suggest that the concept of global health corruption should be expressly defined, discussed, and adopted through an international legally binding framework employing partnership with the World Health Organization and UNODC. They also suggested that global efforts to address global health corruption could be operationalized. Policy makers are recognising that the size of the health sector (expected to reach $18 trillion by 2040) means that the international health community needs to pay more attention to tackling the damaging effect of corruption.
What is needed, but not yet in place, is a unifying governance framework that can enable governments to take more responsibility for addressing the irregularities. The article by Mackey et al (2017) Combating healthcare corruption and fraud with improved global health governance is worth further reading.
Within health, the obvious first place to look for global initiatives and global expertise is the World Health Organisation (WHO). They have been taking the lead on many good governance initiatives, such as Good governance in Medicine and the Medicines Transparency Alliance (MeTA). They also have done specific corruption analyses, for example World Health Organisation (2010) An innovative approach to prevent corruption in the pharmaceutical sector.
However, there seems to have been little focus on tackling health corruption at an international level to date since the initiative on Good Governance in Medicines (GGM) and preventing corruption in the pharmaceutical sector. WHO has itself come under fire for corruption and waste within its own organisation. See for example here and here.
More recently, one group within WHO has started to suggest global action to improve health system governance. The Health Systems Governance Collaborative was born from this urgent need for new collective action. The Collaborative is set up to work as a global network, made up of participants from various backgrounds: technical experts, agencies, policy makers, and citizens’ representatives’ (Bigdeli et al, 2017).
More on the WHO Health Systems Governance Collective
The Health Systems Governance Collaborative express the need from a helpful historical perspective: Back in 2007, the WHO proposed a six building blocks’ framework to categorize and analyse health systems . In this framework, health system governance was defined as: “Ensuring strategic frameworks exist and are combined with effective oversight, coalition-building, attention to system design and accountability”. Then on their website, this group says ‘First, we must admit that for the past decade, we have paid much attention to the first part of this definition: “ensuring strategic policy frameworks exist”….. Secondly, without denying the critical importance of policy-making capacity and strategic planning processes in the health sector, we must also acknowledge the need to examine more closely the latter part of the governance definition put forward by WHO in 2007: “effective oversight, coalition-building, system design and accountability”. Much less has happened in this respect in the recent past, although some authors in the health system literature have ventured this less travelled route: a recent systematic review identifies 16 frameworks for health systems governance published between 1994 and 2014, but only five of them have been applied in practice and only three considered governance at multiple levels of the health system. When travelled, the route therefore remains vastly theoretical; it is difficult to grasp what are the concrete actions that could benefit health system governance and improve health system performance.
Development agencies spend billions of dollars on health improvements in developing countries, although only a few per cent of it is targeted at corruption issues. They do produce some analyses of corruption in health, such as from DFID (DFID How-to Note; addressing corruption in the Health sector). USAID has done a detailed analysis of its anti-corruption programming, which has an Annex with their experience with health projects.
For countries where part of the health budget is provided by partners from other nations, whether this be in the form of aid, or regional projects like in the EU, Development agencies have considerable power that you may be able to leverage. You could press them, for example, to require strong integrity clauses, transparency of contracts, and intrusive audit rights. You can encourage the international bodies to take corruption more seriously. International health specialists, for example, can be uncomfortable when discussing corruption, and development agencies may feel they have more to lose by identifying the extent of the corruption than by passively working around it. Agencies are sensitive to charges that they are not serious about corruption. For a critical review, see Kenney (2017) Results not receipts: how much aid is really lost to corruption?
UNDP produced a guide some years ago Fighting corruption in the health sector UNDP (2011). But UNDP seems to be less active today: on UNDP’s website they simply state that ‘UNDP has strong partnerships with other organisations working on anti-corruption such as the UN Office of Drugs and Crime, Tiri, GTZ, the Basel Institute on Governance, the Huairou Commission and the Institute of Governance Studies of Bangladesh.’
The Global Fund is one organisation that has been at the forefront of some of these efforts as it has sought to eliminate corruption related to its own disbursements (Usher 2016 Global fund plays hardball on corruption).
Professor Taryn Vian and colleagues have been working on corruption in the health sector for over two decades. See for example Vian et al (2010). Anticorruption in the Health Sector: Strategies for Transparency and Accountability, and other publications authored by Vian et al listed in the Bibliography below.
TI’s Pharmaceuticals and Healthcare anti-corruption programme is a global initiative of TI based in London, dedicated to tackling corruption in pharmaceuticals and health care worldwide. Several TI Chapters around the world are also specifically involved in tackling healthcare corruption. The TI Secretariat in Berlin was also instrumental in highlighting the topic of health corruption back in 2006 with a whole annual report on the topic (TI 2006).
EHFCN is a not-for-profit organisation financed through subscription fees, founded in 2005 as a result of the first pan-European conference held in London in October 2004. Its members are healthcare and counter fraud organisations in Europe. EHFCN has published a book on Healthcare fraud, corruption and waste in Europe: national and academic perspectives (EHFCN 2017).
U4 is a resource centre set up by Development Agencies to do independent research on corruption issues in developing countries. As they say in their website We share research and evidence to help international development actors get sustainable results. You can contact them at email@example.com.
Contacting others really helps because corruption is a tough problem, with no ‘manual’ of how to go about tackling it. It is not just a ‘nice thing’ to do.
We find that others working in their sector round the world – whether it be a very public sector like health or a more private sector one like telecommunications – are open to being contacted and happy to respond. People everywhere really hate corruption, and this is why you’ll find lots of support for your reform ideas.
Professionals in each sector know that much of the corruption reform available guidance is generic, in reports or in the form of technical advice from institutions. They’ll be happy to get down to sector level actions, where the real impact of corruption issues is usually seen.
Here’s what we suggest:
Contacting others also has a second benefit. Most of us who are involved in efforts against corruption, whatever their country or sector, are nervous of whether our anti-corruption ideas are plausible. Officials are aware they have no deep knowledge of how to tackle corruption and have less time to spend on this than they would like; so they are lacking in confidence. The best way to gain confidence is to talk with other people who also understand the problems in your sector.
We have assembled in this review all the useful health system guidance and experience that we know of, together with worldwide experience in health system anti-corruption reform. So, do read this review first! There is nothing recent that you can read other than this review, but if you want to read just a little of the older material, we suggest the following three reports:
Transparency International has a programme on tackling corruption in health care. This programme is gradually building up, so their health website is worth following.
Birmingham University UK has a useful page of sources on corruption in the health sector: https://www.birmingham.ac.uk/Documents/college-social-sciences/social-policy/hsmc-library/snappy-searches/Corruption-in-the-health-sector.pdf
The Anti-Corruption Resource Centre U4 has a website with on-line anti-corruption training in the health sector, but access is restricted. A new course will be available from late 2018. https://www.u4.no/courses/addressing-corruption-in-the-health-sector
Health sector: Full bibliography
Afghanistan Anti-Corruption Monitoring and Evaluation Committee (2017) Fourth quarterly monitoring report; following up the implementation of recommendations in the MEC analysis for the Ministry of Public Health. http://www.mec.af/files/2017_05_09_moph_4th__followup_english.pdf
Afghanistan Anti-Corruption Monitoring and Evaluation Committee (2016) Vulnerability to corruption assessment in the Afghan Ministry of Public Health. http://www.mec.af/files/2016_06_04_MOPH_Special_Report_(English).pdf
Anderson, Ian, Maliqi, Blerta, Axelson, Henrik & Ostergren, Mikael (2016) How can health ministries present persuasive investment plans for women’s, children’s and adolescents’ health? Bulletin of the World Health Organization 2016;94:468-474. doi: http://dx.doi.org/10.2471/BLT.15.168419
Azfar O (2005) Corruption and the Delivery of Health and Education Services.In B. Spector (Ed.), Fighting Corruption in Developing Countries: Strategies and Analysis (pp. 181–212). Bloomfield, CT: Kumarian Press. https://www.rienner.com/title/Fighting_Corruption_in_Developing_Countries_Strategies_and_Analysis
Barynina, Maryna and Pyman, Mark (2012) The 3rdline of defence; how audits can help address defence corruption.Transparency International, http://ti-defence.org/publications/the-3rd-line-of-defence-how-audits-can-help-address-defence-corruption/
Berger, David (2017) Corruption in Healthcare. British Medical Journal. http://www.bmj.com/campaign/corruption-healthcare
Bigdeli, Maryam, Schmets, Gérard, Soucat, Agnès (2017) Investing in health system governance: collective action required! Department of Health Systems Governance and Financing, World Health Organization, Geneva. http://www.internationalhealthpolicies.org/investing-in-health-system-governance-collective-action-required/
Björkman, Martina and Svensson, Jakob (2009) Power to the People: Evidence from a Randomized Field Experiment on Community-Based Monitoring in Uganda.The Quarterly Journal of Economics, 2009, vol. 124, issue 2, 735-769. https://academic.oup.com/qje/article-abstract/124/2/735/1905094?redirectedFrom=fulltext
CEG (2016) Integrity in health care organisations: administrators’ perspectives. Netherlands Centre for Ethics and Health. https://www.ceg.nl/uploads/publicaties/Integrity_in_health_care_organisations.pdf
Cockcroft, A., Andersson, N., Paredes-Solís, S., Caldwell, D., Mitchell, S., Milne, D., Ledogar, R. J. (2008) An inter-country comparison of unofficial payments: results of a health sector social audit in the Baltic States. BMC Health Services Research, 8, 15. https://doi.org/10.1186/1472-6963-8-15
Cohen, Jon (2008) Uganda confronts corruption, slowly.Science, July 2008. http://science.sciencemag.org/content/321/5888/522.full?rss=1
Competition Commission of South Africa (2018) Health market inquiry. Provisional findings report July 2018. http://www.compcom.co.za/wp-content/uploads/2018/07/Health-Market-Inquiry-1.pdf
Dagmar, Radin (2015) Why health care corruption needs a new approach. Journal of Health Services Research & Policy 0(0) 1–3, 2015. doi:10.1177/1355819615614870
Development Leadership Program (2018) Inside the black box of political will: 10 years of findings. Australian Aid. http://www.dlprog.org/publications/inside-the-black-box-of-political-will.php
DFID (2010) DFID How-to Note; addressing corruption in the Health sector, November 2010.https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/67659/How-to-Note-corruption-health.pdf
Di Tella and Savedoff, William (2001) Diagnosis Corruption: fraud in Latin America’s public hospitals, InterAmerican Development Bank. http://www.iadb.org/en/research-and-data/publication-details,3169.html?pub_id=b-133
European Commission (2017) Updated study on corruption in the healthcare sector: Final report. https://ec.europa.eu/home-affairs/sites/homeaffairs/files/20170928_study_on_healthcare_corruption_en.pdf
European Commission (2015) Quality of Public Administration- A Toolbox for Practitioners, April 2015. https://ec.europa.eu/digital-single-market/en/news/quality-public-administration-toolbox-practitioners
European Healthcare Fraud and Corruption Network EHFCN (2017) Healthcare fraud, corruption and waste in Europe: national and academic perspectives. http://www.ehfcn.org/ehfcn-nza-book-healthcare-fraud-corruption-waste-europe/
Freedman, Lawrence (2013) Strategy – a history. Oxford University Press. https://global.oup.com/academic/product/strategy-9780199325153?cc=gb&lang=en&
Griffin CC (2009) Reducing Corruption in the Health and Education Sectors.In R. I. Rotberg (Ed.), Corruption, Global Security and World Order (pp. 430–456). Brookings Institution Press. https://www.brookings.edu/book/corruption-global-security-and-world-order/
Gupta S, Davoodi HR, & Tiongson E (2000) Corruption and the provision of health care and education services (No. IMF Working Paper No. 00/116). International Monetary Fund. Retrieved from https://www.imf.org/external/pubs/ft/wp/2000/wp00116.pdf
Holeman I, Cookson TP, Pagliari C (2016) Digital technology for health sector governance in low and middle-income countries: A scoping review. J. Glob. Health 6, 020408, 2016. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5017033/
UN Human Rights, Office of the High Commissioner (2017) Healthcare among most corrupt sectors, warns UN expert, backing “citizen whistleblowers” http://www.ohchr.org/EN/NewsEvents/Pages/DisplayNews.aspx?NewsID=22283&LangID=E
Holmberg S and Rothstein B (2011) Dying of corruption. Health Economics, Policy and Law, 6(04), 529–547. https://doi.org/10.1017/S174413311000023X
Hussman, Karen (2011) Vulnerabilities to corruption in the health sector: perspectives from Latin American sub – systems for the poor (with a special focus on the sub national level). U4 Report. http://www.u4.no/recommended-reading/vulnerabilities-to-corruption-in-the-health-sector-perspectives-from-latin-american-sub-systems-for-the-poor-with-a-special-focus-on-the-sub-national-level/
Institute of Internal Auditors (2012) Transparency of the internal audit report in the public sector.https://na.theiia.org/standards-guidance/Public%20Documents/Transparency%20of%20the%20Internal%20Audit%20Report%20in%20the%20Public%20Sector.pdf
Joudaki, Hossein, Rashidian, Arash, Minaei-Bidgoli, Behrouz, Mahmoodi, Mahmood, Geraili, Bijan, Nasiri, Mahdi& Arab, Mohammed (2015) Using Data Mining to Detect Health Care Fraud and Abuse: A Review of Literature. Glob. J. Health Sci. 7, 194–202 (2015). URL: http://dx.doi.org/10.5539/gjhs.v7n1p194 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4770922/
Kenney, Charles (2017) Results not receipts: how much aid is really lost to corruption?https://www.cgdev.org/blog/how-much-aid-really-lost-corruption
Khan, Mushtaq, Andreoni, Antonio and Roy, Pallavi (2016) Anti-corruption in adverse contexts: a strategic approach. SOAS Research Online. http://eprints.soas.ac.uk/23495/1/Anti-Corruption%20in%20Adverse%20Contexts%20%281%29.pdf
Kirya, Monica (2011) Performing “good governance” Commissions of Inquiry and the Fight against Corruption in Uganda. PhD Thesis, University of Warwick, UK. http://wrap.warwick.ac.uk/47800/1/WRAP_Theses_Kirya_2011.pdf
Kohler JC (2011) Fighting Corruption in the Health Sector. United Nations Development Programme. http://www.undp.org/content/dam/undp/library/Democratic%20Governance/IP/Anticorruption%20Methods%20and%20Tools%20in%20Education%20Lo%20Res.pdf
Lewis, Maureen (2006) Governance and Corruption in Public Health Care SystemsWorking Paper Number 78. Centre for Global Development. Retrieved from http://www.cgdev.org/sites/default/files/5967_file_WP_78.pdf
Liaropoulos L, Siskou O, Kaitelidou D, Theodorou M, & Katostaras T (2008) Informal payments in public hospitals in Greece. Health Policy, 87(1), 72–81. https://doi.org/10.1016/j.healthpol.2007.12.005
Mackey, Tim and Liang, Bryan (2012) Combating healthcare corruption and fraud with improved global health governance. BMC International Health and Human Rights 2012, 12:23 http://www.biomedcentral.com/1472-698X/12/23
Mackey T, Kohler, J, Lewis M, and Vian T (2017) Combating corruption in global health. Sci. Transl. Med. 9, eaaf9547. https://munkschool.utoronto.ca/wp-content/uploads/2017/08/Combating_Corruption_in_Global_Health_STM_09_402_eaaf9547.pdf
Mikkers M (2017) Healthcare fraud, corruption and waste in Europe. National and academic perspectives. Utrecht: Eleven International Publishing. https://www.narcis.nl/publication/RecordID/oai:tilburguniversity.edu:publications%2F662504cc-245a-4eae-a3c8-e4ff7bd29ad4
Mungiu-Pippidi, Alina and Johnston, Michael (2017) Transitions to good governance. Edward Elgar Publishing. https://www.e-elgar.com/shop/transitions-to-good-governance
Muravjovas, Sergejus (2016) Patients who evaluate their visit are less willing to give bribes (Lithuania). http://www.transparency.lt/en/pacientai-kurie-ivertina-savo-apsilankyma-pas-gydytoja-maziau-linke-duoti-kysius/ Accessed 3/12/17
Muravjovas, Sergejus (2016) How to achieve a small victory. The case of the Ladzynai Outpatients clinic (Lithuania). http://www.transparency.lt/wp-content/uploads/2016/11/Social-design-experiments-in-healthcare_2016.pdf. See also this video (with subtitles): https://www.youtube.com/watch?v=G31HLtVdqyo.
OECD (2017) Public governance review Chile: Scan report on citizen participation in the constitutional process. https://www.oecd.org/gov/public-governance-review-chile-2017.pdf?TSPD_101_R0=124eae0f99329d7a5ad96d631b1a981csn900000000000000006e467257ffff00000000000000000000000000005a8c1b8b00d528153b
OECD (2017) Integrity review of Colombia: investing in integrity for peace. http://www.oecd.org/countries/colombia/oecd-integrity-review-of-colombia-9789264278325-en.ht
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Peiffer, Caryn, Armytage, Rosita and Marquette, Heather (2018) Uganda’s Health Sector as a ‘Hidden’ Positive Outlier in Bribery Reduction. Development Leadership Program, Research Paper 56
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