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USING THIS REVIEW
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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 managing editor of CurbingCorruption. Additional contributions have been made by Rich Feely, Sarah Steingrüber, Taryn Vian.
Guidance summary: STEP 1 Analysing the specific corruption types
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
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
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
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
Guidance summary: STEP 2 Reforms & reform approaches
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, with examples
People-centred measures you can consider, with examples
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.
Monitoring reform measures you can consider, with examples
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
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.
One such 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
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.
Integrity measures you can consider, with examples
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.
Whistleblowing measures you can consider, with examples
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.
Guidance summary: STEP 3 Developing an overall strategy
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. The sixth of these quarterly follow up reports has recently been published by the Afghanistan independent Anti-Corruption Committee (2018).
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.
Guidance summary: STEP 4 Transnational initiatives
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, 2010).
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):
4.1 Global governance?
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 ($6.5 trillion in 2012; 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.
- The UN special rapporteur on human rights called in 2017 on States to provide bold leadership to confront corruption and its severe impact on the right to health, including more protection for “whistleblowers” and empowering the public to report corruption. “In many countries, health is among the most corrupt sectors.” The Special Rapporteur stressed that there is a normalization of corruption in healthcare, involving not just corruption that clearly breaks the law, but practices which undermine the principles of medical ethics, social justice, transparency and effective healthcare provision (Office of the High Commissioner for Human Rights, October 2017).
- The British Medical Journal (Berger 2017) in Corruption; medicine’s dirty open secret, the BMJ issued a call for a campaign against corruption in healthcare. Corruption is the very antithesis of patient-centred care. Driven by greed, those in power divert crucial resources away from patients in need, which results in poor quality of care and worsening health outcomes. It is an international problem and no health system is free from it
- The huge Global Fund notes, according to Usher (2016), that ‘A lack of a comprehensive, internationally cooperative framework specifically addressing health corruption on a global level undermines the effectiveness of these independent efforts.’
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.
4.2 Health anti-corruption initiatives and organisations
There are two initiatives worldwide that we are aware of that focus on tackling corruption in health:
Boston University School of Public Health 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.
Transparency International Healthcare programme 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).
In addition, the Anti-Corruption Resource Centre U4, Norway, have published several reports on health corruption in the past, and also have a training module on health corruption, though this has restricted access.
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 (WHO 2010) 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
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?
4.5 Other multilateral and development institutions
United Nations Development Programme (UNDP). 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.’
Global Fund 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).
European Healthcare Fraud and Corruption network (EHFCN) 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 Anti-Corruption Resource Centre, Norway.
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 firstname.lastname@example.org.U4 have expertise in health anti-corruption. They also have an online module on tackling corruption in Health.
A new global anti-corruption standard for health? See the discussion and call for this in Section 4.1 above.
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:
- Ask us. We may be able to offer ideas and/or point you to relevant examples. Just contact us directly at email@example.com
- Get in touch with the people at the transnational organisations outlined in Section 4 of each of the sector reviews. Ask them for their help and input.
- Ask other readers and followers of CurbingCorruption: Use the Twitter and Linkedin buttons below or on the top of the home page.
- Contact the authors of any of the articles and references that we cite. Our experience is that they are happy to respond to questions.
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:
- Vian, Taryn, Savedoff, William and Mathison, Harald (2010) Anticorruption in the Health Sector: Strategies for Transparency and Accountability. Kumerian press, published April 2010.
- USAID’s 2014 analysis of anti-corruption programming, Annex 4 is about the experience with health projects.
- DFID (2010) DFID How-to Note; addressing corruption in the Health sector
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