The purpose of this review is to provide examples and experience of how others in this sector have reduced the damaging impact of corruption. The sector-specific information is relevant for politicians, leaders, managers, civic groups, company executives and others. We hope it will bring both knowledge and inspiration.

Blogs and Podcasts, with Sarah Steingrüber of CurbingCorruption

Health corruption reform experience – using this review

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.

Introduction

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.

1. Corruption issues in health

FOCUS on the specific corruption issues - Guidance summary

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:

1.1 Typology of health corruption issues

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

1.2 Gathering data on health corruption

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

1.3 Doing your own analysis

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

2. Reform measures in health

Specific Reform Measures - guidance summary

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)

2.1 FUNCTIONAL REFORMS IN HEALTH

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:

2.1.1 Service delivery and clinical reforms

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).

2.1.2 Reforms to non-clinical process

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.

2.1.3 Improved HMIS

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.’

2.1.4 Technology reforms

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).

2.1.5 Organisation reform of the Ministry

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).

2.2 PEOPLE-CENTRED REFORMS IN HEALTH

People-centred measures you can consider, with examples

2.2.1 Your leadership

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.

2.2.2 Building committed supporters

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.

2.2.3 Leadership team discussions

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

2.2.4 Informal forums

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.

2.2.5 Formal coalitions

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:

1. ‘reform entrepreneurs’, activists, experts, policy wonks from the world of civil society, NGOs, and academe;
2. reform ‘champions’ from within the administration, in departments, agencies, and the Office of the President;
3. reform ‘champions’ within Congress;
4. advocacy groups, allied associations, organizations, and pressure groups;
5. media outlets: investigative journalists, reporters, social media and Internet websites.

Read more on the process that led to the Sin Tax

2.2.6  With civil society

See Section 2.8 later in this section.

2.2.7 With industry, pushing them to develop & uphold its own integrity standards

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:

1. Invite the industry to meet with the health ministry to brainstorm how they can assist in tackling corruption in your health system. Or, do this with more specific industry groups: the pharma companies and agents, the construction companies, the support companies, etc
2. Invite the health industry associations to set up an ethics certification system so that their companies have all committed themselves to certain principles when working with your health system. Such certification systems are now being established in other sectors, and in both developed and developing countries (see, for example, Ukraine)
3. Set out requirements that wish the government to place on health companies, such as publishing of contracts. The Open Contracting Partnership has many detailed suggestions like this and can help you
4. Require all companies wishing to do business with the Health Ministry to have a ‘compliance programme’ in place. Such compliance programmes are now common in the private sector (see the separate review in this website Sectors>Private Sector) and individual, progressive companies have often taken the lead in bringing the industry on board.
5. Invite people expert in corporate compliance programmes to talk with you and brainstorm on proposals: there are many such people around.
6. Invite companies to join with government to solve specific health corruption issues. Such initiatives have had a significant impact in some sectors and geographies, and many of the world’s larger health and services companies now explicitly support such collaborations. For example, Unilever now requires every one of its brands to have a clear purpose that contributes to a social or environmental concern, and that each product must also contribute to one or more of the targets we have set in the Unilever Sustainable Living Plan. Unilever on collective action. Such companies may be keen to work with you. These are called ‘Collective action’ initiatives; for more information on the concept see the website from the Basel Institute.

2.2.8 Changing the health industry structure to limit corruption

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).

2.3 REFORMS OF MONITORING MECHANISMS IN HEALTH

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:

2.3.1 Strengthen independent monitoring

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.

2.3.2 Strengthen regulatory agencies and oversight agencies

 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).

2.3.3 Strengthen Internal audit

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 3^rdline 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.

2.3.4 Strengthen external audits and investigations

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

2.3.5 General health fraud audits

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).

2.3.6 Strengthen or establish clinical audit

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.

2.3.7 Establish a Commission of Inquiry

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.

Example⁷: Uganda

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.

2.3.8 Citizen Report Cards

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.

2.4 JUSTICE AND ROL REFORMS IN HEALTH

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:

2.4.1 Investigation and prosecution

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.

2.4.2 Exert pressure via discipline, sanctions and penalties

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.’

2.4.3 Carry out a legal review

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.

• The project drafted and submitted to parliament a revised administrative code in order to strengthen the enforcement of the accreditation process of healthcare professionals.
• The most far-reaching legal reforms supported under MGTCP were the government order issued to create corruption reporting systems in all ministries, including MOH, and the whistle blower protection law, which was drafted and submitted to Parliament.
• Legal reforms supported by the program also affected the hiring process in MOH-supported facilities.
• MGTCP supported the MOH in issuing a ministerial order that created a competitive hiring process including objective scoring of candidates.
• MGTCP also worked through the government of Moldova to reform the legal and policy framework in the health sector to improve functionality and monitoring. This included the creation of nine working groups
• This allowed for quick decisions and implementation of key interventions, such as the development of a code of ethics that had not previously existed in Moldova. In collaboration with a specially created MOH working group, MGTCP supported the drafting, editing, and publication of 15,000 copies of the code to medical professionals, including all physicians in the country.
• MGTCP helped reform procurement and bidding processes by creating a government-sponsored integrity pact, which all bidders on public tenders were required to sign.’ USAID 2014 report.

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.

2.5 TRANSPARENCY REFORMS IN HEALTH

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:

2.5.1 Identify public service data that needs to be transparent

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).

2.5.2 Build transparency into systems and metrics

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).

2.5.3 Require all engagements by senior public officials be routinely disclosed

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.

2.5.4 Require that all health budgets, and spending, are disclosed

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.

2.5.5 Consider requiring all internal and external audit reports to be published

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).

2.5.6 Unintended consequences

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.

2.6 INTEGRITY REFORMS IN HEALTH

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:

• Attention to the basics, e.g. the legality and reality of fair hiring, firing, promoting and disciplining staff
• Having clear standards and codes of conduct for health professionals (doctors, nurses, specialists), health officials, Ministers and regulators
• Having credible internal reporting procedures
• Having mechanisms for identification and resolution of conflicts of interest,
• Regulating conferences and benefits from the pharmaceutical companies, etc
• Investing in integrity training; and in anti-corruption education for staff and officials
• Building the capability of locally-accountable hospital and community oversight bodies
• And, speaking out loudly and clearly against corruption.

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.

2.7 WHISTLEBLOWING REFORMS IN HEALTH

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.

2.8 HEALTRH REFORMS THROUGH CIVIC ENGAGEMENT

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.

3. Overall reform approaches in health

Political & Tactical Approaches - Guidance summary

3.1 Objectives and desired impact

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’.

3.2 Strategic alternatives

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: Lithuania and thinking small. Lithuania is a country that has been making significant progress against corruption. Hospital clinics and a local NGO (Transparency International Lithuania) worked together to reduce corrupt ’informal payments’. They found that corruption perception levels can be directly related to the willingness to recommend the institution to others. The NGO produced a guidebook to help others who are striving for small, tangible victories in your work and looking for new, better ways to serve their clients. As the authors say: “We hope that this guidebook will give you a better understanding of how to seek for positive changes in your institution”.

3.3 Collaboration and political skill

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.

3.4 Programme management in health corruption reform

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.

3.5 Formality and alignment in health corruption reform

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.

4. Transnational health initiatives

Transnational initiatives - Guidance summary

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):

4.1 Global health 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 (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 World Health Organisation (WHO)

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

4.3 Development agencies

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?

4.4 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.’

4.5 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).

4.6 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.

4.7 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).

4.8 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).

4.9 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 u4@cmi.no.

5. Ask & Connect

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:

1. Ask us. We may be able to offer ideas and/or point you to relevant examples. Just contact us directly at editor@curbingcorruption.com
2. 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.
3. Ask other readers and followers of CurbingCorruption: Use the Twitter and Linkedin buttons below or on the top of the home page.
4. 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.

Reading and Bibliography

Additional Reading

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:

1. Vian, Taryn, Savedoff, William and Mathison, Harald (2010) Anticorruption in the Health Sector: Strategies for Transparency and Accountability. Kumerian press, published April 2010.
2. USAID’s 2014 analysis of anti-corruption programming, Annex 4 is about the experience with health projects.
3. DFID (2010) DFID How-to Note; addressing corruption in the Health sector

Websites

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

Bibliography

Health sector: Full bibliography