Transparency International (Nordberg), Boston University (Vian)
This 87-page U4 Issue paper from U4, a web-based resource centre on a wide range of anti-corruption issues, presents some resources for anti-corruption work in the health sector and information on the challenges of corruption in the health sector. The overview includes the causes and consequences of corruption, financial resources management, management of medical supplies, and health worker/patient interaction. The issue focuses on good practise examples, budget transparency, and the topic of salaries. It includes a literature review and links to relevant websites on health sector corruption.
As stated in the Causes and consequences section "Corruption [in the health sector] reduces the resources effectively available for health, lowers the quality, equity and effectiveness of health care services, decreases the volume and increases the cost of provided services. It discourages people to use and pay for health services and ultimately has a corrosive impact on the population’s level of health. " A Gallup International survey, Voice of the People 2007, offered data showing that the prevalence of bribery when attending medical services is higher in low-income countries than in high-income countries, and higher in low-income households than high-income households. "Although it is difficult to draw any conclusion based on the findings from the global corruption barometer, the [economically] poor appears to be asked for bribes more frequently than the rich both across and within countries."
Given data on corruption in the health sector among vulnerable populations, the document then names the following processes as having high inherent risk of corruption:
- provision of services by medical personnel
- human resources management
- drug selection and use
- procurement of drugs and medical equipment
- distribution and storage of drugs
- regulatory systems, and
- budgeting and pricing.
Tools for measuring and documenting abuse and corruption - necessities, as stated here, for addressing it - are listed in a table in the document. The section on financial resource management looks specifically at financial accountability, particularly "budget leaks" which divert financial resources from reaching points of health service. According to the document, donor funding, frequently pooled with government funding, can be difficult to track; and, if remedial steps are taken to improve accounting, funding delays can leave clinics to deal with financial shortfalls through informal mechanisms which can contribute to corruption.
Suggestions for financial accountability include the following:
- A legal and institutional framework that provides clear and simple accounting and procurement standards based on transparency, comprehensiveness, and timeliness;
- Public policies, practices, and expenditures open to public and legislative scrutiny, and civil society involvement at all stages of budget formulation, execution, and reporting, as well as an information system that produces timely, reliable, and accurate information;
- Decentralisation with the view to enabling broader public participation, improving local oversight of fiscal resources, enhancing public ability to hold decision makers accountable, and enhancing the responsiveness of the health system;
- Privatisation to reduce the power-monopoly of public providers and limit their opportunity to charge bribes;
- Measuring resource leakages and efficacy of public spending; and
- Information campaigns - publication of survey findings and information dissemination. "For example, ...Uganda started to publish monthly intergovernmental fund transfers in the local media, dramatically reducing the capture and leakage of funds by 78%... These findings are supported by other studies from Uganda, showing that household knowledge on how to report poor bureaucratic practices had an effect on corruption levels and service quality..."
Along with recommendations on monitoring procurement and management of medical supplies, the document includes an analysis of the point of service at which the health worker and patient interact. "Most common abuses include informal charging of patients, theft of drugs and medical supplies, illegal use of public facilities for private practices, self referral of patients, and absenteeism." Included in recommendations for what can be done about abuses in these interactions, the document lists:
- Attention to wage structures and fee structures;
- Defining and monitoring clear performance expectations of civil servants, as well as instilling norms of professional behaviour through a code of ethics for health workers;
- Placing patients in a position to make informed choices and select appropriate providers. "This requires consumers to be informed of their rights, of the services available, and of prices and conditions of access, ...through several possible initiatives to increase patient information, including a strategy to disseminate official price information (conduct trend analyses of drug prices in private pharmacies being reimbursed by the government, and affordability for patients), creation of consumer guides to health regulation, and establishment of a Citizen’s Advocacy Office for Health Concerns"; and
- Involving the community in decision making and monitoring. "Community participation can be achieved through the constitution of local health boards or committees, in which civil society is represented and involved at all levels of the decision-making process as well as in monitoring activities."
The good practices examples section of the document includes tools to address corruption, like frameworks for tracking national health care expenditures, for tracking resource flows, and for collecting service delivery data. Report cards can deliver information to the public. A group of country-specific examples illustrate the use and effectiveness of these tools. The section on budget processes and transparency recommends, among other measures, public participation in the budget process through using information dissemination to inform public debate and input to policy formulation, on a civil society level, among non-governmental organisations with a monitoring function, and through public hearings and citizen score cards. "Presenting expenditure records in easy language to the public and confronting local politicians with the discrepancy between policy statements and actual delivery can trigger civic action against corruption and contribute to accountability. Report cards for public services measure both quantitative and qualitative indicators of service delivery through direct citizen feedback. If they are widely disseminated amongst the public, together with budget information, they provide an opportunity for citizens to get involved in the budget allocation process, and to ensure that the budget addresses their needs."
Editor's note: The U4 Issue paper summarised above and available for download below is one of several resources on U4's Corruption in the Health Sector theme page. Click here to access a number of related U4 briefs, issue papers, and other resources.
U4, Issue 2008:10 accessed on March 5 2009; and email from Elizabeth Hart to The Communication Initiative on June 23 2010.