Corruption in the health sector

Health worker / patient interaction

CONTENT ON THIS PAGE:

The Problems

•  Informal payments
•  Private practices / Absenteeism / Self-referral
•  Training / Licencing / Accreditation
•  Health care fraud
•  Conflict of interest

What can be done

•  Salaries and living conditions
•  Official user fees
•  Hierarchical accountability
•  Code of ethics
•  Access to information
•  Voice based strategies

The Problems

Corruption flourishes at the service delivery points affecting the interaction between health workers and patients when the following conditions arise: staff is underpaid as a result of constrained health budgets, when exceptional performance of health providers is not noticed or adequately rewarded, and when rules and sanctions are not enforced due to lack of oversight and supervision. 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. All these practices undermine the quality, access and use of health services.

Informal payments
Health workers respond to inadequate salaries and difficult living and working conditions by developing individual coping strategies, many of which can be seen as "survival corruption" [1]. Patients pay unofficial fees to gain access to health services that are supposed to be free of charge, to reduce waiting time, receive drugs, treatment or hospital meals as well as to ensure better attention and improved quality of treatment. Such practices are widespread in developing and transition countries. Informal payments have been consistently associated with massive reduction in the use of services in Poland and Uganda, due to financial accessibility of care. In the long run, they also compromise the quality of the health system by channelling out-of-pocket payments outside of the public health system. Many studies have been conducted in the past several years that explore the motivations behind informal payments, which is an essential step in order to design effective strategies to prevent them [2].

Private practices / self-referral / absenteeism
Doctors working for government have been increasingly allowed to open private practices as a strategy to supplement their meagre salaries. This has produced mixed results, with doctors spending official time in private practices, using public facilities and equipment to treat private patients, or merely utilising the public system to channel patients to their private practice. This often leads to high rates of absenteeism which represents a significant loss of funds and public resources. In Bangladesh, unannounced visits to public health facilities showed that doctors were absent more than 40% of the time [3]. Another study showed that absenteeism in primary health care clinics in non-HIV/AIDS afflicted countries ranged from 28-42% [4].
Absenteeism is often associated with low salaries, lucrative opportunities for selling services privately and lack of sanction or punishment.

Training and selling of accreditation or positions and licensing
Political influence, nepotism and favouritism can occur in the selection of candidates for training opportunities, appointment, hiring, and promotion and licensing of health personnel. Training is a particularly vulnerable area with trainees paying bribes to gain a place in a medical school or passing exams, jeopardising the competence of trained health workers. As noted in Nataliya Rumyantseva's article on "Taxonomy of Corruption in Higher Education" [5], higher education has a critical influence on young people's values and beliefs about right and wrong, and thus, on the nation's leadership. Corruption in professional education is therefore of very great concern.

Health care fraud
In countries where governments or health insurance companies can be billed for services rendered, a large range of fraudulent practices can occur, including billing for services that were not rendered, for more expensive services than were rendered, over prescribing or performing unnecessary interventions. Losses can be substantial: the U.S. government has estimated that improper Medicare fee-for-service payments, including non-hospital services, may be in the range of $11.9 billion to $23.2 billion per year, or 6.8 to 14% of total payments [6]. Due to complicated procedures, such practices are often difficult to monitor, detect and sanction.  

Conflict of interest
Pecuniary gains can influence a physician's decision and induce unnecessary interventions or over-prescriptions, whereby performed interventions or prescribed drugs are based on the remunerative aspect of the treatment rather than a patient's medical needs. In Peru, for example, studies have shown that in private hospitals 70% of births were caesarean deliveries against 20 % in public hospitals [7] . Physicians' medical practices can be influenced by questionable relationships of a financial or non-financial nature between doctors, firms and pharmacies.

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What can be done?

For anti-corruption regulations to be effective, the patients’ rights must be clear and well known, channels of complaints simple and well defined and regulatory agencies strong and trusted. Moreover, successful strategies must not only focus on prohibiting corrupt practise and enforcing sanctions against transgressors but address the underlying causes of corruption and provide incentives for good performance and honest behaviours.

Salaries and living conditions
Prohibition of corrupt practices cannot succeed if health workers’ wages remains low, but increasing salaries is not always a realistic option in many developing countries. An experiment carried out in Buenos Aires showed that the effectiveness of anti-corruption wage policies is largely dependent on the accompanying monitoring and auditing measures. Downsizing the public service in order to divide resources available for salaries among a smaller workforce meets much resistance in the public sector. Promoting contractual relationships between government and health workers rather than public service salaried status could be an alternative strategy to investigate further.

Official user fees
The introduction of official users' fees in health centres has been promoted as a strategy to eliminate unofficial payments, generating revenues that can be channelled back into operational costs or used to finance adequate salaries for health workers. This approach has produced mixed results in many countries in terms of financial accessibility and equity of health care and has been consistently associated with reduction of the use of services, especially preventive measures such as immunisation. Users' fees are clearly not an option for prevention, education or disease surveillance functions [8]. At the same time, hospitals and health centers in Cambodia have had success in reducing informal payments by formalizing user fees, and promoting professionalism among staff [9] . For example, one hospital created individual contracts with personnel and increased pay scales while enforcing accountability and sanctioning poor performance [10]. Similarly, reforms in Kyrgyzstan have shown some reduction in informal payments through the introduction of formal copayments [10a] Another hospital in Albania also has used formal user fees to try to decrease informal payments, and succeeded in raising physician salaries five-fold while increasing utilization [11].

Hierarchical accountability and improved management
Monitoring performance of civil servants has great potential to reduce corruption when associated with higher wages. This strategy involves defining clear performance expectations as well as job descriptions, transparent and enforced rules and behaviour standards as well as introducing fairly implemented merit based promotion policies. It also requires effective monitoring instruments that are insufficiently developed at present. Internal supervision can be complemented by external audits, unannounced visits to health facilities and evaluation of services by clients and beneficiaries. Innovative technology and management procedures at the facility level can also enhance efficiency and quality of service provision, reduce long waiting times and opportunities of bribery to gain or speed up access to medical care. External monitoring can be improved by providing channels for whistleblowing and legal support to citizens who feel they have been treated unfairly or harmed through corruption [12].

Code of ethics
Codes of ethics regulating the medical profession can be adopted and promoted through professional organisations and associations to address conflict of interest issues. The promotion of cost-effective evidence-based clinical treatment guidelines at the national and sub-national levels can also limit opportunities for abuse.

Access to information
When seeking health services, patients should be in a position to make informed choices and select appropriate providers at appropriate prices and standards of quality. This requires consumers to be informed of their rights, of the services available, prices and conditions of access. Making information public also tend to have an effect on providers directly by holding them up to scrutiny by peers, making it more difficult to conceal dishonourable activities and so forth [13] . An assessment of vulnerabilities to corruption in Albania suggested several initiatives to increase patient information, including a strategy to disseminate official price information; conduct trend analysis 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 [14].

Voice based strategies
Information and voice-based strategies that involve the community in decisions affecting them, as well as in monitoring activities, have proven to be very effective in regulating health services. 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. Because they are not of visible and immediate value for the community, such strategies may need to be adapted to preventive or educational public health services [15] . Effective citizen oversight boards were associated with lower rates of informal payments and lower input prices paid in municipal hospitals in Bolivia [16]. Efficient complaint mechanisms must also be in place to provide opportunities to report and prosecute abuse and restore the public trust in institutions. 

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References