Corruption in the health sector

Literature review

Corruption in the Health Sector

Corruption and the Provision of Health Care and Education Services
Sanjeev Gupta, Hamid Davoodi and Erwin Tiongron, IMF Working Paper, 2000

This paper reviews the relevant theoretical models and users' perceptions of corruption in the public provision of social services. Reports based on public service delivery surveys are found to confirm the pervasiveness of corruption and bribery in the public provision of health and education services. Evidence that reducing corruption can result in significant gains as measured by decreases in child and infant mortality rates, percent of low-birth weight babies, and primary school dropout rates are provided.

The purpose of the review is to determine whether a link between corruption and the outcome of public provision of social services can be established. However, the question of what causes such links and how to approach the problem of corruption receives less attention. Suggested policy implications appear rather conventional and devoid of contextual considerations.

Corruption and the Health sector
Taryn Vian, USAID/MSI, 2002

In this volume of the Sectoral Perspectives on Corruption series prepared by MSI and sponsored by US Agency for International Development, Taryn Vian describes the important areas of vulnerability to corruption within the health sector and identifies tools and approaches for prevention. Although it is acknowledged that corruption is of concern to all countries, the focus of this work is on developing and transitional economies in which public resources are scarce and inadequate systems are crippling their growth and development. Two areas of special focus are the supply of drugs and medical equipment, and informal economic activities of health providers. These areas account for large losses in resources and have direct effects on health by reducing quality of care and access to services, especially for the poor.

Following a detailed analysis of the types of corruption that occur in the health sector, Vian discusses the procurement and management of medicines, equipment and supplies, including the selection process, promotion, and distribution. She then discusses the informal economic activities of health personnel and health reform in connection to global funds before orienting strategies for health within overall anti-corruption activities at the national level. In addition to stressing the importance of approaching the problem of health sector corruption within a broader multi-sectoral anti-corruption strategy, it is emphasised that commitment should be built by demonstrating how reducing corruption can result in better health outcomes, improved quality and expanded access. The paper is concluded with an agenda for further research and an extensive bibliography. The paper has since been published in Bertram I Spector, ed. Fighting Corruption in Developing Countries (Bloomfield, CT: Kumarian Press Inc., 2005).

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Corruption and the Delivery of Health and Education Services
Azfar, Omar, USAID/MSI, 2002

Another volume of the Sectoral Perspectives on Corruption series prepared by MSI and sponsored by USAID, Omar Azfar starts by reviewing the literature on the effect of corruption on health and education outcomes. Drawing on data collected in a study in the Philippines, he cites a significant and clear effect of corruption on the knowledge of required immunizations by physicians, even after controlling for variables such as income levels, voting rates, media exposure, delays in salary payments and the supply of medicines. The estimated the impact of corruption on patient satisfaction and waiting times was in the right direction (i.e. corruption lowered satisfaction and increased waiting times), but was not statistically significant. The author discusses the nature of corruption in the health sector in terms of relationships: patient-doctor, payer-hospital, hospital-supplier, and within the ministry of health or any particular facility. Causes of corruption are reviewed, as well as emerging empirical data sets and ongoing research (i.e. public expenditure tracking surveys, quantitative service delivery surveys). As with Vian's paper, this paper has since been published in Bertram I spector, ed. Fighting Corruption in Developing Countries (Bloomfield, CT: Kumarian Press Inc., 2005).

Diagnosis Corruption
Di Tella, Rafael and William D. Savedoff, 2001, Source : Book (only chapter 1 available online)

One area not much discussed in the literature on corruption, particularly in Latin America, is health care. Health expenditures represent more than 7 percent of Latin America's GDP, with about 3.5 percent of GDP spent by the public sector alone. More than two-thirds of the public expenditures go to build, maintain, and operate public hospitals and provide related services, creating wide latitude for potential corruption.

Using studies of public-sector hospitals, this book addresses several issues. First, it demonstrates that objective data on corruption can be collected, analyzed, and used to stem corruption. Second, it measures and characterizes the abuse found in Latin America's public hospitals that drains government resources and compromises the health system's ability to serve the people. Finally, it identifies what features in the structure of incentives, accountability, and transparency can be used to reduce the scope and costs of this corruption.

The editors emphasise that this study is only a first step in analyzing a very complex and hidden phenomenon. Because the case studies in this book were designed to focus on fraud and misuse of funds within hospitals, they exclude much of the corruption related to the ministries and institutes that build, maintain, and operate hospitals. Looking at bribes, theft, absenteeism and overcharging for supplies in public hospitals in various countries, this volume shows that it is possible not only to measure corruption in new ways, but to identify systemic factors that encourage or discourage malfeasance in the health sector. The studies provide policymakers, researchers and public sector administrators with insight and tools in the struggle to reduce corruption, strengthen democracy, and build public trust.

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The characteristics of corruption in different health systems
Savedoff, William D., WHO, 2003 (draft - not available online)

This paper is based on the conviction that tackling corruption requires an understanding of the various forms of abuse, and that health care corruption is not exclusive to one kind of health system. It begins by looking at definitions of corruption and fraud and how they manifest themselves in particular ways in health systems. It then discusses how the different structures of health systems lead to different kinds of abuse, and provides a review of the evidence regarding the kinds, magnitudes and effects of corruption and fraud. It concludes with a discussion of some of the mechanisms and policies that show promise in fighting this problem. Although this paper is not limited to developing or transitional economies, it reflects the fact that the majority of the available evidence is focused on such countries.

Global Corruption Report 2006: Corruption in Health
Transparency International

The Global Corruption Report is published annually by Transparency International. In 2006, the theme of the report is health and corruption. The report includes chapters on risks of corruption according to health system and governance structure; the scale of the problem, including problems in both developed and developing countries; costs and consequences of corruption in the health sector, including corruption in hospitals, drug supply systems, and informal payments, and corruption in HIV/AIDS programs.

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Accountability and Health Systems: overview, framework and strategies
- Health systems called to account: a framework and guidelines for exploring accountability issues in the health sector
Brinkerhoff, D., Partners for Health reform plus (PHRplus), 2003

All health systems contain accountability relationships of different types, which function with varying degrees of success. Often it is the perception of failed or insufficient accountability that furnishes the impetus for reform. This paper provides a framework and guidance in reinforcing accountability in government service provision.

The author addresses: definition and clarification of accountability, analytic framework for accountability and health service delivery systems, role of health sector actors in accountability, and accountability-strengthening strategies. The paper describes three accountability-enhancing strategies: reducing abuse, assuring compliance with procedures and standards, and improving performance/learning.

Using an accountability lens can help to generate a system-wide perspective on health sector reform and identify connections among individual improvement interventions. These results can support synergistic outcomes, enhance system performance, and contribute to sustainability.

Accountability, Transparency and Corruption in Decentralized Governance
World Bank, 2006

This short article describes how decentralized governance is strengthened through citizen participation and accountability. Citizen participation allows the public to influence the direction and content of government services, while accountability provides 'validation of participation' by holding government authorities responsible for their actions.

Two types of accountability are discussed: the accountability of government workers to elected officials, and the accountability of elected officials to citizens. The first type of accountability is seen as more problematic and difficult to achieve because of the strong incentives government workers have to evade control by local authorities and maintain relationships with their "parent" ministry. Means of ensuring accountability of elected officials to citizens are discussed at more length, including elections (seen as a blunt tool), political party and NGO activities, informational strategies (including local media and public meetings), and formal complaint procedures.

The article notes that increased transparency may not reduce corruption in the short-run, but will increase citizen awareness of corruption. Beyond transparency, accountability mechanisms are needed to actually reduce corruption.

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Service accountability and community participation in the context of health sector reforms in Asia: Implication for sexual and reproductive health services. Ranjani K. Murthy and Barbara Klugman, 2004, Health Policy and Planning; 19 (Suppl.1): i78-i86. [Online purchase only!]

Community participation is often promoted as a strategy to increase government accountability for provision of services. But does it work? In this article, the authors review the experiences of 18 health sector reform initiatives in Asia, exploring the relationship between community participation and accountability. They conclude that community participation is often not effective in ensuring accountability due to lack of capacity of the communities. The authors recommend investments in building the power of civil society representatives as stakeholders.

Common strategies to increase accountability include increasing competition from the private sector; decentralization; and community financing. The first strategy works by increasing options or citizen choices, while the second and third options increase citizen voice and influence in decision making: strategies which increase the "answerability" of those who hold power to citizens. According to the authors, it is this latter function of accountability that is most important, figuring out how citizens can make sure that governments explain or justify what they actually do.

The article analyzes four different types of community participation in program management, including operations planning, monitoring of health delivery, managing infrastructure, and user fee collection and management, explaining how each type of participation can enforce accountability of health managers and workers. The article also suggests ways central governments can enforce accountability of decentralized units in the implementation of national policies. Suggested improvements for accountability include formalizing 'participation contracts' between civil society and government, and capacity building of civil society stakeholders in terms of better leadership models, and advocacy training.

Public Management and the Essential Health Functions
Das Gupta, M, Khaleghian, P. World Bank Policy Research Working Paper 3220, 2004

This paper provides an overview of how various approaches to improving public sector management relate to the so-called core or essential public health functions (EPHFs) such as disease surveillance, health education, monitoring and evaluation, workforce development, enforcement of public health laws and regulations, public health research, and health policy development (IOM 1987; PAHO 2002). Its purpose is to summarize key themes in the public management literature and draw lessons for the EPHFs. Section I summarizes "new public management" approaches. Section II reviews traditional approaches to public administration and their relevance to the EPHFs. Section III summarizes lessons in point form.

Governance and Corruption in Public Health Care Systems
Maureen Lewis, Centre for Global Development, 2006

This excellent working paper looks at factual evidence to describe the main challenges facing health care delivery in developing countries, including absenteeism, corruption, informal payments, and mismanagement. The author concludes that good governance is important in ensuring effective health care delivery, and that returns to investments in health are low where governance issues are not addressed. The paper provides policy options for promoting better governance.

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