Corruption

What is the relationship between health sector corruption and human rights?

Corruption is defined as the “misuse of entrusted power for personal gain” according to Transparency International and is pervasive across the health-care sector. The health sector is particularly vulnerable to corruption owing to the large amount of allocated public expenditure in many countries, several stakeholders including regulators, payers, providers, consumers and suppliers all interacting in a complex way with a great asymmetry of information between them. Often, private providers are also entrusted with roles that serve the public, thus the identification and control of diverging interests is especially difficult.[1]

Examples of corruption include but are not limited to, resale of free public health-care goods for profit, inflated prices during medicines procurement, and the giving or receiving of bribes to access medical care or services. Corruption has a negative impact on global health outcomes and in low-resource settings marginalized and vulnerable groups are disproportionately impacted.[2]

Aside from the wastage of financial resources, health sector corruption can further deter access to health care and prevent individuals from obtaining life-saving interventions. This can occur because prices for health-care products and services become unaffordable for patients due to the demand for bribes. If health professionals are employed on the basis of nepotism this results in potentially incompetent people providing care and services. In the area of drugs and medicines, the sale of counterfeit products can have a severe negative impact on the quality of medication available for patients. Thus, health-sector corruption has the potential to severely compromise the quality and coverage of healthcare services and therefore undermines the fundamental right to health.

What are the relevant issues/problems with regards to this issue?

It is important to note that the sociocultural context of the country in which the health system is situated can have an impact on which practices are considered to be corrupt. For example, in the case of informal payments for clinical services it can be unclear which payments are bribes or gifts for exceptional service.[3]

Types of corruption in the health sector include:[4]

 

Area or process

Types of corruption or problems

Results

  • Construction and rehabilitation of health facilities
  • Bribes, kickbacks and political considerations influencing the contracting process
  • Contractors fail to perform and are not held accountable
  • High cost, low quality facilities and construction work
  • Location of facilities that does not correspond to need, resulting in inequities in access
  • Biased distribution of infrastructure favouring urban- and elite-focused services, high technology
  • Purchase of equipment and supplies, including drugs
  • Bribes, kickbacks and political considerations influence specifications and winners of bids
  • Collusion or bid rigging during procurement
  • Lack of incentives to choose low cost and high quality suppliers
  • Unethical drug promotion
  • Suppliers fail to deliver and are not held accountable
  • High cost, inappropriate or duplicative drugs and equipment
  • Inappropriate equipment located without consideration of true need
  • Sub-standard equipment and drugs
  • Inequities due to inadequate funds left to provide for all needs
  • Distribution and use of drugs and supplies in service delivery
  • Theft (for personal use) or diversion (for private sector resale) of drugs/supplies at storage and distribution points
  • Sale of drugs or supplies that were supposed to be free
  • Lower utilization
  • Patients do not get proper treatment
  • Patients must make informal payments to obtain drugs
  • Interruption of treatment or incomplete treatment, leading to development of anti-microbial resistance
  • Regulation of quality in products, services, facilities and professionals
  • Bribes to speed process or gain approval for drug registration, drug quality inspection, or certification of good manufacturing practices
  • Bribes or political considerations influence results of inspections or suppress findings
  • Biased application of sanitary regulations for restaurants, food production and cosmetics
  • Biased application of accreditation, certification or licensing procedures and standards
  • Sub-therapeutic or fake drugs allowed on market
  • Marginal suppliers are allowed to continue participating in bids, getting government work
  • Increased incidence of food poisoning
  • Spread of infectious and communicable diseases
  • Poor quality facilities continue to function
  • Incompetent or fake professionals continue to practice
  • Education of health professionals
  • Bribes to gain place in medical school or other pre-service training
  • Bribes to obtain passing grades
  • Political influence, nepotism in selection of candidates for training opportunities
  • Incompetent professionals practicing medicine or working in health professions
  • Loss of faith and freedom due to unfair system
  • Medical research
  • Pseudo-trials funded by drug companies that are really for marketing
  • Misunderstanding of informed consent and other issues of adequate standards in developing countries
  • Violation of individual rights
  • Biases and inequities in research
  • Provision of services by medical personnel and other health workers
  • Use of public facilities and equipment to see private patients
  • Unnecessary referrals to private practice or privately owned ancillary services
  • Absenteeism
  • Informal payments required from patients for services
  • Theft of user fee revenue, other diversion of budget allocations
  • Government loses value of investments without adequate compensation
  • Employees are not available to serve patients, leading to lower volume of services and unmet needs, and higher unit costs for health services actually delivered
  • Reduced utilization of services by patients who cannot pay
  • Impoverishment as citizens use income and sell assets to pay for health care
  • Reduced quality of care from loss of revenue
  • Loss of citizen faith in government

How can the situation be improved?

Although the concept of corruption has officially been acknowledged internationally, and included in the 2003 UN Convention against Corruption (UNCAC), there is still a need for a legally binding anti-corruption instrument to be implemented globally.[5] Coordinated efforts from all the actors in the health-care system is required to decrease corruption in the sector. It is important to investigate the drivers, pressures and behaviours that give rise to corruption in order to develop effective preventative strategies for corruption. Emphasis should be given to the utilization and dissemination of current research on corruption, creating the right balance of incentives and disincentives for good and bad behavior in the health sector.

Generalised anti-corruption strategies include improved public finance management in the health sector, and stricter enforcement of regulation and policies against corruption. As recommended by the WHO GGM (Good Governance in Medicines) Program, the implementation of legislation and the fear of sanctions or fines can be used as a method for combating corruption, at the governmental or an organizational level.[6] Elements of good governance relevant to the health sector include improving transparency, accountability, flows of information, regulation, policy planning and implementation, leadership, ethical behavior etc.

Health workers are advised to work in accordance with best practice guidelines and ensure the timely delivery of affordable care of sufficient quality to their patients. Furthermore, they are encouraged to participate in trainings on ethics and governance. Health workers are given the autonomous power to make decisions such as prioritizing patients, or deciding which medicines to dispense, which is defined as discretion. Strategies are required that give health workers the freedom to make these decisions, with adequate checks and balances in place, which prevent them from abusing this entrusted power. These could include the development and implementation of standard operating procedures, which outline and clarify decision-making processes. Care should also be taken to control the level of discretion without creating dysfunctional bureaucracy.

Professional organisations are urged to incentivize their employees appropriately to prevent them from indulging in fraudulent practices, and clearly outline job responsibilities and accountability.

Governments are encouraged to build capacity and strengthen their health-care systems to reduce inefficiencies, through methods that could include participation in the WHO GGM programme, or informed policy planning at national and regional levels. Governments should ensure that information asymmetry is reduced through increased transparency approaches, e.g., mandated disclosure agreements that require all actors to publically disclose medicines prices and prevent the monopolization of health-care services. Transparency initiatives help document and disseminate information on the scope and consequences of corruption and can aid policy planning and decision-making. Whistleblower protection should be offered to individuals on behalf of the state so that corrupt practices will be detected and reported. Detection mechanisms such as monitoring and surveillance should be improved to identify and remove ‘bad agents’ in the health sector.

International organisations are called upon to build consensus to develop globally applicable binding legislation and policies against corruption, which can be implemented and adapted according to the national law of a specific country.

This page was written by Gauri Deoras and last updated in February 2015.

Notes

[1] Gaal P, McKee M. 2005. Fee-for-Service or donation? Hungarian perspectives on informal payment for health care. Social Science and Medicine 60: 1445-57

[2] Fighting Corruption in the Health Sector: Methods, Tools and Good Practises 2011 : http://www.undp.org/content/undp/en/home/librarypage/democratic-governance/anti-corruption/fighting_corruptioninthehealthsector/

[3] Gaal P, McKee M. 2005. Fee-for-Service or donation? Hungarian perspectives on informal payment for health care. Social Science and Medicine 60: 1445-57

[4] Vian T, The sectoral dimensions of corruption: health care, Chapter 4 in Spector BI (ed.). Fighting corruption in developing countries. Bloomfield, CT: Kumarian Press Inc., 2005, p. 45-46.

[5] United Nations Convention Against Corruption (2003) http://www.unodc.org/unodc/en/treaties/CAC/index.html

[6] WHO Good Governance for Medicines Program: http://www.who.int/medicines/areas/policy/goodgovernance/en/

 

Read more...

Resources

Topics: ,
Type of resource: Books and reports

Corruption in the Pharmaceutical Sector: Diagnosing the challenges (2016) - Jillian Clare Kohler, Martha Gabriela Martinez, Michael Petkov & James Sale
Transparency International

Open resource
Topics: ,
Type of resource: Books and reports

Diagnosing Corruption in Healthcare (2016) - Michael Petkov & Deborah Cohen
Transparency International

Open resource
Topics: ,
Type of resource: Books and reports

Women, Health and Corruption, Redefining Partnerships for Social Change (2014) - Kathleen Gnocato, Anika Harford, Kailee Jordan & Elizabeth Shelley
Graduate Institute of Geneva

Open resource
Topics: ,
Type of resource: Books and reports

Corruption, Inequality and Population Perception of Healthcare Quality in Europe (2013) - Z. Nikoloski & E. Mossialos
BMC health services research, 13, p. 472

Open resource
Topics: ,
Type of resource: Books and reports

Corruption in Global Health: Governance Approaches in Dealing with Forms of Health Related Corruption (2012) - Timothy Ken Mackey
Institute of Health Law Studies

Open resource
Topics: , ,
Type of resource: Books and reports

Addressing Corruption in the Health Sector: Securing equitable access to health care for everyone (2011) - Karen Hussmann
CHR Michelsen Institute

Open resource
Topics: , ,
Type of resource: Books and reports

Confronting Corruption in the Health Sector in Vietnam: Patterns and Prospects (2011) - Taryn Vian, Derick W. Brinkerhoff, Frank G. Feeley, Matthieu Salomon & Nguyen Thi Kieu Vien
Boston University – Center for Global Health and Development

Open resource
Topics: ,
Type of resource: Manuals and guidelines

Fighting Corruption in the Health Sector: Methods, Tools and Good Practises (2011)
UNDP

Open resource
Topics: ,
Type of resource: Books and reports

Addressing Corruption in the Health Sector. How to Note, a DIFID Practive Paper. (2010) - Karen Hussmann
DFID (UK)

Open resource
Topics: , ,
Type of resource: Books and reports

WHO Good Governance For Medicines Programme: an innovative approach to prevent corruption in the pharmaceutical sector (2010) - Guitelle Baghdadi-Sabeti & Fatima Serhan
WHO

Open resource