The disease of corruption: views
on how to fight corruption to advance
21st century global health goals
Tim K. Mackey1,2,3,4*, Jillian
Clare Kohler4,5, William
D. Savedoff6, Frank Vogl7,8, Maureen
Lewis9,10, James Sale11, Joshua
Michaud12,13 and Taryn Vian14
Abstract
Corruption
has been described as a disease. When corruption infiltrates global health, it can be particularly
devastating,
threatening hard gained
improvements in human and economic
development, international security, and population health. Yet, the multifaceted and complex nature
of global health
corruption makes it extremely
difficult to tackle, despite its enormous costs,
which have been
estimated in the billions of dollars. In this forum article, we asked anti-corruption experts to identify
key priority areas
that urgently need global attention
in order to advance the fight against
global health corruption. The views shared
by this multidisciplinary group of contributors reveal several
fundamental challenges and allow us to explore
potential solutions to address the unique risks
posed by health-related corruption. Collectively, these perspectives also provide a roadmap that can be used in support of global health anti-corruption
efforts in the post-2015 development agenda.
Keywords: Global health, Corruption, Anti-corruption,
Sustainable Development Goals, Good governance, International development, Global health
governance
Background
In 1996, former World Bank President
James Wolfensohn made a groundbreaking
speech calling for international action and attention to deal with what he
coined the ‘cancer of corruption’ [1]. Decades
later, this representation
of corruption as a destructive disease seems fitting, as health-related
corruption is now a multifaceted, multijur-
isdictional, and multibillion dollar phenomenon that threatens the
future progress of global health [2, 3].
Similar to cancer, health-related
corruption comes in several types (ranging from “petty” corruption such as
absenteeism of healthcare workers to “systematic” corruption involving multinational companies engaged
in widespread healthcare fraud and abuse, and “grand” corruption occurring
at high levels of government), caninvade and spread (infiltrating public and private sectors
as well as poorer and richer countries alike), has an enormous financial cost,
is often difficult to detect/ diagnose
and, most importantly, is hard to treat [2, 3]. Critically, health-related corruption is distinctly dangerous compared
to other forms of corruption in traditional eco- nomic sectors such as energy,
extractive industries, bank- ing,
and construction, in that it presents a “dual-burden” of limiting both economic/human development while at the same time
endangering patients and population-level health [2, 4].
invade and spread (infiltrating public and private sectors
as well as poorer and richer countries alike), has an enormous financial cost,
is often difficult to detect/ diagnose
and, most importantly, is hard to treat [2, 3]. Critically, health-related corruption is distinctly dangerous compared
to other forms of corruption in traditional eco- nomic sectors such as energy,
extractive industries, bank- ing,
and construction, in that it presents a “dual-burden” of limiting both economic/human development while at the same time
endangering patients and population-level health [2, 4].
The cost of health-related corruption
can extend be- yond the people and communities it directly impacts, as the mere
presence of corruption can lead to negative public perception and criticism
about the role of foreign health aid [5]. This is evidenced by surveys
conducted by the Kaiser Family Foundation that have consistently
explored perceptions of corruption in different public
in- stitutions, including in the medical and health sector. Results from
its 2013 Global Corruption Barometer (GCB) [7] indicate
that perceptions of the extent to
which the medical and health services sectors are affected by corruption vary
widely across different countries (Fig. 3). Collectively, these negative views can
unjustifiably inflate public concerns about the effective- ness of development assistance for health, leading to
lowered government commitment to health aid for de- veloping countries that
depend on these humanitarian investments [5].
The motivation of different actors,
including govern- ment officials, private companies, and organized crime groups
to engage in health-related corruption should come as no surprise: the
healthcare sector is one of the fastest and largest segments of the global
economy, accounting for nearly 10 % of the worldwide gross
domestic product (GDP) according to the World Bank [8]. In
addition, the health sector is characterized by unique risk factors and
inherent complexities particu- larly
susceptible to corruption, including information asymmetry, the large number of
actors and mix of public and private sectors in healthcare systems, market
uncer- tainty, and large amounts of public spending [2–4]. These vulnerabilities allow the presence of
various types of corruption, spanning from bribery, kickbacks, and in- formal
payments to health personnel/administrators;
fraud and abuse involving payments for healthcare goods and services that are
not rendered; collusion and bid rig- ging in healthcare procurement and
contract awards; biased or unfavorable decisions due to conflicts of inter- est
in healthcare transactions/relationships; corruption
in medical practice, education, and research; and diver- sion,
embezzlement and theft of various healthcare resources [2–4, 9–12]. Further,
the diversity and scope of
health-related corruption makes it equally difficult to design programs
effective in preventing, detecting, and controlling corrupt practices [2].
The challenges of health-related
corruption are further accentuated in the context of global
health programs and settings. Specifically, global health
programs are transnational in nature, including participation of one or more
countries, and often involve substantial foreign aid and multiple development
partners. Additionally, many global health programs operate in countries with
weak governance or rule of law [2, 13]. These factors can lead to greater vulnerabilities for infiltration of
corruption that is
multijurisdictional, impacted differently by the varying policies, laws and
regulations, and influenced by local social and cultural beliefs about what
constitutes corrupt acts [2, 9]. There is
also a great deal of money at stake,
with development assistance for health experi- encing a rapid increase from a
mere US$ 11 billion in 1999 to the US$ 36 billion disbursed in 2015, marking the emergence of global health as a
multibillion dollar sector [14].
In an attempt to raise awareness to the
unique chal- lenges of global health corruption, this Forum article presents
views from a set of multidisciplinary experts from fields including public
health, political science, economics, and international development. Our
contrib- utors comprise a mix of
practitioners, implementers, and
researchers from civil society and global health institutions, with experience
working for organizations directly engaged in anti-corruption programs such as
the World Bank, TI, and the UN Development Programme (UNDP). The aim of this
Forum is to bring together these different perspectives to identify key
priority areas that urgently need attention and to lay
out a roadmap for global health anti-corruption
efforts in the post-2015 development agenda.
The following key themes relating to how to advance
anti-corruption goals emerged from our discussions:
1.
Problems with the concept of “zero” corruption: Corruption is endemic
in all health systems, including rich and poorer countries. However,
anti-corruption
initiatives that aim for “zero” tolerance
of corruption may penalize programs that are putting in place the building
blocks for more effective and corruption-resistant health systems.
Harsh
penalties may create perverse incentives to hide corruption, rather than
rooting it out.
2.
Better data: A pervasive
theme among all contributors was the admission that the true scope and cost of
global health corruption is largely unknown. Corruption can be invisible,
difficult to detect, and often highly politicized, all of which require better
indicators, data collection/reporting, and analysis.
3.
Importance of
transparency: Transparency is a critical tool in curbing health corruption.
This includes enhancing transparency and disclosure in financial systems and
controls, healthcare relationships/transactions, and health sector procurement systems.
corruption,
ensuring access to healthcare services and medicines, and encouraging global
multi-stakeholder partnerships as key strategic goals.
International attention concerning
corruption has been steadily growing,
including a recent
2015 anti-corruption summit
hosted by former UK Prime Minister David Cameron. Yet, insufficient attention
has been focused
on the health sector
and particularly on global health,
despite the fact that global health
corruption represents a signifi-
cant barrier to the achievement of universal goals of pro- moting human health, economic
development, security, and poverty alleviation.
In response,
it is critical that the international commu- nity develop a unified framework devoted to combating
global health corruption as
the disease that it is. These efforts
should be underpinned by SDG
3 (“Ensure
healthy lives and promote
well-being for all at all ages”, SDG 16
Global efforts to address global health corruption
could be operationalized
under a newly formed United Nations
High-level Panel on Corruption,
convened by the Secretary General,
that would include in its programmatic
objectives a specific review of the impact of global health
corruption on human health, human rights, security, and international development. The panel should include partnership
with key institutions that have been active in the fight against health corruption.
The proposed panel should deliver a set
of recommendations for concrete solutions, development of SDG indicators that specifically
measure health-related corruption, encourage anti-corruption policy coherence, and establish a roadmap for
achieving health systems
that are liberated from the chains of corruption.
Foreign aid, global health programs, and corruption
Corruption is a problem for health programs world- wide, yet we know surprisingly little
about its scale and impact. Without this information, we
do not know whether anti-corruption
strategies are doing too
much or
too little, whether
they are effective or weak, or whether they improve program impact or get in the way. Worldwide, foreign aid programs have been remark- ably successful in improving health
conditions, even in extremely corrupt settings. Foreign
aid has been essen- tial
to the eradication of smallpox, prevention of vaccine-preventable diseases like
measles, treatment of potentially lethal conditions like diarrhea, and expanded access to
services that improve maternal and infant
Corruption certainly affects health
aid, but it also af- fects all health systems to some degree [3]. In richer
countries, corruption tends to make healthcare delivery costlier, while in
poorer countries, it tends to undermine the delivery of care and exacerbate
inequities. In low- and middle-income countries, petty bribes and absentee- ism
are well documented, as are occasional cases of high-level embezzlement and
kickbacks. Experience shows that foreign aid cannot solve these problems of corruption without political commitment
from the re- ceiving countries [17, 18], but it can improve healthcare
delivery and population health even in very corrupt contexts [19].
The primary approach used by donors to
assure integ- rity in their operations is to control how aid funds are spent
and monitored. Usually, recipients must establish separate accounts, reporting
systems, and bidding proce- dures. Recipients may even have to obtain prior
approval from donors before issuing requests for proposals. This has a positive
side: following such procedures can im- prove local capacity to receive,
manage, and spend funds appropriately. Nevertheless, financial controls can
also raise costs and encumber implementation. In 2010, more than 90 % of USAID
contracts went to US-based con- sulting firms, in part because these firms
could manage the agency’s complex bidding
and reporting require- ments. At the World Bank, one study found that
contracting consultants took 17 months for programs
that only lasted about 2 years [20].
Aid agencies do need procedures to
ensure integrity but current approaches are unbalanced because they aim for “zero” corruption without
regard for results, namely the impact on healthcare delivery and population
health. For example, Germany, Spain and Denmark suspended contri- butions to
the Global Fund to Fight AIDS, Tuberculosis and Malaria in 2011 after a media
report exaggerated the scale of corruption detected by the Fund’s own inspector general’s office. To show
they were tough on corruption, donors halted funding without regard to the
severity or impact of their actions on program results. In doing so, they also
penalized the Global Fund for its efforts at integ- rity and transparency [5]. In their
zeal to root out corrup- tion, investigators can also lose sight of what health
programs are trying to accomplish. In 2013, a report from the Special Inspector
General for Afghanistan Reconstruc- tion called for USAID to suspend a very
successful health
Ignoring information about program
results when fight- ing corruption endangers progress. Simultaneously, it
neglects a powerful tool for detecting fraud and improving anti-corruption
strategies. If agencies did a better job of measuring results, they could use
this information to prioritize how they allocate anti-corruption resources.
They could also use such information to learn how anti- corruption strategies
affect project success so as to make them more effective and less intrusive.
Finally, results measurements can help aid agencies to distance them- selves
from subjective and arbitrary judgments about the trustworthiness of partner
governments and about sus- pending aid Global health programs
are well worth the
money.
The world should invest
more in expanding access to healthcare, disease prevention, and global public goods
like epidemiological surveillance and advance prepar- ation for outbreaks of
epidemics like SARS, highly pathogenic influenza, Ebola, and Zika. Fortunately,
glo- bal health programs succeed despite corruption in many contexts. Aid
should continue to support health pro- grams but with greater attention to
measuring results as a way to
highlight when corruption is an obstacle and to acknowledge when it is not.
Economics, health systems, and corruption
Healthcare
systems underpin both healthcare delivery and efforts towards attaining
universal healthcare (UHC), the global goal for public health organizations
such as the World Health Organization (WHO). Any push to attain UHC can founder
on shifting sand. Infectious diseases like
malaria and HIV dominate the donor and private foundation landscape in
developing countries, but chronic conditions, including cancer, cardiovascular disease, dia- betes and accidents, are
eclipsing communicable diseases as causes of morbidity and mortality across the
globe. On the one hand, this shift represents a remarkable achieve- ment in
controlling infectious diseases, on the other,
prevention and treatment of chronic diseases imply man- agement of more
complex morbidities and more compli- cated services.
The
performance of healthcare systems determines the effectiveness and costs of healthcare
services. Corruption is a significant cost driver and a cancer in undermining
effective healthcare services. The Ebola outbreak, for ex- ample, stemmed from
weakened public health systems suffering from decades of weak institutions and
conflict making conditions susceptible to corruption and mis- trust [21]. As
demonstrated in heavily impacted coun- tries of Liberia and Sierra Leone,
failures in patient diagnosis and treatment can reflect problems in health
system functioning, specifically its clinical, non-clinical, and management
tasks. Economists worry about the costs and effectiveness of services – is there too much or too little
care being provided, are services organized and delivered efficiently, are
resources used most effect- ively to meet needs, and is performance where it
should be? Effective health systems explicitly and implicitly in- tend to
address many of these concerns because they bolster access and performance of
clinical services.making conditions susceptible to corruption and mis- trust [21]. As
demonstrated in heavily impacted coun- tries of Liberia and Sierra Leone,
failures in patient diagnosis and treatment can reflect problems in health
system functioning, specifically its clinical, non-clinical, and management
tasks. Economists worry about the costs and effectiveness of services – is there too much or too little
care being provided, are services organized and delivered efficiently, are
resources used most effect- ively to meet needs, and is performance where it
should be? Effective health systems explicitly and implicitly in- tend to
address many of these concerns because they bolster access and performance of
clinical services.Over
the past two decades, the honesty and integrity of healthcare systems across low- and
middle-income countries has troubled citizens, external and internal ob-
servers, and governments alike. Coming from a broader agenda of corruption and
development that linked poor services and slow growth to widespread corruption [22],the health
sector has had to confront corruption in healthcare systems. Initially,
researchers and policy- makers
implicitly assumed that corruption was not a problem in the health sector, and
organizations like the World Bank determined that investments in health and
education were the preferred options in corrupt societies as they implicitly
believed these sectors were immune. That assumption no longer holds and
evidence bears this out.
Corruption can be defined in abbreviated terms as ‘use of public office for
private gain’ [23]. However, what has led to corruption
in healthcare? Fundamentally, a lack of accountability. This lack of
accountability derives from a number of factors, including inadequate
management, lack of oversight, poor
training, and an absence of per- formance incentives, which in turn make
accountability impossible [24]. Accountability is fundamental as it
re- quires that “officials are called to account and to answer for
responsibilities and conduct” [25], that is,
it ensures consequences for poor behavior and ideally rewards exceptional
behavior. Because accountability in most healthcare systems is diffused across
patients, payers, managers, and citizens, there is effectively little if any
ac- countability to anyone. Without accountability, public servants face few
restraints. Common measures of cor- ruption in healthcare across low- and
middle-income countries include
absenteeism of physicians and nurses
(a practice rife in much of the world), health workers, including
physicians, forced to purchase their public sec- tor jobs, ghost workers,
frequent “stock outs” of drugs and supplies, leakages of
public monies, patients paying “under the table” directly to individual providers, and a perception of healthcare
as among the most corrupt sec- tors in many
countries [9, 24]. Such practices and cir- cumstances compromise the delivery of healthcare.
The leap to
how corruption undermines healthcare
systems should
be obvious. Without personnel, drugs, management, and other inputs, healthcare
services are effectively unavailable. For economists, this scenario translates
into total system breakdown because resources are being wasted, performance is poor, outputs are com- promised, and
expected outcomes remain well out of reach. Indeed, corruption introduces
serious complica- tions as it undermines every
aspect of healthcare delivery from the effectiveness of
providers to the availability of inputs for the care of patients [3]. A move to address any breakdown
in healthcare entails
efforts on multiple fronts.
Numerous public initiatives have attempted to mitigate the observed
consequences of corruption. A sampling of these include reducing costs by bulk
purchasing of sup- plies and drugs, and public hiring and management of
personnel in order to keep human resources “in-house” [24]. These initiatives reflect efforts to
internally manage
and control
healthcare delivery to safeguard basic stan- dards and improve quality.
However, these efforts may have had the opposite effect. They have served to
fuel corruption and erode quality precisely because institu- tions, managers,
and employees are not held accountable by the public healthcare system.
Absent from much of the healthcare agenda is an acknowledgment of any
perverse implicit or explicit incentives that allow for poor behavior.
Economists rely on incentives to encourage good performance through, for example, merit promotions or
bonuses for good performance, or to discourage unethical or illegal be- havior
such as stealing of drugs, absenteeism or financial mismanagement through
sanctions, demotions or firing. However, these incentives remain rare in public
systems even when egregious performance is documented. Des- pite the common
absence of incentives, well-designed explicit incentives with clear
accountabilities remain fun- damental to well performing healthcare systems.
Evi- dence increasingly points to separating the payer and provider to allow
oversight by a different entity, and to contracting out services spanning
clinical care to facility maintenance to private or publicly accountable
entities [24].
Healthcare is among the most complex sectors in any economy. Raising the
bar and improving how these sys- tems work will hinge on clear incentives and
effective accountability that roots out the various forms of corruption that
have infiltrated the health system of this trillion-dollar global sector.
Without that synergy, clini- cians, citizens, and economists will never be
satisfied, nor should they be, with healthcare locally
and globally.
Civil society fights corruption in healthcare
Frank Vogl (Fig. 6)
Concerns about the failure of a large number of well- intentioned
official foreign aid programs and projects in the healthcare sector were one of
the powerful drivers behind the establishment of TI in 1993. TI was the first
global non-governmental organization dedicated ex- clusively to
anti-corruption, and it currently operates through national chapters in more
than 100 countries.
Today, many civil society organizations are planning and implementing anti-corruption projects to specifically
improve healthcare services,
notably for the poor in poor
countries. The scale of the challenge is enormous; for example, TI’s 2016 survey for nine
countries in the Middle East and North Africa showed that 20 % of citi- zens
paid bribes to receive health services, with the rate at 38 % in Morocco [26]. The GCB for sub-Saharan Af-
rica found that 12 % of citizens routinely paid bribes for health services, and in many cases they paid multiple
bribes, notably when needing hospital services
[27].
PTF has been involved in engaging citizens against cor- ruption on many fronts in more than
50 countries through specific projects. Experience from
PTF projects in
●
Raising
public awareness of rights, particularly the costs of medicines and treatments,
is a key first-step to ensuring these rights are appropriately fulfilled.
●
Designing projects to cover a
wide range of issues so that they are capable of hearing a wide variety of
citizen voices and responding to their greatest concerns – this proved to be most
effective, for example, in PTF’s work with 15 communities in
service delivery projects in India.
●
Engaging
constructively with authorities is the most effective way to resolve issues and
achieve change.
●
Advocacy
is more powerful with partnerships between civil society organizations at the
national level, who have access to decision-makers, and the local level, who
can ensure that service delivery is supported by systemic or policy changes.
●
Trained
and supported volunteer citizen committees can be powerful agents to identify
corruption and push for improvements, even on technical issues.
●
Anti-corruption
commissions and public service codes of conduct can be helpful in elevating
corruption issues and strengthening accountability among service providers.
Tragically, progress in improving
healthcare delivery in many
countries suffers not only from the corruption that PTF and its partners have
been addressing community-by-community, but also because of grand corruption – the wholesale theft of health budgets by senior government
officials and politicians. At the level
of grand corruption there is no meaningful way to single out the impact
on healthcare relative to overall eco- nomic
development and the provision of basic
services to all citizens to reduce
poverty. The scale of this problem
is well highlighted by the African
Progress Panel Report 2013 [31], which concluded that grand cor-
ruption was the prime cause of the
extraordinary pov- erty in
many of the natural resource-rich countries of sub-Saharan Africa – core health data for Nigeria and Angola, for example, are
atrocious, especially when the oil wealth of these countries is considered.
For TI, the specific efforts made by many of its national chapters to
implement healthcare projects, plus the thou- sands of complaints they seek to
handle from individual
Emerging tools and health system
interventions to prevent corruption – a role for open contracting
James Sale (Fig. 7)
Of the trillions of dollars spent on healthcare globally on an annual
basis [32], a large proportion is spent through large public contracting
for medicines, equip- ment, and health facility construction. However, esti-
mates suggest that 10–25 % of global spending
on public procurement is lost
to corruption and waste [3]. It is
therefore germane to look at procurement when consid- ering emerging
health sector-wide anti-corruption tools.
Health sector procurement is particularly
vulnerable to corruption due
to its technical complexity, numerous stages, and requirement of high
expertise. It is univer- sally accepted that a fundamental practice for curbing
corruption in public procurement is increasing transpar- ency. This is nothing
new; however, what is new is the growing use of open contracting as a pragmatic
remedy to a lack of transparency as
part of the wider move towards open governments. Open contracting is the
At the 2016
Anti-Corruption Summit in London, open
contracting in public
procurement gained substantial sup- port with a commitment in the Summit Communique to ‘making public procurement open by default – so that citizens and businesses can have a clear public record of how
public money is spent’ [35]. Furthermore, four coun- tries (Argentina, Malta, Mexico, and Nigeria), supported by a UN commitment to work with ‘global, regional and country initiatives that strengthen the transparent procure- ment of health commodities’, committed to progressing open contracting standards in their health
sectors [36]. These
pioneering countries are backed by a genuine
appe- tite for reforming health sector procurement in many more
countries. To encourage more to follow this lead, the added benefits of
reducing procurement corruption through increased transparency need to be demonstrated.
For example, disclosing adequate levels
of data and infor- mation can produce greater
purchasing power for
govern- ments through the knowledge of what others are paying, allowing them to achieve better
value for money and re- ducing the risk of price gouging,
price manipulation, and overpayments [4].
In 2014, hundreds of thousands of
Ukrainians died due to a lack of essential
life-sustaining medicines, affecting those suffering from tuberculosis, viral
hepa- titis, hemophilia, and orphan diseases [37]. One major contributing factor was the failure of the public medi-
cines procurement system, which the Ukrainian govern- ment itself called ‘inefficient, corrupted,
non-transparent’ [38]. In response, the Ukrainian Ministry
of Health out- sourced the procurement of drugs to two UN agencies (UNDP and
UNICEF) and Crown Agents, a British so- cial enterprise working in
international development. The organizations reformed the system to
meet inter- national standards and have already reported large sav- ings and
increased flow of medicines to patients. UNDP reported US$ 1 million of savings
in anti-tuberculosis medicines this year alone, and Crown Agents were able to procure oncology medicines at prices
45 % cheaper than the Ministry of Health paid in 2014, saving nearly US$ 20
million [39,
40].
In addition to the basic reform of medicines pro- curement, Ukraine has
successfully launched the e- procurement platform ProZorro [41]. Formed by a
While national governments are seen as the
key drivers for improving procurement systems, those acting at a
regional and global level are equally crucial for progress. These key actors
need to not only lead by example, but must also have the resources to invest in
innovative solutions and wider adoption. One such innovative approach is
currently being launched by the Global Fund to fight AIDS, Tuberculosis and
Malaria (The Global Fund).
Wambo.org is an e-procurement platform that acts as an e-marketplace for Principle Recipients
of Global Fund grants to purchase quality-assured goods launched in 2016 [42]. The system pools orders and, by combining the purchasing power of governments, aims to
keep costs low and consistent.
Wambo.org is also set to roll out
beyond just Global Fund grantees, including non- for-profit organizations, with
The Global Fund project- ing savings of at least US$ 250 million over the next
4 years.
Wambo.org is an online procurement
system that provides information
on products, prices, delivery times, and tracking [43], much like an online
shop. While principally
acting as an e-marketplace, systems such as Wambo.org can also record the type
of data that is needed for external
oversight and accountability. When adequate public
procurement data is disclosed in a
usable format, civil society is able to scrutinize and identify corruption risks. Data collected through such
e-procurement processes should be publically disclosed and accessible for
further study.
Despite these types of examples, current anti-corruption tools and
interventions are still limited, and there is an absence of key actors
committed to preventing corruption from occurring in health systems. Corruption
remains rife and immediate action is required in order to coordinate a holistic
and multi-stakeholder approach. Until such ac- tion, progressive tools will
have little impact and success will occur in isolation.
Why making the invisible visible
matters for global access to
medicines
Jillian Clare Kohler
(Fig. 8)
Uneven access to pharmaceuticals continues to be a serious global health
challenge despite targeted invest- ments by the development community in
programming
Further
complicating issues is the inherent complexity of the pharmaceutical system,
which encompasses the actions of public and private stakeholders as they move
drugs through the global supply chain from purchasing to delivery to patients.
The system is inherently challenging to govern,
as it is characterized by multiple opportunities
for system failure, limited accountability between stakeholders, and a lack of coordination between the various stakeholders [48]. There are indeed multiple information
gaps at all levels, including between the consumer
and the healthcare
provider (in terms of prescription
drug choice), between the healthcare provider and the manufacturer (in terms of
the therapeutic qualities of the product), and even between the manufacturer and the regulator.
The pharmaceutical system’s vulnerabilities to
corruption are many and in- creasingly understood as a pervasive problem with
nega- tive effects on health status and social welfare [9].
Corruption
in the pharmaceutical system specifically can compel the global poor, who are the most vulnerable to its
worst effects, to make sub-optimal choices
that may include purchasing drugs
from unqualified or illegal drug sellers to save money, not taking needed
medicines if they are unavailable in
the public health system, or
impoverishing themselves further by having to purchase expensive drugs in the
private health system. Further, the
transnational criminal trade in substandard/spurious/
falsely-labeled/falsified/counterfeit medical products is a pervasive problem
in global markets, and is recognized as a global public health threat with
severe consequences, including patient death, treatment failure, and possible
antimicrobial resistance [49]. Thus, pharmaceutical governance, with a focus on
anti-corruption activities, is essential to improve healthcare services and patient
outcomes globally.For decades, global
development institutions ignored ad- dressing
corruption in their policy and
programmatic areas. There are many reasons why this was
the case – it is challenging to provide substantial data about its occur- rence and its impacts, and it is a highly sensitive and polit- ically
charged issue. Thanks to growing
public awareness about the deleterious impacts of corruption, particularly in terms of development
goals, addressing corruption is
now squarely embedded in the global development agenda and it is even included as a specific
target within the new SDGs. However, even before these developments, global organiza- tions, donor funded organizations, and civil society,
such as the WHO, the
Medicines Transparency Alliance, the Global Fund for AIDS, Malaria and Tuberculosis, and most recently, TI, have been active in this area by launch- ing policy and/or
operational work on transparency and
accountability, two key components of
good governance in pharmaceutical systems.
The integrity of the global pharmaceutical supply
chain is indispensable to
securing health outcomes today and to- morrow [46]. However, as stated
above, governance mat- ters. For example, to avoid breaches in the pharmaceutical
procurement system,
an area particularly vulnerable to cor-ruption, e-procurement should be the
norm. Electronic bidding creates a
platform through
which multiple
Health security and corruption
Joshua Michaud
We live in an age of epidemics and potential pan- demics. One need only
list some of the key threats from the headlines of the last few years alone to
get a sense – Zika, Ebola, MERS,
influenza, and rising antimicrobial resistance. Above and beyond the morbidity
and mor- tality they cause, these events often carry huge economic and social
disruption costs, and therefore are increas-
ingly seen not just as public health problems, but also as national and
global security concerns [51].
Health security efforts,
which have received
greater at- tention and
funding from policymakers in the last sev- eral years, seek to minimize
vulnerability to these types of threats. While the increased attention is
welcome, all parties must recognize that such efforts are vulnerable to
corruption just as with other areas of healthcare. As previously discussed,
corruption can take many forms: from “petty” corruption such as
absenteeism or bribe- taking, to criminal activity such as theft and embezzle-
ment of funds, to poor governance and lack of compliance with rules and
regulations abetted by nepo- tism and non-merit-based hiring practices [52]. Corrupt practices not only impact
individual patients and localities
where they occur, but in the case of emerging diseases,
they can potentially have more widespread, even global, consequences for
human health and welfare.
As outlined in the newly launched Global Health Security Agenda (GHSA),
the aim of health security ef- forts is to help countries build a set of core
capabilities to prevent, detect, and
respond to emerging health cri- ses.
However, even if GHSA documents do not mention corruption specifically, these
capacity building efforts are vulnerable just like any other public health initiatives. The remainder of this section
will briefly discuss exam- ples of corruption that can jeopardize capabilities in
each of the three focus areas of the GHSA.
Preventing an outbreak from occurring in the first place is the best possible health security
outcome, but requires an effective public health system with good governance
and oversight being in place. Unfortunately, many healthcare systems struggle
with providing access and high quality services, often due to a variety of
corrupt practices [53–55]. Efforts to stem the spread of anti-
microbial resistance – one of the key GHSA areas
of prevention effort – are jeopardized by the
infiltration of poor quality, falsified, substandard, and counterfeit med-
icines, including antimalarials and antibiotics, into pharmaceutical supply
chains [46, 47, 56].
Health security also requires empowered, effective leadership and
oversight, but the system of global health governance has been weakened by
placements in key po- sitions based on politics and
personal connections rather than expertise or effectiveness. As an example, WHO
country representatives in West Africa at the time of the 2014 Ebola outbreak
were “politically motivated
appoint- ments” whose actions were viewed
as ineffective, and even a hindrance, during the early response to the dis-
ease [57–59]. Corruption reportedly plagues the selec- tion of member state
delegations and the process of electing WHO leadership [60]. We are at an important juncture in this regard, as member states have already begun
negotiations for selecting the next Director
General of the WHO, a process that has been character- ized as far from
open and transparent.
Detect
Early
detection of emerging disease events is critical for intervening quickly to stem impacts,
and detection relies on robust surveillance systems
with a motivated and ef- fective workforce at its foundation. Astute
observation by local health practitioners is often the first step in early
detection of an outbreak. It is unfortunate, then, that many communities often
lack trust in their local health providers due to corrupt practices such as re-
quirements to pay bribes for services even when nomin- ally free and high rates of chronic absenteeism among
health workers. This was certainly a factor in the Ebola epidemic; in 2013, 48
% of patients in Sierra Leone and 40 % in Liberia reported paying bribes to
access health services [7] and mistrust
between local communities and primary public healthcare providers in Sierra Leone pre- existed the outbreak [61, 62].
Even after an outbreak is detected, reporting by authorities can be
incomplete or delayed due to self- interest and skewed incentives. The SARS
episode in China provides an example where ability to intervene early was undermined by conscious misrepresentation of information in order to protect individuals’ careers and the government’s reputation [63]. Similar
behavior has been noted in Saudi Arabia and South Korea regarding MERS, and in
Venezuela regarding Zika [64–66].
Utilizing a broader, more decentralized, and technology- driven
approach to surveillance can help address
some of these challenges. For example, linking mobile
phone disease reporting from civil society and private sector sources
to formal networks can democratize surveillance and loosen
central authorities’ tight control over critical
outbreak infor- mation [67]. Robust platforms already exist for this more
informal, non-centralized type of reporting, though not without their own challenges [68, 69]. This has already
oc- curred to a limited extent at
the global level, as the most re-
cent revision of international regulations around disease reporting
allow WHO, for the first time, access
to and use of
information from non-governmental sources for the pur-
poses of identifying outbreaks of concern [70].
Respond
Epidemic response can involve many actors
and new funds pouring in, sometimes without
adequate oversight and controls being in place. Injecting funds into weak systems not ready to absorb
them or track them can be a recipe for
crimes of opportunity like
embezzlement and diversion of
resources for private gain, as emergency responses in coun-
tries of all income levels have demonstrated [71–73]. In
the case of Ebola, Sierra Leone’s auditor-general found that
To combat such diversion of funds there is no substitute for vigilance
and having robust, risk-based approaches in place prior to the occurrence of an
outbreak. This means having policies, procedures and the means to provide due
diligence for recipients of funds, plus proper documenta- tion, reporting,
monitoring, and oversight of funding. Finally,
transparency on aid flows, covering
public and pri- vate actors, can help provide more
accountability during an outbreak [77].
These are only a few examples of how corruption can impact health
security, and what can be done to address
it. The only way to truly and sustainably address emer- ging threats is
to ensure all corners of the globe have a minimum level of public health
capacity, and a function- ing system of governance is a key part of this goal
that is not always emphasized. Through the GHSA and other initiatives, efforts
are now underway to bolster public health capabilities; however, accountability
and oversight mechanisms to combat corruption should be considered, as these
will ultimately help make funds go even farther and save even more lives.
Anti-corruption and the SDGs – a
pathway forward
Building on the momentum created by the Millennium Development Goals, the
SDGs have set an agenda to eradicate poverty, promote peace, protect the environ-
ment, and advance population well-being over the next 15 years [78]. SDG 3 (“Ensure healthy lives and promote well-being for all at all
ages”) includes targets to reduce
mortality, end epidemics, manage non-communicable diseases, and achieve
systems-wide improvements in ac- cess and financing, among others [79].
The SDG goals and targets
also include a commitment
to improve governance. Strong institutions and good governance are essential to
ensuring equitable access to quality public services, including health and
education [80]. With the
SDGs, we can expect to see more resources dedicated to strengthening
institutions and building capacity to improve governance. This is an im- portant opportunity to invest in
health systems strength- ening to prevent and control corruption.
SDG 16 (“Promote
just, peaceful and inclusive
societies”) specifically includes a sub-target
to “substantially reduce corruption and bribery
in all their
forms”. The UN Inter- Agency Expert
Group on SDG Indicators proposes to
While a single target cannot capture the myriad forms of corruption, the health sector provides
many oppor- tunities for bribes or informal
payments, especially within the
procurement process, during health inspec- tions, and in interactions between
individuals and clini- cians. For example, over 30 % of respondents from eight
African countries reported having to pay bribes to access healthcare services
in one study, with the poorest being most disadvantaged [82]. A review of audit reports for health
grants in Brazil found that 55.9 % of municipal- ities had experienced at least
one incident of corruption, including procurement fraud and over-invoicing [83]. Looking forward, health sector leaders should be setting
their own intermediate targets to reduce
opportunities and incentives for
bribes and informal payments in order to achieve the SDGs.
Researchers studying health sector corruption in Europe developed a typology of six common corruption problems,
including bribery in medical service delivery, procurement corruption, improper
medical device and medicines marketing relations, misuse of (high) level posi- tions, undue reimbursement claims,
and fraud and embezzlement of medicines and medical devices
[89].
Yet, the prevalence and patterns of these problems vary by country.
Reflecting these differences, priority-setting for anti-corruption depends, in
part, on the financing system in place – corruption risks in tax-based systems generally include diversion
of funds at the ministerial level, informal
payments, corruption in procurement, and abuses affect- ing quality of care,
while in social insurance systems there are higher risks for corruption due to
excessive treatment, billing fraud, and diversion of funds [89].
Analyzing risks in particular
settings is important, and can draw on analysis of household budget survey data (to detect informal payments), medicine price surveys (to detect excessive payments for
commodities which might indicate bribery or bid-rigging), past audit reports
(to detect gaps in financial controls), and interviews with key informants (to
identify areas where excess discretion or other systems weaknesses may lead to abuses) [90–92]. The effectiveness of interventions will depend as much on a country’s culture, history,
institutional constraints, and capacities as it does on analysis of forms of
corruption. Attempting to apply standardized solutions without concern for the
particular corruption problem in its own context is counterproductive.
We can strengthen governance in the health sector, and this will help
countries to achieve the SDGs. Monitoring bribery (the target for SDG 16)
through health sector sur- veys will help focus attention on the problem, but
it is not a solution. We need to train a new generation of health leaders who
can diagnose health sector corruption risks
Acknowledgments
WDS thanks Amanda Glassman, Janeen Madan and Amy Smith for the research collaboration on which this piece is based and comments. FV most appreciates the substantial contributions to and the research
for this article by Sara Little,
the PTF programs and communications manager. JCK is grateful to the Canadian
Institute
for Health Research (CIHR) for funding her research related to corruption.
Authors’ contributions
All authors
were involved in drafting the manuscript and agreed to its
publication. All authors read and approved their sections of the final manuscript. TKM (corresponding author) read and approved all sections of the final manuscript.
Competing interests
The authors
declare that they have no competing interests. JS declares that he previously worked
for Crown Agents
but has no financial ties.
Springer Nature remains neutral with regard to jurisdictional claims
in published maps and institutional affiliations.
Author details
1Department of Anesthesiology, University of California, San Diego School
of Medicine, San Diego, CA, USA. 2Division of Global Public
Health, University of
California, San
Diego School of Medicine, Department of Medicine, San Diego, CA, USA. 3Global Health
Policy Institute, 6256 Greenwich Drive,
Mail Code: 0172X, San Diego, CA 92122, USA. 4WHO Collaborating Centre for Governance,
Transparency and Accountability in the Pharmaceutical Sector, University of
Toronto, Toronto, Ontario, Canada. 5Leslie Dan Faculty of Pharmacy, Munk School of Global Affairs,
Dalla Lana School
of Public Health, University of Toronto, Toronto, Ontario,
Canada. 6Center for Global Development, Washington, DC, USA. 7Transparency International, Secretariat, Berlin, Germany. 8The Partnership for
Transparency Fund, Washington, DC, USA. 9Georgetown University, Washington, DC,
USA. 10Aceso Global, Washington, DC, USA. 11Transparency International UK, London, UK. 12Kaiser
Family Foundation, Washington, DC, USA. 13Johns Hopkins University School of
Advanced International Studies,
Washington, DC, USA. 14Boston University School of Public Health, Boston, MA, USA.
Received: 15 September 2016 Accepted: 15 September 2016
References
1.
People and Development: address
to the Board of Governors, Washington, DC, October 1, 1996 (English). http://documents.worldbank.org/curated/en/ 243871468141893629/People-and-development-address-to-the-Board-of- Governors-Washington-DC-October-1-1996. Accessed 5 Aug 2016.
2.
Mackey
TK, Liang BA. Combating healthcare corruption and fraud with improved global health
governance. BMC Int Health Hum Rights. 2012;12:23.
3.
Transparency
International. Global Corruption Report 2006: Corruption and Health. London and
Ann Arbor: Pluto Press and Transparency International; 2006.
4.
UNDP. Fighting
Corruption in the
Health Sector: Methods, Tools and Good Practices. 2011. http://www.undp.org/content/undp/en/home/librarypage/ democratic-governance/anti-corruption/fighting_corruptioninthehealthsector. html. Accessed 7 May 2012.
5.
Savedoff W, Glassman A, Madan J. Global Health,
Aid and Corruption: Can We Escape the Scandal Cycle?
CGD Policy Paper 086. Washington DC: Center for Global Development; 2016. http://www.cgdev.org/publication/ global-health-aid-and-corruption-can-we-escape-scandal-cycle.
Accessed 14 Jun 2016.
6.
DiJulio B, Norton M, Brodie
M. Americans’ views on the U.S. role in global
health. 2016. Kaiser Family Foundation. http://kff.org/global-health-policy/poll-finding/ americans-views-on-the-u-s-role-in-global-health/. Accessed
6 Jun 2016.
7.
Transparency
International. Global Corruption Barometer 2013: Report. https://www.transparency.org/gcb2013/report/.
Accessed 6 Jun 2016.
8.
Health
expenditure, total (% of GDP). 2016. http://data.worldbank.org/ indicator/SH.XPD.TOTL.ZS.
Accessed 5 Aug 2016.
