Understanding corruption in the health sector

Health systems are particularly susceptible to corruption due to:

• Large amounts of resources
• Uncertainty
• Information asymmetry
• The large number of actors
• National healt systems' complexity and fragmentation
• The globalised nature of the supply chain for drugs and medical devices.

Different health systems are prone to different types of corruption, but state and policy capture, and corruption in the drug supply chain, procurement, and appointments, occur in all systems. At service delivery level, cultural differences in what is considered acceptable or unacceptable behaviour require context-specific understanding.

An array of tools can help to diagnose the problems and generate buy-in for anti-corruption measures. Assessment tools focus on experiences or perceptions of corruption, comprehensive sector assessments, specific sectoral risks, or health sector governance. Some tools focus on certain sub-sectors, such as medical drugs or human resources. However, most tools do not assess high-level corruption involving leading health authorities or state capture. In practice therefore, a combination of different tools will be useful, and the support of donors is essential.

Identifying and punishing corrupt practices in health remains difficult and the imperative to save lives may impede frank discussions among government actors and development partners.

Health anti-corruption so far

Many countries have made efforts to address corruption and unethical behaviour in their health systems. The initiatives seem to be targeted at either:

• Problems – eg informal payments / absenteeism / or overbilling
• Processes – eg drug procurement / health workforce management
• Institutions – eg health centres and hospitals.

A summary of this type of problems and potential mitigating strategies is offered in Annex 1. These interventions are often deployed, though, in limited geographic areas and time periods. Generally more holistic, strategic, and medium- to long-term initiatives to address corruption in health systems seem to be rare.

A number of international initiatives have been created for the pharmaceutical sub-sector, for health related procurement, such as the Open Contracting Partnership and Open Contracting for Health. Specific risk areas, such as of transparency in drug pricing and clinical trials, have received attention in terms of policy guidance.

When deploying these various tools it is important to bear in mind that reducing corruption and promoting good governance should not be seen as ends in themselves, but as a means to achieve sector goals.

The tools used are often normative and prescriptive, focusing on rules and procedures that are assumed to prevent corrupt practices. They usually pay insufficient attention to management systems and practices reflecting the principles of transparency, accountability, and participation. Moreover, the tools may not adequately capture the complex dynamics that lead to specific corrupt behaviours.

In spite of these shortfalls, social accountability tools show promise for reducing corruption in health service delivery.

Not much attention has been paid to levers that can have an impact on grand corruption in the health sector. These include as monitoring senior health sector officials' assets and interests as – both in-country and internationally. In addition, there is a surprising lack of documented evidence on initiatives to analyse and address capture of health regulatory agencies, specific health sector oversight agencies, drug price commissions, and similar bodies. Crucially, documented evidence on outcomes of health anti-corruption initiatives is patchy, and impact mostly unknown.

Finally, there is an opportunity to link the three Sustainable Development Goals that contain commitments to addressing health sector corruption to sector strengthening initiatives: goals 3, 16, and 17.

Recommendations for donors

It is important to develop long-term, strategic approaches based on a sound understanding of dynamics in the sector and the diferent actors' roles. Donors should support:

At the international level

1. Linkages of health SDGs with good-governance SDGs
2. Multi-stakeholder initiatives to address corruption in health
3. Support for continuous research and learning
4. Vertical programmes to complement the current fraud control focus with a health systems strengthening approach to increase integrity
5. Civil society at the international level.

At the national level

1. Information and knowledge generation: multi-disciplinary diagnostics, external monitoring and oversight
2. Health strategy and policy: integration of anti-corruption into health policies and plans, sector transparency strategies, government-donor dialogue around corruption in health
3. Targeted reforms and measures: regulatory and institutional integrity, building of bridges between the health and anti-corruption 'communities'
4. Non-state actors: social control and advocacy for integrity in health, piloting of national multi-stakeholder initiatives, integrity in professional associations, teaching and research on corruption and integrity in health.

Actions for development partners themselves

1. Fostering the cooperation between health and governance teams: corruption and integrity lens in new health programmes, identification of ‘red flags’ by health advisors, reaction to incidents of corruption in the sector, application of whole-of-government approach to corruption in the health sector
2. Donor coordination on corruption in health, including the contracting of a specific anti-corruption and integrity expert for the health sector.