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 healthCorruptionAnti-corruptionSustainable Development GoalsGood governanceInternational developmentGlobal health governance
Tim K. Mackey is
the Director of the Global Health Policy Institute, an Assistant
Professor at UC San Diego – School of Medicine, and the Associate
Director of the Joint Masters Degree Program in Health Policy and Law at
UCSD-California Western School of Law. He has a multidisciplinary
background and his research focuses on global health policy, law,
governance, and diplomacy and has worked or consulted for organizations
including the World Health Organization, U.S. Department of State, and
the U.S. Department of Justice
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, multijurisdictional, 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), can 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 economic sectors such as
energy, extractive industries, banking, 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 beyond 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 found that corruption and misuse of funds are
seen as the largest barrier to improving health in developing countries
among the US public (Fig. 2) [6].
Transparency International (TI), an international non-governmental
organization created to combat corruption, has also explored perceptions
of corruption in different public institutions, 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 effectiveness of development assistance for health,
leading to lowered government commitment to health aid for developing
countries that depend on these humanitarian investments [5].
The
motivation of different actors, including government 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 particularly susceptible to corruption,
including information asymmetry, the large number of actors and mix of
public and private sectors in healthcare systems, market uncertainty,
and large amounts of public spending [2, 3, 4].
These vulnerabilities allow the presence of various types of
corruption, spanning from bribery, kickbacks, and informal payments to
health personnel/administrators; fraud and abuse involving payments for
healthcare goods and services that are not rendered; collusion and bid
rigging in healthcare procurement and contract awards; biased or
unfavorable decisions due to conflicts of interest in healthcare
transactions/relationships; corruption in medical practice, education,
and research; and diversion, embezzlement and theft of various
healthcare resources [2, 3, 4, 9, 10, 11, 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 experiencing 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 challenges 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 contributors
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.
4.
Multi-stakeholder partnership:
Many actors, including governments, private sector, and civil society,
have an interest in controlling corruption. Thus, multi-stakeholder
partnerships hold promise as a strategy for advancing transparency and
accountability. Coalitions of local, national, regional, and
international stakeholders in both the public and private sectors
(including civil society) may help to increase trust and gain the
political support needed to ensure that healthcare services and projects
are protected from corrupt practices.
5.
Linkage to global health security:
Combating global health corruption is paramount to international
investments and shared goals to secure national and global health
security arising from the threat of infectious disease outbreaks (such
as the recent Ebola outbreak) and other health emergencies.
6.
Governance is important:
“Good” governance must encompass anti-corruption efforts, including
governance at the national level, governance of global pharmaceutical
supply chains, and governance of the international development agenda.
This is particularly true with the new United Nation’s Sustainable
Development Goals (SDGs), which, for the first time, specifically
address the themes of 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 significant barrier to the
achievement of universal goals of promoting human health, economic
development, security, and poverty alleviation.
In
response, it is critical that the international community 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 (sub-target 16.5, “Substantially reduce corruption and bribery in all
their forms”), and mobilized through robust global multi-stakeholder
partnerships as encouraged under SDG 17 (“Strengthen the means of
implementation and revitalize the global partnership for sustainable
development”). Global partnership should look to leverage all
anti-corruption resources, programs, tools, law/policies, and
initiatives the international community has at its disposal.
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.
Fig. 2
Public perception on the role of corruption in improving health in developing countries (Kaiser Family Foundation) [6].
Surveys conducted by the Kaiser Family Foundation examining Americans’
opinions on the US role in global health have consistently found that
the American public views corruption as a major problem. In its 2015
survey, 44 % of respondents believed that ‘corruption and misuse of funds’
was the most important reason why health cannot be improved in
developing countries. Seventy-nine percent of respondents also believed
corruption was a major barrier, meaning that corruption is viewed by the
American public as the biggest barrier (more than lack of
infrastructure/resources, poverty, lack of political leadership and
effective programs, and lack of funding) to investing in programs that
support global health goals
Fig. 3
Heat map of
Transparency International’s Global Corruption Barometer (GCB):
perceptions of the extent of corruption in medical and health services
institutions. Transparency International’s 2013 GCB uses surveys from
more than 114,000 respondents in 107 different countries to assess
people’s direct experiences and views on corruption in main institutions
in their countries. This includes assessing perception of the extent of
corruption in Medical and Health Services institutions measured on a
scale of 1 to 5, where 1 indicates “not at all corrupt” and 5 indicates
“extremely corrupt.” The above map was generated using publicly
available data from GCB and was visualized in ArcGIS map. It depicts the
varying levels of public perception on how corrupt medical and health
institutions are within respective countries (global mean score of 3.3)
Foreign aid, global health programs, and corruption
Bill Savedoff is a
senior fellow at the Center for Global Development (CGD), where he
works on issues of health policy, performance payments, and corruption.
Before joining CGD, he worked at the Inter-American Development Bank and
the World Health Organization on projects and research in Latin
America, Africa and Asia. His publications include The Health Financing Transition, Governing Mandatory Health Insurance, and Diagnosis Corruption
Corruption
is a problem for health programs worldwide, 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 remarkably successful in improving
health conditions, even in extremely corrupt settings. Foreign aid has
been essential 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 health [15, 16].
This kind of success resonates with taxpayers in wealthy countries who
strongly support aid for health programs; nevertheless, they worry about
corruption. For example, 60 % of Americans think US global health
spending is “too little” or “just right”, but 44 % believe “corruption
and misuse of funds” to be the most important reason behind health aid
ineffectiveness (Fig. 2) [6].
Corruption certainly affects health aid, but it also affects 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 absenteeism 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 receiving 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 integrity in their operations
is to control how aid funds are spent and monitored. Usually,
recipients must establish separate accounts, reporting systems, and
bidding procedures. Recipients may even have to obtain prior approval
from donors before issuing requests for proposals. This has a positive
side: following such procedures can improve 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 consulting firms, in part
because these firms could manage the agency’s complex bidding and
reporting requirements. 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 contributions
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 integrity and transparency [5].
In their zeal to root out corruption, investigators can also lose sight
of what health programs are trying to accomplish. In 2013, a report
from the Special Inspector General for Afghanistan Reconstruction called
for USAID to suspend a very successful health program because they
found inadequate accounting systems within the Afghan Ministry of
Health. The report not only lacked specific evidence of fraud; it also
failed to consider how a program at risk for corruption could have
contributed so much to increases in healthcare delivery and reductions
in child mortality [5].
Ignoring
information about program results when fighting 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 themselves from
subjective and arbitrary judgments about the trustworthiness of partner
governments and about suspending 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 preparation for
outbreaks of epidemics like SARS, highly pathogenic influenza, Ebola,
and Zika. Fortunately, global health programs succeed despite corruption
in many contexts. Aid should continue to support health programs but
with greater attention to measuring results as a way to highlight when
corruption is an obstacle and to acknowledge when it is not.
Maureen Lewis is
the co-founder and CEO of Aceso Global, a non-profit organization that
strengthens health systems in emerging markets and developing countries
by improving hospital management and integrated care, quality, and
performance. She is a non-resident Fellow at the Center for Global
Development and a Visiting Professor at Georgetown University’s School
of Foreign Service. Prior to that, Dr. Lewis spent 22 years at the World
Bank in management and staff positions, most notably as Chief Economist
Human Development. Dr. Lewis was a Senior Fellow at the Center for
Global Development and was previously a Senior Research Associate at The
Urban Institute working in Latin America
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, diabetes and accidents, are eclipsing
communicable diseases as causes of morbidity and mortality across the
globe. On the one hand, this shift represents a remarkable achievement
in controlling infectious diseases, on the other, prevention and
treatment of chronic diseases imply management of more complex
morbidities and more complicated 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 example, stemmed from weakened public health systems
suffering from decades of weak institutions and conflict making
conditions susceptible to corruption and mistrust [21].
As demonstrated in heavily impacted countries 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
effectively to meet needs, and is performance where it should be?
Effective health systems explicitly and implicitly intend 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 observers, 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 policymakers 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 performance incentives, which in turn
make accountability impossible [24]. Accountability is fundamental as it requires 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 accountability to anyone. Without
accountability, public servants face few restraints. Common measures of
corruption 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 sector 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 sectors in many countries [9, 24]. Such practices and circumstances 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 compromised, and expected
outcomes remain well out of reach. Indeed, corruption introduces serious
complications 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 supplies 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 standards and improve quality.
However, these efforts may have had the opposite effect. They have
served to fuel corruption and erode quality precisely because
institutions, 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 behavior 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. Despite the common absence of
incentives, well-designed explicit incentives with clear
accountabilities remain fundamental to well performing healthcare
systems. Evidence 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 systems 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, clinicians, citizens, and economists will
never be satisfied, nor should they be, with healthcare locally and
globally.
Frank Vogl is a
co-founder of Transparency International and the Partnership for
Transparency Fund and serves as an advisor to both organizations. He is
an adjunct professor of government at Georgetown University. Frank is
the author of Waging War on Corruption – Inside The Movement Fighting The Abuse of Power
(new paperback edition, September 2016) updated, 2016) Rowman &
Littlefield. He writes and lectures extensively on corruption – www.frankvogl.com
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 exclusively 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 citizens paid bribes to
receive health services, with the rate at 38 % in Morocco [26].
The GCB for sub-Saharan Africa 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].
An
important challenge is to find ways to obtain first-hand reports from
citizens on the corruption that they encounter in healthcare services
and to bring this to the attention of public officials. Over the last
couple of years, the Partnership for Transparency Fund (PTF), an
independent organization originally started in 2000 by the founders of
TI, has been pioneering a new information and communications technology
(ICT) approach in Uganda. Its likely success can lead to similar
projects in other countries. Namely, PTF, together with the
Anti-Corruption Coalition Uganda, launched the Citizen Action Platform
(CAP) [28]
to deploy ICT to systematically record, aggregate, map, and track cases
of corruption through to their resolution. The aim has been to provide
citizens with a means to safely and anonymously report abuse from their
mobile phone and receive feedback. The ICT approach has dramatically
reduced the costs of monitoring and reporting public service failures,
which provides civil society organizations with sufficient solid data to
constructively engage with service providers through a better
understanding of where, when, and what issues citizens are most
concerned about. The CAP program gained traction after instituting a
partnership with UNICEF’s Ureport program in January 2016, and may serve
as a model in developing more accountable and transparent means of
providing healthcare services and distributing medicine and medical
supplies. While the reports received often relate to waste and
inefficiency in services, more than 25 % of all complaints under the CAP
program included bribe taking.
PTF
has been involved in engaging citizens against corruption on many
fronts in more than 50 countries through specific projects. Experience
from PTF projects in the health sector where, in many cases, demands for
bribes by officials and healthcare workers undermined service delivery
has yielded valuable lessons. PTF has shared these findings widely [29, 30]
and they have, for example, influenced some of its most recent work,
such as the CAP program. Accordingly, PTF has found, for example, that
key approaches in implementing citizen-led projects in the health sector
where waste of resources, inefficiency and corruption are commonplace,
include:
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 economic
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 corruption was the prime cause of the
extraordinary poverty 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 thousands of complaints they
seek to handle from individual citizens who bring forward personal cases
of corruption, go hand-in-hand with a global “No Impunity” strategy. We
believe that far more effort must be made by the international
community to ensure that top government officials and politicians, as
well as the business people they conspire with, no longer operate as if
they are above the law.
Emerging tools and health system interventions to prevent corruption – a role for open contracting
James Sale is the
Program Manager for Transparency International’s Pharmaceuticals &
Healthcare Program. He joined TI in 2014 to establish the
Pharmaceuticals & Healthcare Program having previously worked in
governance and public financial management at Crown Agents and vaccine
surveillance with the World Health Organization
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, equipment, and health facility construction. However,
estimates 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 considering 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 universally accepted that a fundamental practice for
curbing corruption in public procurement is increasing transparency.
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
practice of publishing and using open and accessible information from
key stages of the procurement process. In health systems, this can begin
with publishing needs assessments and continue through to quality
assurance and contract completion [33].
This information is only useful if easily applied to identify potential
issues and hold procurement agents accountable. To achieve this, data
needs to be publically accessible according to measures such as the Open
Contracting Data Standards, so that external oversight can be properly
carried out [34].
At
the 2016 Anti-Corruption Summit in London, open contracting in public
procurement gained substantial support 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 countries (Argentina, Malta, Mexico, and Nigeria), supported by a UN commitment to work with ‘global, regional and country initiatives that strengthen the transparent procurement of health commodities’ , committed to progressing open contracting standards in their health sectors [36].
These pioneering countries are backed by a genuine appetite 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 information can produce
greater purchasing power for governments through the knowledge of what
others are paying, allowing them to achieve better value for money and
reducing 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 hepatitis, hemophilia, and orphan diseases [37].
One major contributing factor was the failure of the public medicines
procurement system, which the Ukrainian government itself called ‘inefficient, corrupted, non-transparent’ [38].
In response, the Ukrainian Ministry of Health outsourced the
procurement of drugs to two UN agencies (UNDP and UNICEF) and Crown
Agents, a British social enterprise working in international
development. The organizations reformed the system to meet international
standards and have already reported large savings 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 procurement, Ukraine has
successfully launched the e-procurement platform ProZorro [41].
Formed by a public-private partnership including TI Ukraine, the system
is based on the Open Contracting Data Standards and has won
international awards. Already having processed some health sector
contracts and demonstrated savings, ProZorro will be mandatory for all
public procurement as of August 2016. As with any new system, there will
undoubtedly be improvements that need to be made; however, it is an
extraordinary accomplishment to create such a system in the context of
political and security instability. This sets a precedent for others.
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 projecting 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 action,
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 is a Professor at the Leslie Dan Faculty of Pharmacy, the Dalla
Lana School of Public Health and the Munk School of Global Affairs. She
is also Director of the WHO Collaborating Centre for Governance,
Transparency and Accountability in the Pharmaceutical Sector. Her
research and teaching are focused on global pharmaceutical policies
related to improving fair access of those in need to critical medicines.
Prior to joining the University of Toronto, she worked exclusively on
global pharmaceutical policy for a number of UN organizations, including
UNICEF, the World Bank and the WHO. She continues to advise global
institutions and NGOs on global pharmaceutical policy issues such as
anti-corruption strategies, drug regulations, and reimbursement policies
Uneven
access to pharmaceuticals continues to be a serious global health
challenge despite targeted investments by the development community in
programming and services. As one illuminating example, 22 million people
living with HIV remain without access to antiretroviral therapy despite
rapid scale-up and increased availability of generic products [44]. We know that improved access to medicines (and vaccines) could save as many as 10 million lives per year [45].
Why then do we have persistent disparities in access to medicines? Much
of the development policy conversation on, and interventions designed
to address, medicine barriers have focused traditionally on
infrastructural limits to service delivery and the impact of
intellectual property; yet, there is an increasing body of evidence that
illuminates how governance challenges may create opportunities for
corruption and result in additional barriers to access to medicines [46, 47].
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 increasingly
understood as a pervasive problem with negative 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 addressing 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
occurrence and its impacts, and it is a highly sensitive and politically
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 organizations,
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
launching 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 tomorrow [46].
However, as stated above, governance matters. For example, to avoid
breaches in the pharmaceutical procurement system, an area particularly
vulnerable to corruption, e-procurement should be the norm. Electronic
bidding creates a platform through which multiple healthcare facilities
can upload their tenders and where prequalified suppliers that have a
proven reliability can participate. Open contracting, along with
e-procurement, can help improve transparency and accountability in the
procurement process and ideally lead to financial savings as well as
more assurance that good quality medicines are being procured [50].
Making the invisible visible and ensuring that mechanisms for good
governance that promote transparency and accountability are in place,
not just in procurement but in all areas of the pharmaceutical system,
are important for improving global pharmaceutical access to good quality
and essential medicines and to achieve health gains.
Joshua Michaud is
an Associate Director for Global Health Policy at the Kaiser Family
Foundation, and an authority on global health policy issues such as
financing, the role of US agencies in global health, global health
diplomacy, and health security and emerging diseases. He is also a
Professorial Lecturer at the Johns Hopkins University School of Advanced
International Studies (SAIS) in Washington DC, where he teaches courses
on global health policy and health and development
We
live in an age of epidemics and potential pandemics. 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 mortality they cause,
these events often carry huge economic and social disruption costs, and
therefore are increasingly seen not just as public health problems, but
also as national and global security concerns [51].
Health
security efforts, which have received greater attention and funding
from policymakers in the last several 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
embezzlement of funds, to poor governance and lack of compliance with
rules and regulations abetted by nepotism 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 efforts is to help countries build a set of
core capabilities to prevent, detect, and respond to emerging health
crises. 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 examples of corruption that can jeopardize capabilities
in each of the three focus areas of the GHSA.
Prevent
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, 54, 55].
Efforts to stem the spread of antimicrobial resistance – one of the key
GHSA areas of prevention effort – are jeopardized by the infiltration
of poor quality, falsified, substandard, and counterfeit medicines,
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 positions 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 appointments” whose actions were viewed as
ineffective, and even a hindrance, during the early response to the
disease [57, 58, 59]. Corruption reportedly plagues the selection 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 characterized 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 effective 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 requirements to pay bribes for services even
when nominally 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, 65, 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
information [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 occurred to a limited extent at the global level, as
the most recent 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 purposes 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 countries of all income
levels have demonstrated [71, 72, 73].
In the case of Ebola, Sierra Leone’s auditor-general found that
one-third of the country’s own contributions to the response within its
borders was unaccounted for [74],
while Liberia’s General Auditing Commission found numerous financial
and reporting irregularities in Ebola response money in the country [75]. Further, Saudi Arabia’s government reported US$ 266 million of its funding for MERS to have been used in a corrupt manner [76].
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
documentation, reporting, monitoring, and oversight of funding. Finally,
transparency on aid flows, covering public and private 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 emerging threats is to ensure all corners of the
globe have a minimum level of public health capacity, and a functioning
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.
Taryn Vian is
Associate Chair of Education and Associate Professor of Global Health at
the Boston University School of Public Health. Her research and
teaching focus on corruption and health, good governance, financial
reforms, and management systems. She has analyzed corruption
vulnerabilities in various countries for clients including USAID,
Transparency International, the Council of Europe, and WHO. She has
participated in Global Advisory Groups and expert meetings organized by
the Bill and Melinda Gates Foundation, USAID, UNDESA, and WHO on public
engagement in anti-corruption, transparency in the pharmaceutical
sector, and supply management
Building
on the momentum created by the Millennium Development Goals, the SDGs
have set an agenda to eradicate poverty, promote peace, protect the
environment, 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
access 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 important opportunity to invest in health systems
strengthening 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 measure this target by the ‘percentage
of persons who had at least one contact with a public official, who
paid a bribe to a public official, or were asked for a bribe by these
public officials, in the previous 12 months, disaggregated by age group,
sex, region and population group’ [81].
While
a single target cannot capture the myriad forms of corruption, the
health sector provides many opportunities for bribes or informal
payments, especially within the procurement process, during health
inspections, and in interactions between individuals and clinicians. 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 municipalities 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.
Some
strategies are known to work. Informal payments can be reduced by
making sure patients are aware of official pricing policies,
implementing payment systems reforms, and improving incentives of
healthcare professionals to provide good quality care so that patients
do not need to resort to bribes [84, 85].
Bribes in procurement can be controlled through price monitoring to
detect and investigate procurements which may have inflated prices to
conceal bribes, through electronic procurement systems which control
discretion and increase transparency, and by regular internal and
external audits [86, 87].
Community monitoring for accountability has proven effective in
reducing medicine stock-outs, unjustified absenteeism, informal
payments, and other forms of abuse of power [88].
These strategies need to be adapted to context, paying attention to
local knowledge and building on local values that are compatible with
improved integrity and better governance.
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 positions, 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 affecting 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, 91, 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 surveys 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 and
incorporate solutions into health policies and plans. Unaddressed
corruption directly impacts attainment of the SDG health goals, and
cannot be accepted.
Declarations
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.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/),
which permits unrestricted use, distribution, and reproduction in any
medium, provided you give appropriate credit to the original author(s)
and the source, provide a link to the Creative Commons license, and
indicate if changes were made. The Creative Commons Public Domain
Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Mackey
TK, Liang BA. Combating healthcare corruption and fraud with improved
global health governance. BMC Int Health Hum Rights. 2012;12:23.View ArticlePubMedPubMed CentralGoogle Scholar
Transparency
International. Global Corruption Report 2006: Corruption and Health.
London and Ann Arbor: Pluto Press and Transparency International; 2006.Google Scholar
Vian T. Review of corruption in the health sector: theory, methods and interventions. Health Policy Plan. 2008;23:83–94.View ArticlePubMedGoogle Scholar
Liang
BA, Mackey T. Confronting conflict: addressing institutional conflicts
of interest in academic medical centers. Am J Law Med. 2010;36:136–87.PubMedGoogle Scholar
Levine
R, The What Works Working Group. Millions saved: proven successes in
global health. Washington, DC: Center for Global Development; 2004.Google Scholar
Glassman
A, Temin M, The Million Saved Team and Advisory Group. Millions saved:
new cases of proven success in global health. Washington, DC: Center for
Global Development; 2016.Google Scholar
Norwegian
Agency for Development Cooperation. Anti-corruption approaches: a
literature review. Evaluation studies 2/2008. Oslo: Norad; 2008.Google Scholar
Persson
A, Rothstein B, Teorell J. Why anticorruption reforms fail—systemic
corruption as a collective action problem. Governance.
2013;26(3):449–71.View ArticleGoogle Scholar
Vian
T, Savedoff W, Mathisen H, editors. Anticorruption in the Health
Sector: Strategies for Transparency and Accountability. Sterling:
Kumarian Press; 2010.Google Scholar
Casartelli
G, Wolfstetter E. World Bank Policy on the Selection and Employment of
Consultants: Study of its Effectiveness. Washington, DC: World Bank;
2007.Google Scholar
World Bank. World Development Report: The State in a Changing World. Washington, DC: World Bank; 2007.Google Scholar
Bardhan P. Corruption and development: a review of issues. J Econ Lit. 1997;35(3):1320–46.Google Scholar
Lewis
M, Pettersson G. Governance in Health Care Delivery: Raising
Performance. Policy Research Working Paper No. 5074. Washington, DC:
World Bank; 2009.View ArticleGoogle Scholar
Oxford English Dictionary. Oxford: Oxford University Press; 2014.
World Health Organization. World Medicines Situation. Chapter 7: Access to Essential Medicines. WHO: Geneva; 2004.Google Scholar
Kohler
JC, Mackey TK, Ovtcharenko N. Why the MDGs need good governance in
pharmaceutical systems to promote global health. BMC Public Health.
2014;14:63.View ArticlePubMedPubMed CentralGoogle Scholar
Attaran
A, Barry D, Basheer S, Bate R, Benton D, Chauvin J, Garrett L,
Kickbusch I, Kohler JC, Midha K, Newton PN, Nishtar S, Orhii P, McKee M.
How to achieve international action on falsified and substandard
medicines: a consensus statement. BMJ. 2012;345:e738.View ArticleGoogle Scholar
Kohler
JC, Ovtcharenko N. Good governance for medicines initiatives: Exploring
lessons learned. Bergen: Chr. Michelsen Institute; 2013.Google Scholar
National
Academy of Medicine. The Neglected Dimension of Global Security: A
Framework to Counter Infectious Disease Crises. Washington, DC: National
Academies Press; 2016.Google Scholar
Michaud
J, Kates J, Oum S. Corruption and Global Health: Summary of a Policy
Roundtable. Oakland: Kaiser Family Foundation; 2015.Google Scholar
Savedoff
W, Hussmann K. Why are health systems prone to corruption? Global
Corruption Report 2006. London and Ann Arbor: Pluto Press and
Transparency International; 2006. p. 4–13.Google Scholar
Witvliet
MI, Kunst AE, Arah OA, Stronks K. Sick regimes and sick people: a
multilevel investigation of the population health consequences of
perceived national corruption. Trop Med Int Health. 2013;18(10):1240–7.View ArticlePubMedGoogle Scholar
Karunamoorthi
K. The counterfeit anti-malarial is a crime against humanity: a
systematic review of the scientific evidence. Malar J. 2014;13:209.View ArticlePubMedPubMed CentralGoogle Scholar
Pieterse
P, Lodge T. When free healthcare is not free. Corruption and mistrust
in Sierra Leone’s primary healthcare system immediately prior to the
Ebola outbreak. Int Health. 2015;5:400–4.View ArticleGoogle Scholar
Cohn
S, Kutalek R. Historical Parallels, Ebola Virus Disease and Cholera:
Understanding Community Distrust and Social Violence with Epidemics.
PLoS Current Outbreaks. 2016; Edition 1. doi:10.1371/currents.outbreaks.aa1f2b60e8d43939b43fbd93e1a63a94.
Santillana
M, Nguyen AT, Dredze M, Paul MJ, Nsoesie EO, Brownstein JS. Combining
search, social media, and traditional data sources to improve influenza
surveillance. PLoS Comp Biol. 2015;11(10):e1004513.View ArticleGoogle Scholar
Olson
SH, Benedum CM, Mekaru SR, Preston ND, Mazet JA, Joly DO, Brownstein
JS. Drivers of emerging infectious disease events as a framework for
digital detection. Emerg Infect Dis. 2015;21(8):1285–92.View ArticlePubMedPubMed CentralGoogle Scholar
Wilson
K, Brownstein JS, Fidler DP. Strengthening the International Health
Regulations: lessons from the H1N1 pandemic. Health Policy Plan.
2010;25:505–9.View ArticlePubMedPubMed CentralGoogle Scholar
Brinkerhoff
DW, Bossert TJ. Health governance: principal-agent linkages and health
system strengthening. Health Policy Plan. 2014;29(6):685–93.View ArticlePubMedGoogle Scholar
Kankeu
HT, Ventelou B. Socioeconomic inequalities in informal payments for
health care: An assessment of the 'Robin Hood' hypothesis in 33 African
countries. Soc Sci Med. 2016;151:173–86.View ArticlePubMedGoogle Scholar
Avelino
G, Barberia LG, Biderman C. Governance in managing public health
resources in Brazilian municipalities. Health Policy Plan.
2014;29(6):694–702.View ArticlePubMedGoogle Scholar
Miller
K, Vian T. Strategies for reducing informal payments. In: Vian T,
Savedoff WD, Mathisen H, editors. Anticorruption in the Health Sector:
Strategies for Transparency and Accountability. Sterling: Kumarian
Press; 2010. p. 55–66.Google Scholar
Falkingham
J, Akkazieva B, Baschieri A. Trends in out-of-pocket payments for
health care in Kyrgyzstan, 2001–2007. Health Policy Plan.
2010;25(5):427–36.View ArticlePubMedPubMed CentralGoogle Scholar
Elbahnasawy NG. E-government, internet adoption, and corruption: an empirical investigation. World Dev. 2014;57:114–26.View ArticleGoogle Scholar
Garuba
HA, Kohler JC, Huisman AM. Transparency in Nigeria's public
pharmaceutical sector: perceptions from policy makers. Glob Health.
2009;5(1):1–13.View ArticleGoogle Scholar
Bjorkman
M, Svensson J. Power to the people: evidence from a randomized field
experiment on community-based monitoring in Uganda. Quart J Econ.
2009;124(2):735–69.View ArticleGoogle Scholar
European
Commission – Directorate-General Home Affairs. Study on Corruption in
the Healthcare Sector. HOME/2011/ISEC/PR/047-A2. Luxembourg:
Publications Office of the European Union; 2013.Google Scholar
Vian
T. Implementing a transparency and accountability policy to reduce
corruption: The GAVI Alliance in Cameroon. U4 Brief 9. Bergen: U4
Anticorruption Resource Centre, Chr. Michelsen Institute; 2013.Google Scholar
Vian
T, Feeley FG, Domente S, Negruta A, Matei A, Habicht J. Barriers to
universal health coverage in Republic of Moldova: a policy analysis of
formal and informal out-of-pocket payments. BMC Health Serv Res.
2015;15:319.View ArticlePubMedPubMed CentralGoogle Scholar
