Review of Corruption in the Health Sector: Theory, Methods and Interventions

Published in Health Policy and Planning (Vol. 23, No. 2, pp. 83-94), this article presents a conceptual framework to guide policymakers in examining corruption in the health sector and to identify possible ways to intervene. When power is abused for private gain, one place to look for explanation is how corruption is linked to various aspects of management, financing, and governance. Behavioural scientists and anthropologists also point to individual and social characteristics which influence the behaviour of government agents and clients. The article discusses implications for intervention, and presents examples of how theory has been applied in research and in practice. Challenges of tailoring anti-corruption strategies to particular contexts, and future directions for research, are addressed.

In the introductory sections, author Taryn Vian cites evidence illustrating that corruption is a pervasive problem in the health sector, with negative effects on health status and social welfare. She then describes the various types of corruption that affect government health facilities and services, explaining that definitions of corruption will vary by country and even within areas of a country.

Looking at corruption from the viewpoint of the government agent, Vian presents a framework suggesting that corruption is driven by 3 main forces: government agents who abuse public power and position for private gain do so because they feel pressured (financially or by clients) to abuse, because they are able to rationalise their behaviour or feel justified (attitudes and social norms support their decision), and because they have the opportunity to abuse power. According to economic theory, opportunities for corruption are greater in situations where the government agent has monopoly power over clients; officials have a great deal of discretion, or autonomous authority to make decisions, without adequate control on that discretion; and there is not enough accountability for decisions or results. Vian explores each of these concepts in detail.

She also examines the meaning of citizen voice, which refers to the channels and means for active participation by stakeholders in planning and provision of services. One purpose of citizen voice, she says, is to increase external accountability of government. Strategies to promote citizen voice include local health boards where citizens can have input into the budgeting and planning processes; patient surveys to provide feedback on satisfaction; and complaint offices to record and mediate reports of unethical or corrupt conduct. Research she cites here suggests that civic education can be effective in increasing citizens' willingness to participate in civic and political life, and their skills in explaining their problems. However, increasing citizen voice is not always easy; in countries where citizen participation was repressed for many years, there may be limited experience with non-governmental organisations (NGOs) and other forms of civic activism.

Vian next unpacks the concept of transparency, which centres around the idea that by actively disclosing information on how decisions are made, as well as measures of performance, we can improve public deliberation, reinforce accountability, and inform citizen choice. In addition, she explains, transparency helps document and disseminate information on the scope and consequences of corruption - information which can help build support for anti-corruption programmes and target enforcement efforts. Strategies to increase transparency include public service "report cards", which involves price monitoring and release of government documents or decisions through websites, public databases, public meetings, and the media. Vian discusses transparency initiatives in Argentina, Morocco, and Uganda that show the range of interventions possible.

Detection and enforcement includes steps taken to collect evidence that corruption has occurred, and to punish those who engage in corruption. Enforcement includes such activities as surveillance, internal security, fraud control, investigation (including investigative journalism), whistle-blowing, and punishment.

In addition to the above-cited institutional or organisational factors, behavioural scientists have studied the ways in which individual beliefs, attitudes, and social norms influence corruption. For example, researchers point to eroding public service values which create a vacuum in which corruption appears justified; for example, capitalism suggests that "everything has its price", which seems to endorse aggressive pursuit of self-interest even within government institutions. Personality character traits and demographic characteristics may also be important in explaining corruption. Vian discusses additional pressures to embezzle or abuse trust, stemming from factors such as low salaries or bribery.

Vian laments the fact that very little research exists to link these concepts to corruption in the health sector, arguing that this is an important area for future study. She contends that clearer understanding of these factors can help in crafting professional education programmes, codes of conduct, and information campaigns to correct misinformation, as well as to promote effective role modelling.

Several tools exist to help measure corruption and define the problem, including corruption perception surveys, expenditure surveys, qualitative data collection, and control systems reviews. These methods are summarised in Table 2 of the document, and described in narrative form. To describe only one, control systems review revolves around the internal operational processes by which an organisation makes decisions and uses resources to perform its mission. A review of these systems starts by identifying areas with high inherent risk of corruption, then assesses the existence of "best practice" safeguards, looking for such things as clear operating policies and procedures, appropriate division of responsibilities, use of computers for collecting and analysing data, and procedures for financial management and audit. Vian explains that the control systems review approach works best when systems are stable.

Next, a theoretical framework is presented to guide policymakers in examining corruption in the health sector and identifying possible ways to intervene to increase accountability, transparency, citizen voice, detection, and enforcement, and to control discretion and reduce monopoly power. Examples are provided to show how anti-corruption strategies can be tailored to deal with particular types of corruption, such as abuses involving HIV/AIDS drug supply. General strategies to mitigate risk of corruption in drug supply include procurement technical assistance to strengthen systems which are open and competitive; price transparency; and security interventions to protect the pipeline. The President's Emergency Plan for AIDS Relief (PEPFAR)-funded Supply Chain Management System (SCMS) Project, responsible for procurement of over US$500 million in AIDS drugs, provides an example of how these general strategies are applied in practice. One of the many components of the SCMS project discussed here is an online database of price information, which provides a standard against which other procurements can be measured. The information can be used by local procurement agents, national audit offices, development partners, or civil society organisations (CSOs) to inform decisions and hold government agents accountable.

As part of her closing comments, Vian calls for further research to refine and expand this framework, and to evaluate and document effective anti-corruption policies and programmes in the health sector.