GRANADA, Spain — When stakeholders discuss the biggest obstacles to universal health coverage, conversations often linger on well-known challenges such as increasing access to last-mile populations, or how to achieve sustainable financing.
While finding solutions to these hurdles is vital for achieving UHC, there is another critical obstacle that receives far less attention: corruption in the health sector.
According to a recent report by Transparency International, corruption in the health care industry “kills an estimated 140,000 children a year, fuels the global rise in anti-microbial resistance, and hinders the fight against HIV/AIDS and other diseases.” In total, the report links corruption to annual losses of more than $500 billion, which it notes is more than it would cost to bring about UHC worldwide.
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A 2018 World Health Organization report has also flagged health system corruption as both a “significant drain on domestic health resources,” and “a major barrier to efforts to transform health systems as a part of the universal health coverage agenda.”
Despite this, many stakeholders shy away from bringing up the subject at all, according to Rachel Cooper, director of Transparency International’s health initiative. For UHC to be achieved, stakeholders need to be open to having frank discussions about the issue of corruption, its drivers, and potential solutions, she said.
“Corruption in health care has been ignored, in part because it’s such a sensitive issue and because we’ve lacked the evidence of the scale of it,” Cooper said. “But before solutions can happen, we first need to acknowledge it exists.”
Transparency International defines corruption as “the abuse of entrusted power for private gain.” However, according to Dina Balabanova, associate professor of health systems and policy in the department of global health and development at the London School of Hygiene & Tropical Medicine and senior adviser at the Anti-Corruption Evidence Research Consortium, although more stakeholders are becoming aligned on this definition of corruption, not everyone agrees about how it is applied.
“For a long time, no one could agree on what constituted corruption,” Balabanova explained. “While bribery and informal payments are clear cases of corruption, others — such as absenteeism or securing a preferred posting using connections — can be seen as a rational response to institutional problems, linked to underfunded and inefficient health services.”
While more stakeholders are beginning to understand “the new informal exchange” — such as making under-the-table payments or giving gifts to care providers — to be a form of corruption, “there’s been an unwillingness to regulate this because there is a perception that you can’t regulate human relationships,” Balabanova said.
That is why getting on the same page about what constitutes corruption is critical if stakeholders are serious about looking for solutions to combat it.
“Corruption needs to be acknowledged, defined, and measured,” said Cooper. “Our main goal with the report was just to get corruption in health care service delivery on the agenda, and to build a network and allies around the need to build awareness of the issue — this is a problem that needs to be brought into the room.”
Identifying and understanding key drivers
While even defining corruption poses a challenge, determining which form of corruption is affecting patient treatment can be even more tricky.
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That is why it is important to do a proper analysis of the risk points in the health delivery system, to assess where the weaknesses are and what can be done to fix them, according to David Clarke, team leader for universal health coverage and health systems law at WHO.
“Historically, corruption in the health care setting used to be approached as a law enforcement issue — something that required investigation and sanctions. But that approach really doesn’t work,” he said.
Instead, Clarke recommends taking an “anti-corruption epidemiology approach,” building a better understanding of the scale and nature of the problem through data collection and analysis, and designing interventions and policies to tackle the problem. This would then be followed by monitoring and evaluation of the impact of those interventions, before scaling up the strategies that appear to work.
“There's a whole range of issues that need to be understood before we can look at this in a systemic way,” said Clarke. “We need to understand what causes people to behave in health systems the way that they do, and what are the factors that contribute to that corruption, before we can talk about meaningful interventions.”
One of the biggest remaining challenges is that the factors leading to corruption can be very specific, and can vary widely between different health care settings and country contexts, further complicating the search for scalable and replicable solutions.
Take the example of absenteeism — the practice of regularly staying away from work without good reason — one of the most pervasive forms of corruption.
In rural Nigeria, absenteeism is so common that many health clinics may only be open one or two days a week, according to Obinna Onwujekwe, a professor of health economics, policy, and pharmacoeconomics at the University of Nigeria, who studies the subject in-depth as part of the Anti-Corruption Evidence Research Consortium.
“People don’t go to work, which means there’s no service delivery. And no service delivery means no health care,” he explained. “It’s a huge problem.”
Onwujekwe’s research into absenteeism in rural Nigeria found key drivers to include problems such as a lack of public transportation to rural areas, low wages that led some workers to take side gigs to supplement their incomes, and gender — as women may be expected to work in the fields during certain seasons, leading them to miss work. But in other countries, high rates of absenteeism might be driven by other factors.
“We always say that the context is important, but that’s often forgotten when crafting strategy,” said Balabanova, explaining that before stakeholders can begin to identify workable solutions, they first have to be able to identify incentives and reciprocal relationships at the local levels.
“All of these are underpinned by how power is shared within a social group or a network, which is why strategies that only target health systems are unlikely to be sustainable,” she said.
Taking a ‘carrot and stick’ approach
A first step to discouraging corruption should be to do an audit of the entire health care delivery system, in order to identify potential weak points that might lead to corrupt practices, according to Balabanova’s research.
In addition to identifying drivers, it is also important to assess what systemic problems might be causing them.
But Balabanova cautions that interventions intended to curb corruption need to be carefully assessed as there may be unintended consequences. For example, reducing informal payments or introducing inflexible work schedules may result in fewer doctors willing to work in remote locations.
And while sanctions are important, relying on them exclusively is unlikely to address the systemic issues that often lead to corrupt practices in the first place.
“What you can do is incentivize people not to do it by offering them something else. It’s a ‘carrot and stick’ approach,” she said.
Taking this approach to discourage absenteeism in Nigeria, for example, might mean both sanctioning employees who did not come to work, while also offering solutions to some of these systemic challenges. This could include creating flexible hours or ensuring transportation for employees that live far away from health care facilities — particularly in rural areas — according to Onwujekwe’s research.
Effective interventions should also avoid a top-down approach, and instead involve the buy-in of both health care workers and the communities they serve, said Onwujekwe.
Strategies include publishing a roster with health workers’ phone numbers, so everyone knows who is supposed to be there at what time. This could make it easier for the community to monitor who is absent, he said.
A need for additional research
One of the biggest obstacles to finding sustainable solutions to corruption is a dearth of high-quality research into the topic, according to Balabanova. In 2016, the U.K. medical research organization Cochrane reviewed nine studies examining strategies to combat corruption in health care settings. Some of the promising interventions included the use of independent agencies to investigate and punish corruption, ensuring transparency around health care prices, and increasing health workers’ salaries. Ultimately, however, the report concluded that “there is a paucity of evidence regarding how best to reduce corruption.”
“If you look at the big picture, we know very little [about] what works,” said Babalanova. “The most common approach is ‘we need regulation’ ... But we know that approach has limitations — it is often difficult to enforce consistently and new loopholes are quickly found. More research is really needed.”
Update Oct. 8, 2019: This article was updated to reflect that Obinna Onwujekwe and Dina Balabanova are both associated with the Anti-Corruption Evidence Research Consortium.
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