Fighting Corruption in the Health Sector: Methods, Tools and Good Practices

Commissioned by the United Nations Development Programme (UNDP), this study presents methods, tools, and good practices to map corruption risks, develop strategies, and sustain partnerships to address challenges and tackle corruption in the health sector. The study complements UNDP's MDG Acceleration Framework (MAF), which enables governments and development partners, within established national processes, to identify and systematically prioritise the bottlenecks to progress toward achieving the Millennium Development Goals (MDGs) and then devise ways to overcome them. Specifically, the study focuses on MDGs 4 (reduce child mortality), 5 (improve maternal health), and 6 (combat HIV/AIDS, malaria, and other diseases). It considers several quantitative and qualitative studies that analyse and present evidence of the negative impact of corruption on health outcomes. The study acknowledges the complex nature of the sector and the information asymmetry that exists within the system. Additionally, within this framework, the report reviews existing literature and discusses methods, tools, and good practices on how to address corruption at various levels in the health sector.

As explained in the introductory section, some of the key reasons for corruption in the health sector are weak or non-existent rules and regulations, over-regulation, lack of accountability, low salaries, and limited offer of services (i.e., more demand than supply). The scale of corruption also varies: it may range from bureaucratic or administrative corruption that takes place at the implementation level where the people (recipients of services) interact with public officials to corruption at a higher level, notably at the policy level.

The next section discusses some key diagnostic/assessment methodologies that donors, governments and non-governmental organisations (NGOs) can use to assess the health sector’s vulnerability to corruption. Those such as the World Health Organization (WHO) and World Bank risk assessment tools described in Sections 2.1 and 2.2 are designed to identify any weak points in a given health sector. Other tools, such as Transparency International's Corruption Perceptions Index and household surveys, are designed more specifically to measure the level of corruption in a country at the national, regional, or local levels.

The study presents concrete evidence for the importance of building multi-stakeholder partnerships, including with direct beneficiaries of the public health sector, to promote accountability and improve service delivery. For example: the public posting of medical supply prices can help prevent collusion; regular external and internal audits can help ensure budgets are allocated and spent appropriately; and citizen scorecards and participatory monitoring can help decision makers identify where potential problems lie. Several text boxes in the report provide case studies, such as the Anti-Corruption Participatory Monitoring (ACPM) project in Armenia. The UNDP-supported ACPM project developed tools to ensure quality control, such as guidelines on responsibilities of a community group's members, norms of ethics, and ground rules and instruments for conducting observations, expert interviews, focus groups, and in-depth interviews. After that, the project supported community groups to monitor 22 outpatient clinics and hospitals. The findings from the participatory monitoring described the baseline situation in the health care sector, in particular corruption risks and manifestations in various aspects and levels of health care system. On this basis, recommendations for systemic changes were developed and communicated to the responsible State authorities and the Prime Minister's Office. In the end, the majority of the project recommendations were accepted and included in the new national anti-corruption strategy. The key point to emerge is that what is needed is a multi-pronged approach that includes a variety of supporting interventions mainstreamed across sectors.

The study concludes with 10 key lessons:

1. There is no "one size fits all" approach to mitigating corruption in the health sector.
2. More than one anti-corruption intervention should be employed to deal with one risk.
3. Governments and others involved in health projects and programming should prioritise areas of the health system that are most susceptible to corruption and implement appropriate interventions.
4. It is important to work with other sectors.
5. Health policy goals should include anti-corruption considerations.
6. It is advisable not to wait for corruption to happen before beginning to deal with it.
7. Numerous empirical diagnostic tools should be employed to ensure accurate information.
8. Partners with experience in implementing anti-corruption strategies and tactics should be identified and contacted for technical support.
9. Involving NGOs, citizens, and designated experts in health budgeting, monitoring, and consulting can help heighten transparency and lessen the likelihood of corruption.
10. Set up appropriate incentive structures that help promote adherence to good behaviour; it is also important to sanction those individuals who are engaged in corrupt activities where possible.

Annexes include: overview of key tools to identify, track, and measure corruption risks and corruption; select results from WHO's Good Governance for Medicines (GGM) programme; cited partners for health and anti-corruption; proposed terms of reference for country case studies on anti-corruption in the health sector; and case studies from Uganda, Malawi, and Tanzania.