Addressing Corruption in the Health Sector: Lessons for Botswana

19 Aug 2019

Over the past decades, the honesty and integrity of healthcare systems across, low- and middle income countries has troubled citizens, external and internal observers, and governments alike as noted by Lewis M (2016), in her works, Economics, health systems, and corruption.

Coming from a broader agenda of corruption and development that linked poor services and slow growth to widespread corruption, the health sector has had to confront corruption in health care systems. Initially, researchers and some village Professors, were of the view that this was the preserve of public health and those wanting to study health policy analysis were diverting from their core discipline. Thus their thinking was implicitly assumed that corruption was not a problem in the health sector. That assumption and village professor mentality no longer holds and evidence bears this out.

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 Transparency International (TI) in 1993 and the Partnership for Transparency Fund (PTF). TI was the first global non-governmental organization dedicated to exclusively to anti-corruption and it currently operates through national chapters in many countries.

PTF has been involved in engaging citizens against corruption on many fronts through specific projects. Experiences from PTF projects in the health sector where, in many cases, demands for bribes by officials and health care workers undermined service delivery has yielded valuable lessons. PTF has shared these findings widely.

Accordingly, PTF has found that key approaches in implementing citizen led projects in the health sector where inefficiency and corruption are commonplace include;

Raising Public awareness of rights, particularly the cost of medicines and treatments, is key first step to ensuring these rights are appropriately fulfilled. Advocacy is more powerful with partnerships between civil society organisations 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.

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”. This representation of corruption as a destructive disease seems fitting, as health related corruption is now a multifaceted and multibillion dollar phenomenon that threatens future progress of heath systems and global health. When corruption infiltrates health systems of various countries as well as global health, it can be particularly devastating, threatening hard gained improvements in human and economic development, it has been argued.

Similar to cancer, health related corruption comes in several types, ranging from “petty” corruption to “systemic” corruption involving multinational companies engaged in widespread healthcare, fraud and abuse, and “grand” corruption occurring at high levels of government. Critically, health related corruption is distinctly dangerous compared to other forms of corruption in traditional economic sectors such as energy, construction and banking, in that it presents a “dual burden” of limiting both economic and human development while at the same time endangering patients and popular level health.

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.

Corruption can be invisible, difficult to detect and often highly politicised. Transparency therefore is a critical tool in curbing corruption. This includes enhancing transparency and disclosure in financial systems and controls, health care relationships, transactions and health sector procurement systems.

Many actors, including governments, private sector, and civil society, have an interest in controlling corruption. Thus, multi-stakeholder partnership, 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 may help to increase trust care services and projects are protected from corrupt practices.

Corruption can be defined in abbreviated terms as “use of public office for private gain. However, what has led to corruption in healthcare is fundamentally, lack of accountability. This lack of accountability derives from a number of factors, including inadequate management, lack of oversight, poor training, and absence of performance incentives, which in turn make accountability impossible.

Accountability is fundamental as it requires that officials are called to account and to answer for responsibilities and conduct, that is, it ensures consequences for poor behaviour and ideally rewards exceptional behaviour. Because accountability in most health care systems is diffused across patients, payers, managers, and citizens, there is effectively little if any accountability to anyone.

Common measures of corruption in healthcare across countries include abseentism of physicians and nurses, health workers, ghost workers, frequent stock outs of drugs and supplies, leakage of public monies, patients paying under the table directly to individual providers, and a perception of healthcare as among corrupt sectors in many countries. Such practices and circumstances compromise the delivery of health care.

The leap to how corruption undermines healthcare systems should be obvious. Without personnel, drugs management and other inputs, healthcare services are effectively unavailable. Absent from much of the healthcare agenda is an acknowledgement of any perverse implicit or explicit incentives that allow for poor behaviour, Lewis M, (2015) noted.

Economists rely on incentives to encourage good performance through, for example, merit promotions or bonuses for good performance, or to discourage unethical or illegal behaviour such as stealing of drugs, absenteeism or financial mismanagement, 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. 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.

Healthcare systems underpin both healthcare delivery and efforts towards attaining Universal Health Care (UHC), the global goal for public health organizations such as the World Health Organization (WHO). Infectious diseases like malaria and HIV dominate the donor and private foundation landscape in developing countries but chronic conditions, including cancer, 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 services. 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.

Tackling corruption in the health sector is thus essential for achieving better health outcomes. Tackling corruption in health needs to be linked to broader governance reforms, including public finance, public administration and external oversight reforms. Both supply and demand side reform measures need to be supported, taking into account government commitment and implementation capacity, as well as the capacity and environment for civil society engagement.

Strategies to address corruption can systematically be integrated into health sector plans using the WHO health systems model or health sector integrity strategies. TI also has also developed a framework which can be used as a guide. In the absence of an integral sector wide anti-corruption approach, health advisors and health sector division should actively look for opportunities to address corruption and unethical behaviour in specific sectors, for example, drugs, hospital management, Medical insurance companies and their pricing methods, ensuring responsive and quality health service delivery and protecting citizens against the financial costs of illness.

In Botswana, the Ministry of Health introduced anti-corruption policy in 2013. The development of this Policy is a demonstration that the Ministry of Health has embraced the national anti-corruption strategy, and commits to its successful implementation within the Ministry. The Policy intends to promote an organisational culture that is ethically upright and upholds the spirit of none tolerance to corruption. As to whether it has lived to its intended policy objectives or top address un-intended consequences remains to be seen.

Recent developments in the provision of primary health care in Botswana, reports to the contrary, to the extent that Princess Marina, Deborah Retief Memorial Hospital to name but a few have been viewed as slaughter houses. The teaching hospital at the University of Botswana, which has the state of art facilities has been marred by controversy and some of their facilities are now an eye sore. There is need for stringent measures to be put in place as to how tenders are awarded by the MoH and PPADB, to whom and why.

Thabo Lucas Seleke is a Researcher & Scholar in Health Policy Analysis