The Ignored Pandemic: Corruption in Health Care Service Delivery

07 Jul 2019

It is almost two decades ago since the then World Bank President James Wolfensohn, in his address to the Board of Governors said: ‘We have seen how corruption flourishes in the dark, how it prevents growth and social equity, and how it creates the basis for social and political instability’.

Hope R and Chikulo B C reported in 2000   that corruption in Africa has reached cancerous proportions. In fact, so pervasive is this phenomenon in the region that it has been labeled the ‘AIDS of democracy’ which is destroying the future of many societies in the region.

The corruption problem in Africa reflects the more general, and now legendary, climate of unethical leadership and bad governance found throughout the continent.

Corruption has manifested itself in different forms - inter alia considerable lack of exemplary ethical leadership by politicians and senior public officials where personal interests take precedence over national interests.

Despite the devastating effects of corrupt practices that rocked many African states coupled with economic mismanagement that gave rise to an intellectual movement called ‘Afro-pessimism’, Botswana stood out as an example of economic development, functioning governance, and multi-party liberal democracy and as an exception that confounds generalizations.

Botswana’s exceptionality thus attracted considerable scholarly attention with some calling it developmental success story with Stedman referring to it as the ‘Switzerland of Africa’. Niemann referred to the diamond industry in Botswana as the state’s “best friend” because of the impressive rate of economic growth resulting from this natural resource.

Botswana’s Corruption Perception Index for many years has been remarkable, according to the Transparency International Corruption Perception Index for 2003, Botswana scored 5.7, making it the least corrupt state in Africa, in 2004 Botswana was placed at 6.0, 5.9 in 2005 and 5.6 in 2006 and even for 2007.  It even instructively had positive worldwide ranking, maintaining a stable position of 24 and 31 for the longest period. Such a position made it a far better performer than some countries in the developed economies and some of the Asian Tigers.

Botswana even ranked higher than Italy, Greece, and Taiwan among others. Botswana’s score placed it above 10 members of the European Union included in the survey. General trends then supported the view that corruption persisted but was not endemic and that the systematic corruption that has plagued most of Africa did not seem to have been experienced by Botswana. To add a cherry on top of the cake, its third President former President Festus Gontebanye Mogae became a recipient of the prestigious Mo Ibrahim award.

That was then. The honey period is now over.

In his book Samatar argues that Botswana has eluded the rampant corruption and mismanagement that bedevil most Third World countries, something that compelled Monageng Mogalakwe (2003) to question Samatar’s analysis and wondered as to whether this was just another addition to a list of accolades on Botswana’s miracle.

Mogalakwe’s critique to Samatar’s analysis deserves great credit. It has since emerged that much of the accolades that were given to Botswana was just a façade. The volcanic eruption of corruption scandals that rocked the country in the early 1990s although rampant was nothing worse as compared to the one during the reign of Ian Khama. The alleged corruption tsunami that swept across the country from April fool day 2008 to 2018 under the watchful eye of former President Ian Khama has left many political observers and commentators with no option but to dismiss the Khama’s regime as a sweet for nothing, and now bitter cheap talk from the man who has now turned himself into an opposition mafia godfather, “Maranzano”.

However, in as much as the levels of corruption has been widely reported much has not been reported on how corruption in health care service delivery threatens Universal Health Coverage globally as well as in Africa with Botswana not being an exception.  Informal, under-the-table payments to public health care providers are increasingly viewed as a critically important source of health care financing in developing countries. With minimal funding levels and limited accountability, publicly financed and delivered care falls prey to illegal payments.

Financing of health care in developing countries takes many forms. Ironically, the poorest countries have the highest out-of-pocket spending as a percentage of income, more especially for NCDs patients.   Government commitment to finance health care falls short in the lowest-income countries for a number of reasons, the most obvious being modest tax revenues that limit spending on public health care services, leading to a gap between  ideal  investments and what can be afforded. A frequently overlooked factor is the low quality of public services and the related poor motivation of public servants that together undermine public investments and compromise the value of those investments.  Despite uneven spending by the public sector, private spending is universal. A less apparent but important source of that private spending is under-the-table, or informal, payments by patients to public-sector providers. Such payments make up a sizable amount of spending in some countries and in most cases are illegal because all citizens are meant to receive free health care.

The World Health Organization (WHO) has made ensuring universal health coverage (UHC) its top priority. UHC mean that all individuals and communities can access essential quality health services without suffering financial hardships. Thus moving towards UHC will require strengthening health systems in all countries including Botswana.

According to WHO, globally over 7% of health care expenditure is lost to corruption. Thus curbing corruption in the sector could free up enough resources to pay for universal health coverage worldwide. Multiple studies have found that high levels of corruption are linked to weak health outcomes, and there is strong evidence to suggest that corruption significantly reduces the degree to which additional funding for the sector translates into improved health outcomes, (Makuta et al, 2015).  Corruption significantly undermines the efforts to achieve Sustainable Development Goal 3, which is to ensure healthy lives and promote well- being for all at all ages. A key target under Sustainable Development Goal 3 is to end the global epidemic of AIDS, but corruption is weakening the struggle against the disease. In Botswana, since Former President Festus Mogae, the Champion of HIV/AIDS passed the baton to his successor Ian Khama’s there was minimal commitment in the fight against HIV/AIDS. It was a disaster with reported high increase on alleged corruption scandals with the cases now before the courts of law. Some people became instant over night   multi millionaires when hospitals and clinics were short of required medicine and drugs.

The latest reports on the new incidences of HIV/AIDS in Botswana and failure to attain   U=U (Undetectable  = Untransmitttable) is more than revealing.  A clear scrutiny on the amount of imports of antiretroviral drugs to new cases of AIDS at the national level needs to be done and see whether that contribute positively to U=U as a result of the same quantity of medicine imported.

Stock- outs, often due to drug thefts and absenteeism cause interruptions in individual patients treatment regimes. This not only shortens the lives of individual patients, but also raises the costs of health service provision, as stock outs and fears of stock outs can dramatically increase the quantity of drugs needed to treat the same number of people.

Corruption severely affects all five dimensions of health system performance, equity, quality, responsiveness, efficiency and resilience. More money spent on medicines will only cure more patients if it reaches those in need.  It is on the basis of the foregoing that WHO has actually identified good governance as a critical element of efforts to achieve UHC.  Corruption is a serious threat to global health outcomes, leading to financial waste and adverse health consequences. Yet, forms of corruption impacting global health are endemic worldwide in public and private sectors, and in developed and resource-poor settings alike. Allegations of misuse of funds and fraud in global health initiatives also threaten future investment. Current domestic and sectorial-level responses are fragmented and have been criticized as ineffective.

Corruption also causes long term systemic problems. In particular treatment discontinuities create a high risk of the fast mutating virus developing drug resistance, which will reduce the effectiveness of future medical treatment for patients with HIV.

It is therefore, very important that the recently assembled team on the “National Strategy Transformation team set up by President Mokgweetsi Masisi that it should have a wing / committee that will specifically tasks with ensuring that there is a deliberate policy intent towards obtaining UHC, look as well as look  into health system strengthening. Such a committee/ wing should have few physicians and should have well trained personnel in health economics, health policy analysts, health financing and procurement, health informatics experts as well as public health experts and not just generalists.

A clear scrutiny on the medical aid schemes with respect to prescription  drugs they cover as well as some  physicians on their billing methods needs to be probed for corruption  lest  we find ourselves made to walk through a health genocide.

Thabo Lucas Seleke, Researcher & Scholar, Health Policy Analysis