Health systems are comprised of complex interactions between multiple different actors with differential knowledge and understanding of the subject and system. The health sector is a dynamic system composed of complex interactions between patients, providers, payers, suppliers, and policy makers. It is exactly this complexity that makes it particularly vulnerable to corruption.
The literature on corruption, commonly defines it as the “abuse of entrusted power for private gain,” and it is a problem within health care systems globally. According to various scholars on this discipline, “corruption” not only encompasses actions that are illegal in most countries with Botswana not being an exception, but also those that could reasonably be considered unethical, and when pervasive, weaken and foster distrust in the health system.
Corruption takes many forms even within the health sector and occurs at all organizational levels from government agencies to the direct provision of care. The motivations underlying health sector corruption varies widely in many different settings. Therefore, it may be challenging to adapt corruption-mitigating strategies that are successful in one health system to another system with completely different incentives, accountability structures, enforcement mechanisms, and socio-economic and political contexts. Given the heterogeneity and dynamic nature of health systems, sustainable reductions in corruption and resultant improvements in health care delivery require a systems thinking approach, the question remains, what is that we are doing as a country to curb corrupt practices within our health system?
Various scholars have indicated that reducing corruption in the health sector is imperative to strengthening health systems and advancing health equity, particularly in the global south. Health sector corruption constitutes a pervasive challenge and a major obstacle to the equitable enjoyment of the right to health by exacerbating health inequalities within societies , while often eroding public trust primarily amid public health crises threaten human security. Corruption in the health sector can be a matter of life and death. It affects all five dimensions of health system performance , access, quality, equity, efficiency and the effectiveness of health services.
Corruption is recognized by the global community as a threat to development generally and to achieving health goals, such as the United Nations Sustainable Development Goal number 3, ensuring healthy lives and promoting well-being for all. As such, international organizations such as the World Health Organizations and the United Nations Development Program are creating an evidence base on how best to address corruption in health systems.
Corruption can also be understood as a global wicked problem, which is characteristically described as being challenging and “influenced by a constellation of complex social and political factors”. Corruption manifests in many forms; it may, for instance, be petty or grand, and it transcends all jurisdictional borders. Although there is seldom a single identifiable cause of corruption, certain factors may contribute to its manifestation including poverty, low social and economic status of public officials, and insufficient or an absence of institutional transparency and accountability mechanisms.
In order to understand manifestations of health sector corruption, it is important to be familiar with actors in health systems and their relationships to one another. The exact actors vary from country to country, but roles within health systems can be characterized based on a continuum of service delivery. On one spectrum of health systems, furthest removed from direct provision of services, are governments and the government officials who are responsible for crafting health-related policies, executing the policies, and regulating the health system as managing proposal call out with limited expertise.
At the level of direct service delivery are the health care workers who provide services (e.g., physicians, nurses, pharmacists, etc.), and patients who are the recipients of those services. In between the actors involved in policy and regulation and those involved in the direct provision of care are the payers and suppliers. Payers fund the health system and, depending on the country, may be government agencies, non-profit or for-profit insurance companies, or patients themselves. Suppliers are those that provide the infrastructure and environment for health care to be delivered, e.g., medical device and pharmaceutical companies, equipment manufacturers. Importantly, corruption can occur at any level and involve any actor within this complex system.
There is no doubt that the health sector corruption is a problem in need of a systems-thinking approach. A systems thinking approach is important to developing and successfully implementing corruption mitigation strategies that result in sustainable improvements in health systems and consequently, the health of populations. The six forms of health sector corruption according to the literature are improper financial relationships, theft and diversion of resources, fraudulent billing, absenteeism, informal payments, and counterfeit medical supplies.
Improper financial relationships
Improper financial relationships are associations between actors within the health system that have the potential to create a conflict of interest. Specifically, they foster situations where individuals are motivated by financial enrichment over medical indication, patient well-being, and or public health. At the highest level of service delivery, improper financial relationships can occur between government officials and for-profit entities within the health sector (e.g., pharmaceutical, medical device, insurance companies). According to Transparency International (2022), other potential manifestations of improper relationships at the highest level of government include deregulation of the health sector to the benefit specific interest groups, influence over health-related recommendations or guidelines, expediting approval of pharmaceuticals or medical devices, etc.
Improper financial relationships involving providers can also exert inappropriate influence at the level of direct service delivery. Two common business relationships that fall within this category are self-referrals and kickbacks. Self-referrals occur when providers refer patients for medical services performed by an entity with whom the provider or family member has a financial relationship. Although they may be legal, these financial relationships have the potential to result in medically unnecessary interventions or more expensive interventions that financially enrich providers at the expense of patients or payers, (Mitchel, 2012).
Fraudulent billing and claims
Fraudulent billing refers to the act of obtaining reimbursement for services or items that were either not provided, more complex than what was provided, or medically unnecessary. The actors involved in fraudulent billing can vary depending on how health care was financed. In countries without well-established health insurance systems where out-of-pocket payments predominate, providers may fraudulently obtain reimbursement from patients.
Theft and divertion
Theft occurs when individuals take resources to which they not entitled without consent or permission. Diversion refers to taking and reselling resources for another purpose without consent or permission. Theft and diversion of resources can occur at all levels of a health system. At the government or payer level, theft often takes the form of embezzlement, where government officials or insurance company employees siphon health-related funding for personal use, (Transparency International). At the provider level, health care workers may divert supplies, medication, equipment, or official fees for financial enrichment.
Absenteeism
Frequent, unauthorized absenteeism is regarded as corrupt when public sector workers “choose to engage in private pursuits during working hours”, (Transparency International 2020). Commonly cited factors driving absenteeism include low and or unreliable salaries in the public sector, lack of monitoring and accountability, and substandard work environments that includes demanding workloads partially induced by frequent absenteeism argued, (Lindew M et al 2006).
Informal payments
Various literature sources indicates that informal payments are defined as “payments to individual and institutional providers, in kind or in cash, that are made outside of official payment channels or are purchases meant to be covered by the health care system”. They can involve actors at all levels of the health care system from government officials, suppliers, and providers. Informal payments can be illegal or legal and encompass a broad range of unofficial exchanges including overt bribes, favours, substantial gifts, and payments solicited under the guise of an official transaction or fee. Some of the motivations underlying informal payments are similar to those described for absenteeism and theft diversion, namely, low public health salaries, (Akwataghibe et al 2013).
Counterfeit medical supplies
Lastly, the WHO report (2017) indicated that counterfeit therapeutics, medical devices, and other medical supplies represent an important form of corruption that disproportionately impacts health systems in many countries. Potential factors giving rise to the circulation of counterfeit medical supplies include poor governance in the global south where the regulatory capacity is inadequate to ensure the authenticity of these products, (WHO, 2017). This regulation is further complicated by the fact that many of these supplies are the product of complex multinational supply chains.
The above forms of health sector corruption represent the tip of the iceberg, the events and patterns that are readily visible to observers. However, effectively and sustainably reducing corruption requires an understanding of what is underneath the surface, the structure of health systems, the political and socio-economic environment, and historical context that drive these visible manifestations of corruption.
The questions, is what is that we are doing as Botswana to address corruption in our health system? In 2013, the Ministry of Health developed anti-corruption policy recognising that “Corruption is real and it is a challenge that affects all sectors”. Are they talking the talk?
*Thabo Lucas Seleke, Doctoral Candidate LSHTM, UK
