Whether a healthcare system is financed and controlled privately or by the state may give some indication of possible avenues for corrupt practice. In state-controlled systems, low pay coupled with poor control mechanisms contribute to a high incidence of informal payments, absenteeism and drugs being diverted for resale. A 2002 survey of households in Central Europe singled out public hospitals as one of the most corrupt government institutions, with 81% of people poll reporting the need to offer gifts to hospital doctors in order to obtain services to which they were legally entitled for free. [Miller 2002] In private health systems corruption commonly manifests itself in the form of insurance fraud, the unethical procurement and distribution of drugs, and low-quality treatment.

Corruption in the health sector is of grave concern in all countries but acts as a particular obstacle for developing and transitional economies where public resources are already scarce. Three of the eight Millennium Development Goals refer directly to health and governments have a direct responsibility to ensure that these goals are met. Although all healthcare systems have vulnerabilities, transparency measures and greater financial accountability can help minimise the risk of corruption.

The WHO has developed a table identifying methods of financing different healthcare systems and the risks of corruption each system may entail.

[Table derived from Macroeconomics and Health: Investing in Health for Economic Development - Report of Working Group 3, 2002, World Health Organization Commission on Macroeconomics and Health, and William D. Savedoff, “The Characteristics of Corruption in Different Health Systems”, 2003, World Health Organization – draft. Published on U4 website developed by the Christian Michaelson Institute http://www.u4.no/themes/health/causesandconsequences.cfm]

William Savedoff and Karen Hussmann, ‘Why are Health Systems Prone to Corruption?’
The authors examine why health systems particularly are so prone to corruption and outline three key features and their characteristics that contribute to this vulnerability: an imbalance of information between health professionals, pharmaceutical and medical device companies and patients; uncertainty in health markets as policy makers and health administrators cannot know who and when will fall ill and how effective treatments will be; and the large number of parties involved in a health system. The authors characterise the ways in which corruption manifests itself in the health sector and analyse different health systems and their respective weaknesses and vulnerabilities. Global Corruption Report 2006, Ch1, p4

Derick Brinkerhoff, ‘Accountability and Health Systems: overview, framework and strategies. Health systems called to account: a framework and guidelines for exploring accountability issues in the health sector’
Brinkerhoff points to a critical problem with the concept and implementation of accountability which, in his view, constitutes the major factor behind leakage and the greatest obstacle to health sector reform. He claims that simply calling for greater accountability is not helpful and instead, in order for accountability to inform action, further conceptual, analytical and operational work needs to be done. This paper includes an analytical framework for accountability and health service delivery systems, and an assessment of the role of health sector actors in strengthening and maintaining accountability mechanisms.
Partners for Health reform plus (PHRplus), 2003.

Das Gupta Khaleghian, ‘Public Management and the Essential Public Health Functions’
The authors provide an overview of how different approaches to improving public sector management relate to so-called core or essential public health functions, such as disease surveillance, health education, monitoring and evaluation, workforce development, enforcement of public health laws and regulations, public health research and health policy development. The authors summarize key themes in the public management literature and draw lessons for their application to these core functions.
World Bank Policy Research Working Paper, February 2004

Conceicao Van Lerberghe and Ferrinho Van Damme, ‘When Staff is Underpaid’
The authors of this report examine the ways in which health sector workers respond to inadequate salaries and poor working conditions in under-funded health systems. The paper reviews what is known about these practices and their potential consequences. Such consequences may include absenteeism, poor motivation, under-the-counter fees and the erosion of basic values that underpin public service. The paper asserts that a more proactive approach is required from governments in combating these ‘coping strategies’ and points to various ways this may be achieved.
Bulletin of the World Health Organisation, 2002

Barr, Lindelow and Serneels, ‘To Serve the Community or to Serve Oneself: The Public Servant’s Dilemma’
The authors of this study use an economic experiment to investigate the determinants of corrupt behaviour. They focus on three aspects of behaviour: embezzlement by public servants, monitoring efforts by designated monitors and voting by community members when provided with an opportunity to select a monitor. The experiment allows the authors to study the effect of wages, effort observance, rules for monitoring, and professional norms on Ethiopian nursing students. The authors find that service providers who earn more embezzle less, although the effect is small. Embezzlement is also lower when observance (associated with the risk of being caught and sanctioned) is high, and when service providers face an elected, rather than a randomly selected monitor. World Bank Policy Research Working Paper 3187, January 2004

U4 pages on Corruption in the health sector
These web pages present essential resources for on the challenges of corruption in the health sector and what can be done by health professionals, civil society organisations and the donor community to address these challenges.

Maureen Lewis, Governance and corruption in public health care systems
This paper gathers factual evidence to describe the main challenges facing health care delivery in developing countries, including corruption, absenteeism, under-the-table payments for services and mismanagement. The paper concludes that the returns to health investments are low where governance is addressed, and that more detailed understanding of the problem is needed – including plugging gaps in what is very fragmented evidence on the nature of the problem and lack of meaningful indicators for cross country comparison.
Center for Global Development working paper number 78 (January 2006)

Venezuela/Columbia:
Health system reforms: the cases of Columbia and Venezuela compared
Savedoff, William, ‘A Tale of Two Health Systems’, Global Corruption Report 2006. Chapter 1, p14

USA:
The US experience of corruption in healthcare
Malcolm K., Sparrow, ‘Corruption in Health Care Systems: The US Experience’, Global Corruption Report 2006, Chapter 1, p16

Cambodia:
Corruption in Cambodia’s Health Sector
Lisa Prevenslik-Takeda, Global Corruption Report 2006, Box 1.2, p22

Costa Rica:
Maladministration and Corruption in the Costa Rican health system
Emilia, González, ‘Case Study: Grand Corruption in Costa Rica’, Global Corruption Report 2006, Chapter 2, p26

Bangladesh:
Absenteeism in Bangladeshi health facilities
Chaudhury and Hammer, “Ghost doctors: Absenteeism in Bangladeshi health facilities”, World Bank, Research paper 3065, World Bank, 2003.

Mozambique:
Tracking primary health services in a complex system
Magnus Lindelöw, Oatrick Ward and Nathalie Zorzi, “Primary Health Care in Mozambique: Service Delivery in a Complex Hierarchy”, World Bank, 2004

Transparency International’s recommendations for the health sector
Drawing from the essays included in the Global Corruption Report 2006, TI recommends reforms that increase transparency, accountability and civil society participation and oversight. Recommended measures include codes of conduct, integrity pacts for contracting processes, whistleblower protection and public databases listing the protocols and results of all clinical drugs trials.
Transparency International, Executive Summary, Global Corruption Report 2006

Measuring and tracking losses in health service budgets by Britain’s Counter Fraud Service (CFS)
The CFS attempts to accurately measure and track losses to fraud and corruption in each area of the NHS budget. Jim Gee details ways in which they have accurately identified the nature and scale of the problem and mobilised civil society to act as a deterrent to it. Jim Gee, ‘Fighting Fraud and Corruption in Britain’s National Health Service’
Global Corruption Report 2006, Chapter 2, p46

Cash Registers Inject Transparency and Revenue into Kenya’s Coast Provincial General Hospital
Hospital managers have installed a network of electronic cash registers into Kenya’s Coast Provincial General Hospital in order to detect fraud in the user-fee collection system.
Taryn Vians, Global Corruption Report 2006, Box 3.1, p53

Summary of a series poverty reduction strategy papers (PRSPs) examining various monitoring tools used to curb corruption in healthcare
The report comments on household surveys and participatory poverty assessments that are used to formulate longer-term objectives for curbing corruption in healthcare. The report also looks at areas most in need of monitoring; how best to conduct system monitoring; and for whom and what the information gathered will be useful. Examples given show how certain aspects of financial tracking can lead to policy improvement and shows practical ways in which changing incentives and empowering service users can help combat corruption. The survey also raises questions as to whether community-based monitoring of healthcare services could be extended to national systems.
D. Booth and H. Lucas, “Good practice in the development of PRSP indicators and monitoring systems: Integrating PRSP indicators into policy formation processes”, Overseas Development Institute (ODI) Working Paper 172, 2002.

WHO guidelines on working with private sector to achieve health outcomes
Set of WHO guidelines referring to commercial enterprise, product development, donations, seconded personnel, contributions in kind and other areas of good practice.
World Health Organisation, 2000