5.5 Improving integrity in the health sector – stories from the field long report

Samuel De Jaegere, Sjoerd Postma, Eelco Jacobs, Niyada Kiatying-Angsulee, Taryn Vian, Goodwell Lungu, Charmaine Rodrigues, Mohamed Ramzy Ismail, 14th IACC, Workshop report, Governance, Development

 

Short WORKSHOP REPORT FORM

Number and title of workshop: 5.5 Improving integrity in the health sector – stories from the field
 
Coordinator: Samuel de Jaegere
 
Date and time of workshop: 12 November 2010, 17.30-19.30
 
Moderator (Name and Institution): Mohamed Ramzy Ismail, WHO Regional Office for the Eastern Mediterranean
 
Rapporteur (Name and Institution): Charmaine Rodrigues, UNDP Pacific Centre
 
Goodwell Lungu, TI Zambia, Executive Director
Taryn Vian, Boston University School of Public Health (USA), Associate Professor of International Health
Niyada Kiatying-Angsulee, Chulalongkorn University (Thailand), Director Social Research Institute & Chair Social Pharmacy Research Unit
Eelco Jacobs, Basel Institute on Governance (Switzerland), Researcher “Governance of Health Systems” project
Sjoerd Postma, Asian Development Bank, Senior Health Specialist
 
Main Issues Covered

Goodwell Lungu, TI Zambia
 
- A range of corruption problems besetting the country’s health system – eg. abuses in procurement, theft of medicines, bribery, etc. In 2009, scandal erupted over US$14 million stolen from the Ministry of Health + $5.6 million stolen in another scandal + senior govt official embezzled $3 million by procuring counterfeit HIV drugs
 
(1) Medicines Transparency Alliance Zambia (MeTA) – aimed to increase access to essential medicines by improving procurement. Multi-stakeholder approach drawing together approx 30 key bodies from govt, pharmaceutical industry, civil society. Each stakeholder had access to key info – carried out a baseline study to assess willingness of stakeholders to share info. Presented findings to multi-stakeholder group – enabled stakeholders to identify their weaknesses and then develop strategies accordingly. Key success was recognising the power and influence of each stakeholder and using that analysis to strengthen the coalition.
- Government has taken action to charge and prosecute people over corruption scams in health sector. Most CSOs involved in MeTA were not health experts – had to undertake training first to empower them to do better advocacy. 
- MeTA has worked specifically with parliamentarians – briefed both Govt and Opposition MPs, and resulted in a motion being moved in Parliament highlighting the need to ensure the drug supply chain in Zambia has a high level of transparency. 
- Engaged with the grassroots – developed a basic communications strategy to explain to the public how the drug supply chain works and at what point the public could get involved in trying to hold health providers accountable. Tied the work to another campaign “Stop Stockout Campaign”, directed at ensuring medicines available in health clinics. Raised awareness re need for transparency in procurement through radio programmes, articles and direct letters to officials. 
 
(2) Transparency in Service Delivery in Africa (TISDA) – Looking at how are services being delivered in the health sector. Did research to identify structures at local level where citizens are represented – District Health Management Teams (neighbourhood health committees – citizens committees) – could then enable people to engage with them. Looking at procurement, access, quality of services. Now it is very common for citizens to talk about issues of transparency in the health sector.
 
Taryn Vian, Boston University School of Public Health, USA 
 
- Need to recognise corruption as a public health issue – with better governance, health services can be delivered more effectively, to align finances with public policy goals for public health. Corruption weakens governance foundations of health system – reduces demand bc citizens can’t pay bribes and/or cannot get decent services + reduces quality of service delivery bc human resources poorly managed 
- Simply feeding more money into a corrupt system will not result in progress towards meeting health MDGs – need to tackle the root of corruption 
- Three elements to reduce corruption – reduce opportunities for corruption; provide incentives for better behaviour; deal with “rationalisation” of corruption
- Need to strengthen govt institutions (top down) but also mobilise citizens for social change (bottom up)
- Case study – in Pakistan had a health project which grew quickly, without any review of systems in place. Accountant started stealing funds bc he had been given huge discretions and could abuse confused systems – he rationalised his behaviour on the basis that it was “just donor money” 
- Case study – improved systems in Boston health system due to 2 deaths, including one of a reporter. Resulted in a flood of articles on poor health system, which prodded reforms. 
- Case study – Rwanda Performance Financing System – combined incentives from Govt to improve performance which has resulted in better uptake of services. But there is still corruption in the form of inflated reporting on performance.
- Case study – Moldova adopted a sector wide AC strategy in health sector to reduce discretionary powers of health providers, service personnel and procurement people. Improved human resources – required all managers to re-apply for their jobs based on new standards. Introduced quality control panels doing regular audits and patient surveys.
- Case study – Vietnam organised roundtable on corruption in health sector brining together stakeholders to share experiences and build networks. UNDP presented data on a study looking at corruption stories in the media re health sector to identify key problems to be addressed.
 
Niyada Kiatying-Angsulee, Chulalongkorn University, Thailand
 
- Project started in 2004 with four countries and focused on pharmaceuticals, not service delivery more broadly. Three partners - Chulalongkorn University + Ministry of Public Health + FDA 
- Started with a regional workshop in 2004 organised by WPRO/WHO – didn’t know a lot about governance and ethical frameworks at the time – trained on the issues and then developed a concept for Thailand and related tools. Went back to the field to collect data and then in 2005 shared preliminary results and refined data tools at another meeting.
- Three phase approach: (1) national transparency assessment based on WPRO assessment tool; (2) development of national Good Governance for Medicines (GGM) framework (3) implementation of national GGM programme. Four reports on key findings (1 in 2006 + 3 reports in 2009).
- 10 key elements for WHO framework: moral values, code of conduct, socialisation of moral values, moral leadership training, enforcement of existing systems, whistleblowing, sanctions, improving management systems, inter institution collaboration, M&E. Balance between top down and bottom up – value based and discipline based. 
- Project has been implemented over three phases – 7 countries in first phase, 12 countries in second phase and 7 countries in third phase
- In Thailand, there are 3 main health/medical benefit schemes – involve both public and private health care providers. Strong civil society, who were active in tackling corruption in health sector, eg. their activities resulted in conviction of Health Minister. During the Project, did an assessment of health procurement based on WHO tool. Found relatively strong systems in Thailand. Study did identify some weaknesses (eg. no requirement for disclosure of conflicts of interest) and these are now being addressed. Work resulted in major National Health Assembly in 2009 focused on abolishing unethical drug promotion practise. But still need to make procurement more transparent + need more info for continuous assessment + need education of officials and public but is a difficult challenge. Also still need to work out how to bring CSOs in as partners.
 
Eelco Jacobs, Basel Institute on Governance, Switzerland
 
- Implementing Research Project on Analytical Framework for Health Systems Governance
- Reviewed existing governance tools (WB, UNDP, OECD, DFID, ODI) but then developed a more comprehensive tool that focused on both formal and informal dimensions of power. Look at what institutions and actors are important in decision-making, shaping opinion and welding power beyond those which are formally recognised (eg. warlords, elders councils, religious groups)? What is the motivation behind their actions (eg. bribery, charity, nepotism)?
- Tajikistan Case Study –partial decentralisation of financing and management + copayments but with exemptions for maternal, infant and HIV care (MDGs 4, 5 and 6). When they applied their Analytical Framework they found numerous weaknesses in the system – but the biggest issue was that local authorities who were being given responsibility for health care were very weak and severely underfunded + informal institutions were very strong. Response – recognise importance, risk AND potential to work with informal institutions, eg. support community development projects and strengthen accountability through existing local institutions and actors.
 
Sjoerd Postma, Asian Development Bank
 
- ADB has identified “Integrity Violation Definitions”, eg. corrupt practice, fraudulent practice, coercive practice, collusive practice, conflict of interest, obstructive practices, abuse 
- Over last 10 years, ADB’s key integrity violations in health sector relate to corruption/fraud. 56 complaints resulting in 31 firms and 20 individuals being sanctioned. Integrity violations across the whole range of health administration and service provision. In reality though, it has been very hard to collect sufficient info/evidence of violations to successfully prosecute cases.
- ADB now has a range of integrity approaches – AC Policy and Integrity Guidelines + Office of AC and Integrity which is independent and reports directly to the Board + website listing of barred companies + cross debarment with other MDBs is coming online + staff admin orders on AC and compulsory staff training + guidelines for procurement of works, supplies and services 
 
Q&A:
- One approach to dealing with informal payments has been to formalise payments, which has resulted in lower fees for services in reality. Another approach is to review remuneration for health officials to reduce their willingness to take a bribe. 
- Important to recognise how many countries simply aren’t putting enough money into the health sector. This exacerbates problems, as officials then have a bigger discretion on prioritising funding support for health policies
 
Challenge of “sustainable” participation in tackling corruption – need more than ad hoc consultation at specific points of intervention. Experience has shown that it is essential to break down the message at the grassroots – need to package information to show the public why these issues are relevant to them, eg. if they don’t demand their right for better services in the health sector, then when they get sick, they may not get proper treatment. 
 
Main Outcomes

- One of the strengths of WHO Health Sector Assessment Tool is that it helps people identify specific points of vulnerability within health sector procurement processes so that specific strategies can then be developed to address them.
 
- Important to strengthen leadership and commitment to ethical values 
 
- Notable that in Thailand, corruption issues were introduced into curriculum for health professionals – important and effective way of sensitising future health officials on their responsibilities and ethical values UNDP Country Offices and national counter-parts taking part in the discussions of the workshop expressed interest in supporting integrity intervention in the health sector at the national level 
 
Main Outputs

- Awareness raising of the audience attending the workshop about the importance of tackling corruption in the health sector and possible means to address the issue
 
- Workshop report is available online /video of the workshop may also be posted later on
 
Recommendations, Follow-up Actions

• Need to:
- Recognise corruption as a public health problem – literally a threat to lives 
- Understand deeply the system causes of corruption
- Accept, as public health professionals, the responsibility to fight corruption
 
• Need to change culture amongst health professionals that even if they see corruption from their colleagues, it is NOT acceptable
 
• Need to identify and support role models – important to highlight successes to maintain momentum for reforms
 
• Important to distinguish between governance inputs, process and outcomes – recognising the centrality of accountability as the connecting factor. Need to recognise that governance can be formal AND informal – don’t overlook the developmental potential of informal institutions as an entry-point to tackle corruption and strengthen governance in delivery of health services 
 
• Need to take holistic approach – not just public service reform in the health sector in the broad, but specific initiatives such as remuneration reviews, procurement training with a focus on ethics, public financial management training, etc. 
 
• Important to provide whistleblower protection for health and admin officials – will assist in facilitating info flows that are necessary for successful prosecutions for corruption
 
• In all sectors, it has been recognised that in reality very few crimes are every successfully prosecuted. Therefore need to be careful not to rely too heavily on criminal
sanction/prosecution but to also focus strongly on prevention measures. Nonetheless, when prosecutions ARE undertaken, should highlight “wrong role models” – to act as a deterrent to other officials.
 
• Need to do research to explore whether and what the correlation is between fees and class. Rather than a sliding scale, (limited) evidence seems to show that the poor actually pay MORE because they are less empowered and have less skill to negotiate informal payments Need to recognise the important role that the media and other watchdog bodies can play in highlighting issues in health sector and pressuring for change. 
 
Workshop Highlights

Various interesting initiatives are taking place to curb corruption in the health sector all over the world.
 
There is no universal solution to the problem of corruption, each country and even locality has to figure out what works.
 
Fighting corruption within sectors, as well as system wide, is emerging and gaining momentum as an effective approach which can be tailored to suit the technical needs of each sector. 
 
Sharing experience across countries and initiatives is much needed as fighting corruption in the health sector is a relatively new and experimental field. Knowledge gained and lessons learned should be broadly disseminated. 
 
Stakeholder participation in health decision making is an effective way to promote transparency and decrease health system vulnerability to corruption.
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