5.6 Improving integrity in the health sector – stories from the field short report

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

 

Short WORKSHOP REPORT FORM

Number and title of workshop: 5.6 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: Mohamed Ramzy Ismail, WHO Regional Office for the Eastern Mediterranean
 
Rapporteur: Charmaine Rodrigues, UNDP Pacific Centre
 
Panellists:
Goodwell Lungu, TI Zambia
Taryn Vian, Boston University School of Public Health, USA
Niyada Kiatying-Angsulee, Chulalomgkorn University, Thailand
Eelco Jacobs, Basel Institute on Governance, Switzerland
Sjoerd Postma, Asian Development Bank
 
Main Issues Covered

The five presenters reflected on a range of field experiences in tackling health sector corruption, in particular, in relation to pharmaceutical procurement and health service delivery. In Zambia for example, Goodwell Lungu discussed TI Zambia’s active involvement in two initiatives: (i) Medicines Transparency Alliance Zambia (MeTA), which aims to increase access to essential medicines by improving procurement and (ii) Transparency in Service Delivery in Africa (TISDA) which looks more broadly at how services are being delivered in the health sector. Both programmes use a multi-stakeholder approach designed to bring in people from the government, private sector and civil society to develop practical strategies to tackle corruption in the health sector. 
 
Presenter Taryn Vian from the Boston University School of Public Health made the strong observation that it is essential to recognise corruption as a public health issue. With better governance which is able to tackle corruption, health services can be delivered more effectively, whereas corruption reduces the quality of health services delivery as well as the likelihood of citizens accessing said services even where they are available. It was noted that simply feeding more money into a corrupt system will not result in progress towards meeting health MDGs. Rather, a three pronged strategy to addressing corruption needs to be developed: reduce opportunities for corruption; provide incentives for better behaviour; deal with “rationalisation” of corruption. Case studies from Pakistan, Rwanda, Moldova and Vietnam were presented. 
 
Niyada Kiatying-Angsulee from Chulalomgkorn University in Thailand presented on a WHO Project, which they have been implementing in health sector governance since 2004. The Project has applied WHO’s Health Sector Assessment Tool to the Thailand health sector. A three phase approach was adopted: (1) national transparency assessment based on the WHO assessment tool; (2) development of national GGM framework (3) implementation of national GGM programme. Four reports on key findings (1 in 2006 + 3 reports in 2009). There are 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. 
 
Eelco Jacobs from the Basel Institute on Governance in Switzerland discussed their Research Project on Analytical Framework for Health Systems Governance. The Project 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. The tool looks at which institutions and actors are important in decision-making, shaping opinion and welding power beyond those which are formally recognised (e.g. warlords, elders councils, religious groups), and tries to identify the motivation behind their actions (e.g. bribery, charity, nepotism). Mr Jacobs presented a Case Study on Tajikistan where the new Analytical Framework was used to identify weaknesses in the health sector. The analysis recognised the importance, risk AND potential to work with informal institutions, and interventions were developed accordingly. 
 
Sjoerd Postma from the Asian Development Bank discussed the Banks Integrity Framework. ADB has identified “Integrity Violation Definitions”, e.g. corrupt practice, fraudulent practice, coercive practice, collusive practice, conflict of interest, obstructive practices, abuse. Over the last 10 years, ADB’s key integrity violations in the health sector relate to corruption/fraud. 56 complaints resulted 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. 
 
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 the curriculum for health professionals – important and effective way of sensitising future health officials on their responsibilities and ethical values 
 
Main Outputs

Recommendations, Follow-up Actions

• Need to:
- Recognise corruption as a public health problem – literally a threat to lives 
- Understand deeply the systemic 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. In practice, this may require adopting a “cross-cutting” programming approach, e.g. health sector implications of public administration reform, health implications of climate change, health sector and the budget 
 
• 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 successfully prosecuted. Therefore, there is not only the 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, they 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 the health sector and pressuring for change.
 
Workshop Highlights (including interesting quotes)
pdf5.6 Improving integrity in the health sector – stories from the field short report

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