Corruption in health services: Reducing its impact on the patient (Part 2)

Anke Martiny, Daniel Winkler, Beatriz Londono, Te Kuy Seang, 10th IACC, Workshop report, Civil Society

 

Chair:
Ms. Anke Martiny, Transparency International-Secretariat, Berlin, Germany

Panellists:
Dr. Dan Wikler, World Health Organization, Geneva
- Conflict of Interest and Ethics in Health Research in Developing Countries
Dr. Fatimah Al Awa, World Health Organization, EMRO, Egypt
- The Tobacco Industry Influence in the East Mediterranean Region
Beatriz Londono, Colombia
- A Successful Strategy to Curb Corruption in the Health-care System
Dr. Te Kuy Seang, Ministry of Health, Cambodia
- Under-the-table Payments for Health Services

Contribution by Dr. Dan Wikler

Conflict of Interest and Ethics in Health Research in Developing Countries

The research imperative: 90% of funds spent on populations bear only 10% of diseases.

However, pharmaceuticals are drawn to developing countries for trials since most of the patients are there, lower costs, weak regulations, patients lack alternatives. That is an ethical minefield: there are consent problems, standards of care are not necessarily similar to those in developed countries; it is a "Safari" research, with no long-term considerations and exploitation of the poor and vulnerable.

Another dimension to that ethical complexity is that of conflict of interest: increased commercial involvement by scientists adds a commercial interest to the traditional balancing of clinical and scientific missions.

Situation in developing countries: bounties for enrolling patients, payment for prescribing in the form of research and education support, and research has become and is used as a marketing tool and is not always a real research. These bounties in developing countries are fraud: they are supported through financial incentives to enrolling patients.

An ethical review was carried out in developed countries. In developing countries it is more complex: lack of funds for ethical reviews, conflict of interest is not yet on the agenda, pharmaceutical companies set the agenda.

What can we do:

global campaign on these ethical issues and add conflict of interest to the agenda, closer scrutiny in developed countries by oversight agencies in sponsored countries, agreements or conventions of fees vs. bounties for researchers.

Contribution by Dr. Fatima Al Awa

The Tobacco Industry's Influence in the East Mediterranean Region (EMRO)

Tobacco control programmes in EMRO started in the 1880s. Tobacco use despite these efforts is popular and is on the rise due to tobacco industry activities. A report held in this region (voices of truths) showed that the industry not only promoted tobacco use, but also undermined governmental efforts to combat tobacco as a health risk.

In 1970, the industry created a regional working group (META). Later on, smaller ad hoc groups were focused on dealing with emerging issues.

The industry was involved in trying to manipulate the tobacco control efforts of the WHO in the region, through attempts to influence ministries from member states, for example. Also, the industry tried to influence the media, planting articles occasionally.

In the 1990s, a more concentrated campaign had begun. Fighting regulatory attempts: developing arguments and undermining efforts to ban tobacco advertising.

The tobacco industry also tried to explore the issue of religion. Muslim creeds usually ban tobacco use. The industry encouraged and recruited religious leaders who were more favourable to tobacco use to combat this, for example. The tobacco industry was attempting also to fight second hand smoke issues through resisting smoking restrictions. The strategies were to influence popular attitudes. WHO encouraged more countries to perform such enquiries.

The tobacco case shows that corruption has both an upstream and downstream component.

Contribution by Beatrice Londono

A Successful Strategy to Curb Corruption in the Health-care System. New Ways of Corruption and Colombian Health System Reform

Case study from Bogota

In 1993, there was a large-scale health reform in Bogota. A subsidised regime was proposed for the poorest of the poor. A system was put to select eligible families, give freedom to patients to choose their health care providers

What was found:
The whole regime had been abused and manipulated by the administrators of the system: deceased people were included, double affiliations, false signatures, rubber stamps, membership cards were not introduced.

114,000 real people could have been be covered by the regime, had these practices not been used. There is a need to reconcile economic and social interests. The lesson learned was to disclose information and enhance knowledge and training to the professionals and the public. Transparent rules of the game are crucial to the implementation of health system reform.

Contribution by Te Kuy Seang, Cambodia

Under-the-table Payments for Health Services

Cambodia is a very poor post conflict country, the poorest country in the Asian Pacific Region. Infant mortality is very high. Household spending is 29 dollars per capita per year. Only 2 dollars come from the government and 5 more from other donors.

The data of 1996 which indicated high costs of care at public facilities drew attention to the existence of unofficial payments as health services were supposed to be provided for free during those times. This prompted the government to bring official changes to induce accountability and regulatory mechanisms among service providers.

User fees were first brought in as a pilot strategy through the national health financing charter in 1996. The principles included decentralised management of facility based health finance systems, retaining 99% of revenues at facility level to be channelled into performance based bonuses to the staff and operational costs for quality improvements. Some provision of exempting the poor from payment, and a clear process for accountability and transparency in financial management, procurement of logistics and supplies and staff regulation.

There have been many success stories and problems during the pilot phase. The lessons are that good leadership, community involvement and customer feedback were essential to effective regulation and elimination of corrupt policies. An effective strategy for improving performance and reducing unofficial payments was to issue individual contracts to staff members that outlines their responsibilities, their rewards and entitlements. Team building also contributed to improving transparency and accountability. Last but not least, it would be possible to remove unofficial fees without improving salaries to sufficient living wage levels.

docCorruption in health services: Reducing its impact on the patient (Part 2)

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