Corruption and Health in Developing and Transition Economies Maureen Lewis Chief Economist for Human...
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Transcript of Corruption and Health in Developing and Transition Economies Maureen Lewis Chief Economist for Human...
Corruption and Health in Developing and Transition
Economies
Maureen LewisChief Economist for Human DevelopmentWorld Bank
Major Sources of Corruption in the Health Sector
Contracting and procurement Petty theft Selling accreditation or positions Public funds disappearing Staff nonattendance Informal payments
Measuring Corruption Perceptions of leaders, providers
and the public; Contracting: audit and supervision; Petty theft: difficult, track supplies; Selling accreditation: anecdotal; Public funds use: PETS; Staff attendance: surveys, records; Informal payments: surveys/studies.
Perceptions Out of 22 countries, 10, or almost
half, consider health in the top 4 most corrupt sectors;
In 60% of 22 countries canvassed, over half of interviewees perceived corruption in health, and in over 85% of the sample corruption was apparent to 60% of the public.
Contracting/Selling Accreditation and Positions Part of broader corruption problem; Hard to single out one sector unless
it is a pilot; Tend to correlate with other forms of
corruption or bad public practices; In Buenos Aires procurement data
showed 15% drop in prices during corruption crackdown.
Misuse of Public Funds Public Expenditure Tracking Studies
(PETS) trace the flow of funds from the budget to expenditure at the front line – in clinics and hospitals;
Quantifies the bureaucratic capture, leakage and problems with deployment of human and other inputs.
Misuse of Public Funds: Education Tracing flow of funds in primary
school showed that in the base year: 87 percent of funds in Uganda never
reached the schools; 60 percent of funds in Zambia never
reached the schools.
Staff Nonattendance Time and motion studies and full costing
and expenditure review of hospital. In D.R. 12% of contracted physician time available at hospital. Training of interns by MDs nonexistent;
Quantitative/Qualitative surveys of users and providers includes: qualitative assessment of incentives; interviews with providers; exit/follow up patient interviews (Armenia,Poland, Georgia).
Staff Nonattendance (cont.) Quantitative Service Delivery
Surveys (QSDS) based on unannounced spot checks of clinics (Bangladesh, Honduras, India, Peru, Uganda);
Apply questionnaires for: local health administration; health facility records; exit interviews (Uganda).
0
5
10
15
20
25
30
35
40
45
Perc
ent
Bangladesh Honduras* India Peru Uganda
Absence Rates among Health Care Workers, 2002
Informal Payments Household surveys Corruption surveys Reviewing patient records Qualitative studies
• Focus groups of providers/ patients/community• Provider/administration interviews• Exit surveys/follow up patients• (Poland, Georgia)
0
10
20
30
40
50
60
East Asia LAC South Asia ECA Africa (Ghana)
Average Frequency of Bribes/ Informal Payments
Frequency of Informal Payments: Hospital vs. Total/ Outpatient
0
10
20
30
40
50
60
70
Albania Armenia Khazakhstan Kosovo Kyrgyz Romania Ghana
Total/Outpatient
Hospital
0
20
40
60
80
100
120
140
160
180
200
Armenia Bulgaria Kyrgyz India Pakistan Ghana Cambodia Thailand Peru
Average Informal Payment Per Visit, Constant PPP$
Outpatient/Total
Hospital
0%
20%
40%
60%
80%
100%
120%
140%
Armenia Bulgaria Kyrgyz India Pakistan Ghana Cambodia Thailand Peru
Average Informal Payment as Percentage of 1/2 Mean Monthly Income, PPP$
Outpatient/Total
Hospital
Average Outpatient Expenditure (% of monthy mean income, PPP$)
0 10 20 30 40 50 60 70
Armenia
Bulgaria
Kyrgyz
Albania
Georgia
Post-2000
Pre-2000
Average Inpatient Expenditure (% of monthly per capita income, PPP$)
0 50 100 150 200 250 300
Armenia
Bulgaria
Kyrgyz
Albania
Georgia
Post-2000
Pre-2000
Underlying Causes of Corruption Lack of clear standards of performance
for providers Organizational and management deficiencies
Lack of effective auditing and supervision Collusion in contracting Lax fiscal controls in flow of public funds
Limited enforcement of rules/no sanctions Abuse is unchecked Good performance unnoticed
Underlying Causes of Corruption (cont.) Lack of accountability and oversight
Nonattendance of staff Poor quality of care Informal payments
Lack of citizen involvement and of local oversight and authority
Absence of monitoring and evaluation
Remedies Government-wide anti-corruption
stance; Culture of public service; Procurement and contracting rules,
and enforcement of rules; Public standards of conduct and
oversight; Effective enforcement of rules and
rewards/punishment for behavior;
Remedies (cont.) Improvement in civil service rules, pay
and review; raise quality of public management of
health services; Reform of provider units (TQM) – health
providers input to raise productivity and performance;
Charge official fees and compensate providers accordingly for efforts;
Promote private sector alternatives;
Remedies (cont.) Allow accountability at health service
delivery unit to stem petty theft and improve management potential
Improve fiscal oversight with consequences for unlawful practices Local accountability Local advertising of expected funds
receipt
Challenges Cultural change is difficult; Physicians hard to influence; Oversight is costly and complex; Some level of corruption emerges in
most health systems; Without controlling corruption health
system is compromised in eyes of the public.
Total Hospital Outpatient Albania 53 Armenia 49 57 40 Bosnia 23 Bulgaria 18 Croatia 11 Latvia 15 Khazakhstan 26 9 Kosovo 15 3 Kyrgyz 26 5 Macedonia 24 Romania 35 66 Slovakia 16 58 Tajikistan 66 Bangladesh 58 India 25 Nepal 18 Pakistan 96 Sri Lanka 92 Bolivia 38 Peru 3 Paraguay 9 Thailand 2 Indonesia 42 Cambodia 57 Ghana 26 30
Frequency of Bribes or Informal Payments