April 7, 2018
By Natasha Viveiros RN, MPH
Corruption in the healthcare sector is pervasive and undermines the achievement of the Sustainable Development Goals (SDGs). Informal payments are a form of corruption, and can vary in degree from a patient’s offer to pay into an underfunded healthcare system, a healthcare provider requiring a bribe to access services that should be free, or to be assured of better health services. The lines of informal payments are often blurred as it can present itself in the form of a gift of food or a more obvious cash offering, but the intention of bribery is often the same. Bribery disproportionally affects poorer populations and can lead to reduced service utilization, disparities in access to healthcare, inequitable allocation of healthcare services, and poor health outcomes.1 In addition to negatively affecting care-seeking behaviors and population health, informal payments also impact global hunger, gender equality, social justice, economic growth and the alleviation of poverty that the SDGs strive for. Using the lens of informal payments, we will take a closer look at how corruption affects people’s access to healthcare and the implications for the achievement of the SDGs.
Informal payments for healthcare can push people into poverty and have wide reaching negative consequences for those already living in poverty by forcing them to sell personal assets (produce/animals), dip into meager savings, decrease household consumption, and rely more heavily on social networks for assistance.1 For example in Albania, informal payments were made by selling possessions or borrowing money to pay for services. Bribes for healthcare diminishes personal financial protections, increases overall debt, and in some cases result in catastrophic loss.1
When household income is used to pay a bribe it reduces the amount of money that people can contribute to ensuring good nutrition.2 Families might be forced to choose cheaper foods of lesser nutritional value, or skip meals. Poor nutrition can lead to malnutrition, a greater susceptibility to illness, and reduced economic productivity pushing families even further into poverty.
Paying bribes can lead people to avoid or delay seeking care because they cannot afford it.3 This then poses great risk to the health and wellbeing of the individual and their community; it can also create a perceived decrease in demand for health services. Furthermore, health is a predictor of productivity and earning potential. If the head of a household is hampered by sickness, it can decrease household income,4 which can perpetuate the cycle of poverty and illness. For example, children under five born into poverty are twice as likely to die compared to wealthier families.3 Furthermore, bribes are most often observed in settings of low healthcare quality, which can mask problems with low or inadequate health workforce wages, distort the country’s health financing capabilities, and impede future efforts to improve health financing and health system functioning.5
When families must spend funds on paying a bribe for healthcare, this can reduce the funds available for children’s education and they subsequently miss out on opportunities to achieve higher education and circumvent poverty. Additionally, when families restrict or avoid medical treatment for children because of an inability to pay bribes, it can lead to persistent illness and malnutrition, which impact school absence and cognitive development which can have lasting effects on the educational advancement of entire communities.1
Over their lifetime, women are more likely to engage with healthcare providers due to sexual, reproductive and maternal health needs, as well as the accompaniment of children. This exposes women to potentially greater health inequities from bribes.6 If women are unable to access the care they need it can lead to unwanted pregnancies and poor birth spacing. Additional bribes for the healthcare of girls may also impact educational attainment, as in some cultures the education of boys takes precedence over that of girls. Thus informal payment directly influences the capacity of women to achieve equality compared to their male counterparts.
Social inequalities harm growth and impede progress in global development. Wealth inequality can strongly influence health outcomes as well as the quality of care received at health facilities, as bribes have a disproportionately negative effect on poor populations.7 Compared to the wealthy, the poor pay a larger share of their income for out-of-pocket expenditure on healthcare costs.8 Access to and the quality of health services received is also lowered for those unable to pay bribes.9 Corruption in the healthcare setting undermines the assurance of fundamental human rights, including the right to health for all.6
Goal 16 calls for just, peaceful and inclusive societies, and one of the goal’s targets is to reduce corruption and bribery, including informal payments. Efforts made to achieve this goal can have widespread impact on the success of the other SDGs, and because of this, Transparency International advocates for a joined-up interdisciplinary approach to addressing corruption in the health sector.
Call to Action
The specific cost of corruption in the health sector is almost impossible to measure, but it is clear that the practice of bribes for services has a very tangible impact on the lives of regular people, particularly poor populations, and that they gravely affect the achievement of the SDGs. Interventions to reduce bribery within the healthcare sector must be tailored to patient and provider motivators. Some interventions include clearly defining informal payments to healthcare personnel, training supervisors to detect bribery and discipline when necessary, providing complaint mechanisms for patients, and practicing transparent financing so patients are aware of the uniform cost of health services and their rights and entitlements.10 It might also be necessary to address insufficient funding of medical personnel to ensure their needs are being met, and to further investigate the individualized perceptions which perpetuate a normalized culture of bribery in healthcare.11 For the SDGs to attain maximum impact, informal payments must be addressed as a deterrent to overall social growth and economic development, and health systems should be enabled to ensure equitable access to healthcare for all regardless of socioeconomic status.
This blog post is part of a series of five posts written by Masters students of the Boston University School of Public Health 2017 course, Fighting Corruption through Transparency and Accountability, taught by Dr. Taryn Vian.
Natasha Vivieros is a nurse by training and has a Masters of Global Health from Boston University. Her interests and areas of expertise span global development topics such as mental health, childhood malnutrition, and sexual education curriculums in Nicaragua. Natasha also sits on the board of the Global Nursing Caucus, and strives to work in poverty alleviation and medical quality improvement.