Delivery of Healthcare Services

Service delivery is the part of a health system where patients receive the treatment and supplies they are entitled to. All the other parts of the health system examined in this map support the delivery of healthcare services and, as a result, corruption in these other areas will indirectly impact on the quality of delivery. For example, unpublished harms data from clinical trials could lead to healthcare providers basing the treatments they give on unsound medical knowledge.

However, there are multiple forms that corruption can take specifically in the delivery of healthcare services. Corruption here has a negative impact on access to services, compromising the ability of governments to provide healthcare to citizens. Likewise the quality of care can be diminished as patients receive needless treatments. Vulnerable populations will be most affected as they struggle to meet unofficial or unnecessary payments and instead may choose to forgo treatment or seek treatment from unauthorised providers.

Some experts suggest that low wages and poor working conditions for healthcare workers are the causes of corruption in this part of the health system. For example, doctors may demand informal payments from patients and provide private practices using public resources, as they seek to subsidise their wages with other or higher payments. Others have suggested that these corruption types should be seen as an effect of wider governance failures in the health systems including limited oversight of worker performance and minimal sanctions for malpractice. However, in other instances it may simply be an abuse of power to satisfy greed.

These corruption types can be prevalent in both high-income and low-and middle-income countries. Regulators in all health systems must implement measures to minimise the risks of prevalent types of corruption in healthcare service delivery.

A whistleblower, an office manager, came in and reported … suspicions of dispensing chemotherapy drugs that were unnecessary, false diagnoses, delivery of iron deficiency drugs … The initial interviews came back and said this is absolutely a problem, this is absolutely happening … I believe he got 45 years.

— Agent of the US Department of Health and Human Services, Office of the Inspector General

Corruption Types

Informal payments from patients

Unofficial, under-the-table payments from patients to healthcare providers in return for receiving healthcare services.
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Essentially a bribe from a patient to a healthcare professional, these payments can be cash or any other type of gift. These inducements can be given to receive services that should be free such as seeing a doctor and receiving drugs, as well as getting better services or preferential treatment.

In countries experiencing overcrowding and high demand for services, patients may be more likely to make informal payments. In cultures where gift giving is widespread, healthcare workers may not demand additional payment but patients may feel it is obligatory.

In a number of transitioning economies informal payments are widespread, partly because universal healthcare is offered but health funds are low. However, it is difficult to make generalisations about where informal payments are likely to be prevalent, due to difficulties in measuring unofficial payments. By their nature, no record of the payment is made and healthcare providers may be unwilling to discuss them.

Unnecessary referrals and procedures

Healthcare workers encourage patients to have services or treatments they do not require, in return for receiving a benefit from the party performing the service.
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A healthcare worker may be incentivised in multiple ways to provide excessive diagnosis or more treatment than is necessary to a patient. A doctor in a private hospital may be encouraged to generate business for their employer, or indeed themselves. A doctor could receive payments from a hospital in return for referring patients there. Or a doctor may have a financial stake in a private laboratory to which they send patients for diagnostic tests. In some countries it is illegal for doctors to receive kickbacks for referring patients.

As well as increasing the costs that patients must pay, this type of corruption can impact on patient safety if they undergo unnecessary treatments. In the most severe cases patients have died from unnecessary procedures. This diminishes the trust that patients have in healthcare providers and, in countries where corruption is already systemic, trust in the health system more generally.

The corruption type false treatment reimbursement claims in the financial and workforce management category also covers this issue. However, in contrast to this corruption type, it focuses on the process of a healthcare provider making a false claim to a payer for unnecessary procedures, as well as procedures that were undelivered or overcharged.

Private use of public products, equipment, facilities or time

Healthcare providers divert patients to private care and use publicly paid for supplies, facilities and time.
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By providing treatment and services to patients in their private clinics, healthcare providers are able to receive a supplementary income to the one they receive in the public sector. This phenomenon is linked to the corruption type absenteeism in the financial and workforce management category, with healthcare providers providing private services when they should be providing public services.

As well as using facilities and supplies from the public sector, using publicly paid for time to provide private care wastes finite health funds and places additional strain on public health systems. In some countries this is a systemic issue, with most doctors in the health system providing private practices at the same time as receiving payments to work in public health facilities.

Like other corruption types, such as informal payments from patients and absenteeism, this corruption type can be linked to low salaries, poor working conditions and inappropriate selection for employment opportunities. However, it is also seen in high-income countries where healthcare providers are simply abusing their positions of power for their own private gain.

Favouritism

Healthcare professionals offer preferential service or better treatment to friends, family members or specific groups at the expense of the wider population.
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This could involve a healthcare provider moving a family member to the front of a queue for treatment and/or waiving fees that are due. On a larger scale, favouritism could involve a hospital’s budget being targeted at specific groups that are unobjectively preferred by management.

Overcharging for services or providing inferior services

Patients are overcharged by a healthcare provider or health facility for the services they receive, or patients do not receive the level or quality of service they should receive.
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Any type of healthcare provider may be able to overcharge for the services and treatments provided. For example, pharmacists may charge patients too much for medicines and medical devices dispensed. This could be part of a facility-wide policy to extract money from patients. Alternatively, patients may be denied the quality of service that they have paid for or that is due to them. For instance, hospitals may require doctors to provide low quality medicines when pre-paid by insurance, thereby saving the hospital money.

Manipulation of outcome data

Health facilities or healthcare providers exaggerate, distort or suppress data on the standard of care received by patients.
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Doctors may selectively choose the patients they see in order to increase their ratings. This may occur if a patient has a more complex illness or is at a higher risk of complications.

In health systems that require doctors and health facilities to report the outcomes of their results there may be a failure to do so as well.

This has the effect of denying treatment to those who may need it most and putting patients at risk of receiving treatment by an underperforming doctor or health facility.

Case Studies

UK, January 2015 – The truth about cash referrals

Hong Kong, May 2016 – Gov’t dentist charged by corruption watchdog for falsifying records to claim free services for brother

Cyprus, May 2016 – State hospital’s ENT chief arrested for bribery, more pending

USA, September 2016 – Toms River doctor sentenced for taking bribes

India, August 2015 – Meet the women fighting corruption and saving mothers’ lives in India

The Pharmaceuticals & Healthcare Programme is an international programme of Transparency International, based in the London office of Transparency International UK.

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