A good health workforce requires well-trained staff that are productive. A well-functioning health financing system involves adequate funds that are delivered on time. Both are crucial to providing high quality healthcare services to patients. However, without good governance, transparency and accountability, corruption can thrive.
The public sector health workforce is often one of the biggest employers in a country. Management procedures that provide effective oversight must be implemented to ensure that jobs and promotions are given based on merit, workers do not skip work while still claiming a salary, and workers do not steal medicines, equipment and supplies. A strong culture of integrity is crucial to minimising these corruption risks, including a speak up policy for healthcare workers to inform management about colleagues involved in corrupt activities, without the fear of retaliation.
The theft of funds from health systems is a serious issue in many countries. The loss of healthcare funds reduces the total amount available to provide services and treatments for patients. This can force health facilities to charge fees to patients for services that should be free. The effects are most serious when politicians and prominent officials at the highest levels of a health system steal funds, as the size of the funds taken can endanger the entire system.
Minimising the risk of embezzlement requires good management processes, reliable record keeping, and regular audits. Donor funds are at a higher risk for theft and diversion as their use is harder to track and control, particularly in environments where cash payments are predominant.
Payers must also be aware of healthcare provider fraud. For example, healthcare providers may provide false reimbursement claims for services that were unnecessary or that were actually not provided. In health systems where this is a high risk, payers must devote sufficient resources to carry out effective checks on healthcare providers applying to provide reimbursed treatments, to adequately check claims and to investigate potential false claims.
“Absenteeism - not showing up to work or only showing up for part of the day, often not at all. I've never worked in a country where it doesn't happen in the public system.”
— Maureen Lewis - CEO, Aceso Global; Adjunct Professor, Georgetown University
This can occur at any level of the health system, from individuals based in health ministries to healthcare providers in local health facilities.
In some health systems payments are required to get a job in the public healthcare sector and then for every subsequent promotion. In others, some jobs and promotions may be based on personal connections, which can simply involve hiring a family member or friend. It could also include politicians selecting appointees for jobs based on their personal connections with individuals; this is particularly prevalent with high profile positions such as directors of hospitals or national medical agencies.
This corruption type will affect the quality of healthcare provided by health facilities. Inexperienced management personnel can result in the mismanagement of budgets and unqualified healthcare workers could lead to the suboptimal delivery of healthcare services and treatments provided to patients. Furthermore, healthcare workers may seek to reclaim the money spent to purchase a job through corrupt practices in their line of work, such as demanding bribes from patients wanting to receive care.
Similar to informal payments, this corruption type is often related to low wages in publicly financed health systems and to poor working conditions. Healthcare workers claim a salary but take on other employment. For this reason absenteeism is strongly linked to the corruption type private use of public products, equipment and facilities in the healthcare service delivery category. Healthcare providers may not fulfil their paid work commitments because they provide parallel private consultations from which they can receive higher fees.
In a range of low-and middle-income countries absenteeism has been documented as a serious issue. As well as causing a backlog of care, remote health facilities with a small number of staff may have to completely shut due to staff absences. Poor record keeping can make it hard to measure, track and put in place measures to tackle absenteeism.
Healthcare providers issue false reimbursement claims to increase the disbursements that they receive from the payer. They can occur in several ways: healthcare providers can claim for services that were not actually provided; healthcare providers can claim for services that were not actually needed by the patient; and healthcare providers can over-invoice and state that the patient had a more severe condition than they actually had, a practice called ‘upcoding’.
This corruption type has an inherent vulnerability: patients may only know as much about the treatment received as the healthcare provider has told them, and payers such as insurance funds are limited in how much they can check about the delivery of the treatment. It is harder for payers to detect overbilling than undelivered services, as the doctor may give a seemingly good clinical reason for the treatment. Patients are less likely to be aware if something was done rather than nothing at all.
This type of corruption is common where there is a fee-for-service reimbursement. In the USA it is one of the most prevalent forms of healthcare fraud, with considerable national resources devoted to its detection and elimination.
The corruption type unnecessary referrals and procedures in the delivery of healthcare services category also covers this issue. However, in contrast to this corruption type, it focuses solely on the process of a healthcare provider making a false claim to a payer for unnecessary procedures.
This can occur at any level of the health system, as funds are transferred from the treasury to health facilities. At the national or ministerial level, high-ranking officials and politicians may siphon off large amounts of the funds. Effective record keeping and regular audits can minimise the risk of embezzlement and misuse.
Inadequate funding can result in the non-payment of salaries and medical supplies not being purchased. As a result, health facilities may have to charge patients to cover their costs, severely limiting the access to healthcare for vulnerable populations.
Commonly, funds earmarked to pay staff salaries are misappropriated at the health facility level. Often the complicit official will covertly route the funds to ghost workers – former, deceased or fake workers. This may affect the level of service provided: the failure to pay salaries to healthcare professionals may mean they do not attend work and instead offer their services privately.
Funds from international donors are often at the highest risk of misappropriation. The funds may travel through a number of international and national organisations, and the funders are geographically distant from where the funds will be used. As a result it can be difficult to track and audit funds and resources.
Similar to the embezzlement and misuse of national funds, high-ranking officials and politicians may attempt to steal large quantities of the funds.
Donor funding is mainly focused on low-and middle-income countries and record keeping in these regions can be poor, making it difficult to track funds. Added to this, funds from donors often have a short time period to be spent, especially after natural or human disasters. In these circumstances normal controls and oversight of budgets may be compromised due to the urgency of the situation.