Coronavirus: The perfect incubator for corruption in our health systems? 7 key COVID-19 points to consider.

Delivery of Healthcare Services

Transparency and Equity in the COVID-19 Vaccine Rollout

By Natalie Rhodes

During disease outbreaks, such as those of Ebola and COVID-19 we see health systems struggle as they handle the increased pressure on resources. In recent days many have flagged how this brings to light weak points within a health system, such as workforce shortages and poor access to medicines. As I’ll outline in this article, corruption is another of these weak points.

Corruption already weakens the daily functioning of health systems, during an outbreak this only worsens as we see an increase in supply and demand in health systems, making it a perfect storm for corrupt actors to take advantage of the ensuing uncertainties, distractions and disruptions.

The role of corruption in the outbreak, spread, and slow containment of Ebola during its 2014 – 2016 outbreak has been well documented and saw international organisations such as the Red Cross reporting evidence of over $6 million USD being lost to corruption and fraud over this period[i]. There was evidence of diversion and mismanagement of funds with misreporting of salaries and payments for supplies being duplicated, alongside public services accepting bribes to allow people out of quarantined zones[ii].

Whilst corruption poses particular challenges for low-middle-income countries with weaker institutions and lower resources, it manifests in every context. Therefore, whilst COVID-19 is currently predominantly impacting higher-income countries, at least for now, corruption will still undermine outbreak response. So, while we all take responsibility for minimising spread of the virus, governments, regulators, funders and practitioners should look out for the following as the make decisions on how best to respond.

1. The pressure is on for the development of a vaccine against COVID-19. As a result governments have been investing heavily in research and development, since 2002 the US alone has spent nearly $700 million USD on research into coronaviruses[iii], with governments such as the UK pledging a further £20 million GBP to research[iv], the EU mobilising €5 million[v] alongside Wellcome and the Gates Foundation setting up a $125 million USD coronavirus drug fund[vi]. There are over 30 candidate vaccines already undergoing rigorous testing with hopes they will get through to human clinical trials. However, publication rates of clinical study results is notoriously low, particularly for public funded research institutions[vii]. Privately funded trials have a better publication rate but are known for their reports to be full of redacted text to protect commercially sensitive data. And on top of this, data itself can be manipulated to produce favourable results[viii]. Both cases greatly undermine transparency and public health. Vaccine development already suffers from a weak pharma appetite due to low financial incentives, therefore it’s imperative that clinical trials are published in their entirety to support scientific innovation. Development of a vaccine must be a transparent and collaborative effort, not a secret competition.

2. Whilst we wait for the successful development of a vaccine there is need for a reliable treatment regimen. However, there’s a lesson to be learnt from the swine flu outbreak which saw the world spending over $18 billion USD in stockpiling Tamiflu[ix]. However, a scientifically rigorous Cochrane review of all clinical data (which involved 4 years of protracted efforts to even get all the information from the pharmaceutical manufacturer, Roche) suggested that Tamiflu was a no more useful than paracetamol in treating swine flu due to safety and efficacy concerns[x]. So whilst there is an undeniable need for a treatment for COVID-19 there must be total transparency of any studies and rigorous analysis to ensure it is indeed effective before 100s of millions of taxpayers money is wasted again.

3. COVID-19 is also affecting manufacturing processes. As a result there have been reported shortages of medicines. Yet USA’s Food and Drug Administration (FDA) stated they will not release the drug names currently in shortages as this is “confidential commercial information”[xi]. By doing so they are robbing health communities the ability to effectively put in place mitigation strategies, such as finding an alternative manufacturer, in favour of espousing corporate interests. This information must be made publicly available to ensure that access to life-saving medicines is not impacted by COVID-19.

4. Procurement in health systems is one of the activities most hard-hit by corruption. With medicine and medical supplies shortages being reported there will be an additional strain on procurement. It’s estimated that 10-25% of all money spent in procurement globally is lost to corruption[xii], and in the EU 28% of health corruption cases are related specifically to procurement of medical equipment[xiii]. With the increased demand for medicines and equipment there’s the potential increased risk of collusion and that suppliers might demand higher prices knowing that governments have no other option but to pay. Having open and transparent contracting processes would allow red flags of corruption to be more easily spotted, leaving corrupt actors less space to hide and ensure governments are being charged reasonable prices so they can provide the best care possible to patients.

5. There have been shortages in medical supplies created by people stockpiling items such as masks, gloves and hand sanitizer. In attempts to profit off the hysteria around the outbreak traders have been setting inflated prices[xiv]. In order to tackle this the Indian government has set up a helpline for citizens to report items being sold above the recommended retails price[xv] and companies such as Amazon have been actively removing listings they believe are price-gouging or falsely advertising products as being able to cure or protect against the virus[xvi]. Governments and companies must continue taking similar approaches to prevent this unethical profiteering.

6. There have been concerns that health professionals are being muzzled on speaking out about the realities of COVID-19. So we saw the whistle-blower Li Wenliang’s early warnings being silenced in China[xvii] and in the USA where the vice-president Mike Pence announced he will be controlling all messaging on COVID-19 from health officials[xviii]. Corruption underpins low levels of trust in governments consequently weakening impact of government-led health interventions. This distrust can then lead to mistrust in fake news, something which the World Health Organisation labelled as an ‘infodemic’[xix]. Therefore, it’s crucial that governments behave in an open and transparent manner in order to maintain trust from their citizens.

7. Hospitals are struggling to cope with COVID-19 as they face bed shortages and lack sufficient health workforce. This raises concerns over the increased risk of bribes. In 2019, the Global Corruption Barometer for Africa[xx] and the Middle East and North Africa[xxi] found bribery rates in hospitals and health centres to be 14% each. In Latin America and the Caribbean, the rate is 10%[xxii]. So, in the context of an outbreak health professionals will have to prioritise care to those who most need it or might most benefit from it. Consequently, we might see an increase in the frequency of those patients willing to pay a bribe to receive care as soon as possible, leaving those most vulnerable who are unable to pay at the bottom of the waiting list. To mitigate this, a range of interventions can be taken such as having transparent waiting lists, clear codes of conduct, strengthening the judicial system, and changes in attitudes towards corrupt practices.

As of writing we are still anticipating the height of the outbreak. Following the Ebola outbreaks in West Africa health care infrastructure has improved as a result of the increased scrutiny and resources dedicated towards health system strengthening. So whilst outbreaks are certainly nothing to be celebrated they create space for more open and frank discussions on issues in health systems. In that spirit we implore governments to always act in a transparent manner. Public health, not political or corporate interests, must always come out top.

[i] https://media.ifrc.org/ifrc/ifrc-statement-fraud-ebola-operations/

[ii] https://www.cmi.no/publications/file/5522-ebola-and-corruption.pdf

[iii] https://www.citizen.org/article/blind-spot/?eType=EmailBlastContent&eId=0a4b146b-3346-496c-8ff3-f294d3028bc9

[iv] https://www.gov.uk/government/news/20m-announced-to-fund-vaccines-for-coronavirus-and-other-infectious-diseases

[v] https://ec.europa.eu/info/live-work-travel-eu/health/coronavirus-response/medical_en#research-and-innovation

[vi] https://www.ft.com/content/566acfb0-6216-11ea-b3f3-fe4680ea68b5

[vii] https://988e032c-518c-4d3b-b8e1-0f903f16a792.filesusr.com/ugd/01f35d_42e869002189401d80a672d4ecff3f73.pdf?index=true

[viii] https://www.bmj.com/content/367/bmj.l6576

[ix] https://www.bmj.com/content/348/bmj.g2524

[x] https://www.cochrane.org/CD002745/ARI_amantadine-and-rimantadine-to-prevent-and-treat-influenza-a-in-children-and-the-elderly

[xi] https://www.statnews.com/pharmalot/2020/02/28/fda-coronavirus-shortage-confidentiality/

[xii] 5 UNODC, 2013. Guidebook on Anti-Corruption in Public Procurement and the Management of Public Finances, p.1