By Daniela Cepeda Cuadrado

2020 marks the first anniversary of Transparency International Health Initiative’s ground-breaking report revealing how corruption in healthcare service delivery threatens Universal Health Coverage (UHC) – that is the worldwide commitment to provide access to essential quality health services for all.

This year, we are also entering a 10-year count-down to meet all global commitments on sustainable development, including health (Sustainable Development Goal – SDG 3). That. Is. Only.10. Years.

And, of course, we are in the midst of a global pandemic that has brought health systems around the world to the brink of despair. Tens of thousands are dying around the world every single day. Many hospitals are struggling to acquire medical equipment and failing to adequately protect their health workers. COVID-19 has proved that we are only as strong as our weakest health system.

Despite all this, global health advocates have not given up on their ambitious goal of UHC. Advocacy has revolved around the need to secure political will; mobilise economic resources; prioritise budgets for cost-effective interventions – with special attention to Primary Health Care (PHC); invest more and invest better; reduce the social burden of out-of-pocket expenses; and reach those left behind. Now, in the face of COVID-19, they are calling on world leaders to recognise the interconnectedness of UHC and health emergencies.

The global discussion has been one of securing commitment and action. Dr Tedros, WHO’s Director, has declared that “all roads lead to UHC.[1]” Yet, one thing has left us concerned: corruption continues to be ignored within the global health advocacy for UHC. Today, we would like to remind you why corruption can no longer be dismissed from the conversation if we are truly serious about making substantial progress on UHC within the next decade.

Make some coffee (preferably an expresso because we need you alert!) and hear us out.

1. Data tells us corruption DOES limit progress on UHC

Before I enter into the specifics of how corruption limits UHC, let’s start with data.

Many studies have shown how corruption impacts health. Here are two significant examples: In 2011, Hanf and other scholars assessed the impact of corruption on under-five mortality rates in 2008 and found that roughly 140,000 annual children deaths could be indirectly attributed to corruption[2]. When children die because their parents cannot afford to pay a bribe to access the services and medicines they need, we should seriously question our own humanity.

The second study is from Mon-Chi Lio and Ming-Hsuan Lee, who estimated the effects of corruption on five major health indicators in 2015. They found that, in general, a lower level of corruption or a better control of corruption in a country can lead to longer life expectancy, a lower infant mortality rate and a lower under‐five mortality rate for citizens[3] [4].

Now, it is 2020 and you might think: “Oh well, those studies are quite outdated; they don’t really prove that much in today’s world.”

We hear you. We need more updated data to prove that corruption is a parasite eating up health systems’ capabilities and resources. In our report on petty corruption, we have called for more sustainable investments towards the collection and analysis of data because this will help us better manage health systems, monitor their performance, and keep them accountable.

Knowing how powerful data can be, we decided to conduct a linear regression model between the UHC Service Coverage Index[5] and the World Bank’s Control of Corruption indicator[6] in 2017.

The regression proves to be positive and statistically significant[7]: countries have better scores on Universal Health Coverage when they are also perceived to be better at controlling corruption. In other words, those countries providing quality, affordable and accessible health services to their populations are generally the less corrupt ones.

So, how exactly does corruption hurt health?

2. Corruption blocks all roads that lead to UHC

Corruption affects all areas that are important for well-functioning and strong health systems, such as service delivery, health workforce, health information systems, access to essential medicines, financing, and leadership/governance. These are, according to WHO, the building blocks of health systems. Work on strengthening one or more of these blocks and you will reap off the benefits across the whole system.

At Transparency International Health Initiative, we have identified 37 types of corruption and clustered them into eight categories that represent different areas in the health sector: health systems governance, health systems regulation, research & development, marketing, procurement, product distribution & storage, financial and workforce management, and the delivery of healthcare services[8]. All these areas also fit nicely within WHO’s typology of health systems blocks.

In our report on petty corruption, we have outlined the types of corruption risks in health service delivery. They are frequent and cause great cumulative damage. They range from the existence of phantom healthcare workers; illegal absenteeism; informal payments by patients; theft and embezzlement of money, medicines and other medical equipment and supplies; to kickback referrals; unnecessary procedures; overcharging; provision of inferior services; false treatment reimbursement claims; favouritism; and manipulation of data in the form of fraudulent billing and the creation of phantom patients.

Corruption at the level of service delivery has huge repercussions in all other areas of health systems. There are not isolated cases of corruption with confined consequences for health systems.

For example, key resources are squandered when there are large numbers of phantom health workers receiving their pay checks. Unless we have transparent health information systems, we will not be able to tackle this source of wastage. Look at the Dominican Republic, where the government was able to reinvest $6.2 million into the health sector thanks to a Ministry of Health payroll analysis that revealed 10,000 phantom workers.

Not fighting corruption in the health sector makes all our efforts to achieve UHC futile. With not enough resources to invest in health systems, how can we expect governments to provide quality, affordable and accessible healthcare services for all?

I am talking to you, the policymaker, the health expert, the doctor, the nurse, the patient, the parent, the student, the activist, the lobbyist, the pharmacist. I am talking to you, the person who deserves access to quality and affordable healthcare, just because it is your human right:

If we want to achieve UHC, we need to address corruption risks in the health sector.

Let’s start talking openly about this.

 

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[1] https://www.who.int/news-room/commentaries/detail/all-roads-lead-to-universal-health-coverage

[2] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3206868/#__ffn_sectitle

[3] https://onlinelibrary.wiley.com/doi/abs/10.1002/hpm.2305

[4] Their estimation found no significant association between corruption and individual diseases including human immunodeficiency virus prevalence and tuberculosis incidence.

[5] The UHC Service Coverage Index is based on tracer interventions that include reproductive, maternal, new-born and child health, infectious diseases, non-communicable diseases and service capacity and access. It is presented on a scale of 0 to 100. https://datacatalog.worldbank.org/uhc-service-coverage-index

[6] Control of Corruption captures perceptions of the extent to which public power is exercised for private gain, including both petty and grand forms of corruption, as well as “capture” of the state by elites and private interests. Estimate gives the country’s score on the aggregate indicator, in units of a standard normal distribution, i.e. ranging from approximately -2.5 to 2.5.” https://datacatalog.worldbank.org/control-corruption-estimate-0

[7] P-value: 0.000

[8] http://ti-health.org/corruption-categories/