United Nations Development Programme FIGHTING CORRUPTION IN THE HEALTH SECTOR METHODS, TOOLS AND GOOD PRACTICES

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1 Uited Natios Developmet Programme FIGHTING CORRUPTION IN THE HEALTH SECTOR METHODS, TOOLS AND GOOD PRACTICES

2 Copyright October 2011 Uited Natios Developmet Programme Bureau for Developmet Policy Oe Uited Natios Plaza New York, NY 10017, USA Website: ad Ackowledgemets This study was commissioed by UNDP ad writte by Jillia Clare Kohler, Ph.D, a associate professor at the Uiversity of Toroto s Leslie Da School of Pharmacy ad Muk School of Global Affairs i Caada. The case studies preseted i Aex 5 were writte by Alle Asiimwe with assistace from Ashaba Ahebwa ad Victor Agaba (idepedet cosultats). The views expressed i this publicatio are those of the authors ad do ot ecessarily represet those of the Uited Natios Developmet Programme (UNDP). The study received support from a Advisory Committee that provided guidace ad reviewed the drafts of the report. The Committee comprised Guitelle Baghdadi-Sabeti (WHO), Kare Hussma (Cosultat), Shatau Mukherjee (UNDP), Reata Nowak-Garmer (UNDP), ad Tary Via (Bosto Uiversity). The author is also grateful to Shajar Gleiser ad Ashley Pereira for research assistace. The study also beefited from discussio held at UNDP s Fourth Commuity of Practice meetig ad various workshops orgaized by UNDP durig the 14th Iteratioal Ati-Corruptio Coferece (November 2010, Bagkok, Thailad). Thaks are also due to Gerardo Berthi, Tuva Bugge, Fracesco Checchi, Arka El-Seblai, Samuel de Jaegere, Da Dioisie, Tsegaye Lemma, Siphosami Maluga, Job Ogoda, Christiaa Pagalos, Paavai Reddy, Charmaie Rodrigues, ad Paulie Tamesis for their helpful iputs ad suggestios that sigificatly cotributed to this project. We would also like to thak Jeff Hoover for copy-editig this report. UNDP is the UN s global developmet etwork, advocatig for chage ad coectig coutries to kowledge, experiece ad resources to help people build a better life. UNDP is o the groud i 135 developig coutries, workig with them o their ow solutios to global ad atioal developmet challeges. Editors: Phil Matsheza, Aga R Timilsia ad Aida Arutyuova Desig ad layout: First Kiss Creative

3 TABLE OF CONTENTS Foreword 3 Acroyms ad abbreviatios 5 Executive Summary 6 1. Settig the Cotext: Backgroud ad Overview Purpose of report Methodology ad structure of study Global recogitio of the impact of corruptio o huma developmet Corruptio, health ad the Milleium Developmet Goals How ad why the health sector is susceptible to corruptio Diagostic Tools Relevat for Assessig the Health Sector s Vulerability to Corruptio WHO s Good Goverace for Medicies programme World Bak Framework for Rapid Assessmet i the Pharmaceutical Sector USAID methodology to test for corruptio i the health sector Iteratioal parterships: the example of MeTA Corruptio Risks i the Health Sector ad Select Itervetios Health care providers Abseteeism Theft of drugs ad medical supplies Iformal paymets Fraud Govermet regulators i the pharmaceutical market Procuremet of pharmaceuticals ad medical supplies Distributio ad storage of drugs Health budgets Top Te Lessos from this Study 40 Refereces 42 Fightig Corruptio i the Health Sector: Methods, Tools ad Good Practices 1

4 TABLE OF CONTENTS Aex 1. Overview of key tools to idetify, track ad measure corruptio risks ad corruptio 47 Aex 2. Select results from WHO s Good Goverace for Medicies (GGM) programme 48 Aex 3. Cited parters for health ad ati-corruptio 49 Aex 4. Proposed terms of referece for coutry case studies o ati-corruptio i the health sector 50 Aex 5. Case Studies from Ugada, Malawi ad Tazaia: Mappig Good Ati-Corruptio Practices i Sub-Sahara Africa 53 2 Fightig Corruptio i the Health Sector: Methods, Tools ad Good Practices

5 FOREWORD Over the past decade, impressive progress has bee made towards meetig the global commitmets outlied i the Milleium Developmet Goals (MDGs). Legal frameworks, systems ad processes are i place, ad aggregate public spedig o social services such as educatio, health, water ad saitatio has icreased i may coutries. However, disaggregated data o MDG achievemets preset a picture of ueve progress across regios, betwee ad withi coutries. The reaso for isufficiet progress is ot just due to a failure to address etreched disparities ad iequalities or the lack of fiacial resources geerated withi ad/or flowig to developig coutries, but also from the major bottleecks such as systemic corruptio that result i diversio of valuable resources. The poor ad vulerable sectios of the society are ultimately the oes to suffer the cosequeces of corruptio. The outcome documet of the 2010 MDGs Review Summit has idetified corruptio as the major barrier for achievig the MDGs. It calls for decisive steps to be take to combat corruptio i all its maifestatios. This requires a uderstadig o how corruptio maifests itself ad where corruptio risks exist i differet sectors, i order to devise strategies to address the uderlyig goverace ad ati-corruptio bottleecks impedig MDG progress. This UNDP-sposored study presets methods, tools ad good practices to map corruptio risks, develop strategies ad sustai parterships to address challeges ad tackle corruptio i the health sector. It complemets UNDP s MDG Acceleratio Framework (MAF), which has bee edorsed by the UN Developmet Group ad eables govermets ad developmet parters, withi established atioal processes, to idetify ad systematically prioritize the bottleecks to progress toward achievig the MDGs, ad the devise ways to overcome them. The study brigs together UNDP s efforts to support coutries to develop frameworks to accelerate their efforts to meet the MDGs as well as successfully meet the commitmets of the UN Covetio agaist Corruptio. It also specifically takes forward UNDP s ageda to develop sectoral approaches to address corruptio i differet sectors. MDGs 4, 5 ad 6 set basic targets to promote complete physical, metal ad social well-beig i order to expad capabilities ad elarge the choices people have i fulfillig their lives. This report cosiders several quatitative ad qualitative studies that aalyse ad preset evidece of the egative impact of corruptio o health outcomes. This study goes oe step further, however. It ackowledges the complex ature of the sector ad the iformatio asymmetry that exists withi the system. Additioally, withi this framework, the report reviews existig literature ad discusses methods, tools ad good practices o how to address corruptio at various levels i the health sector. The study presets cocrete evidece for buildig multi-stakeholder parterships, icludig with direct beeficiaries of the public health sector, to promote accoutability ad improve service delivery. Fightig Corruptio i the Health Sector: Methods, Tools ad Good Practices 3

6 FOREWORD We sicerely hope that this study will ispire further coutry level aalysis of corruptio risks i the health sector. We also expect that the methods, approaches ad good practices preseted i this study will serve as a resource for developig coutry-level itervetios ad buildig sustaiable parterships. Sicerely, Geraldie Fraser-Moleketi Director, Democratic Goverace Group Bureau for Developmet Policy, UNDP Selim Jaha Director, Poverty Reductio Group Bureau for Developmet Policy, UNDP 4 Fightig Corruptio i the Health Sector: Methods, Tools ad Good Practices

7 ACRONYMS AND ABBREVIATIONS CSO DFID GGM IMF MDG MeTA MoH NGO UNDP USAID WHO Civil society orgaizatio UK Departmet for Iteratioal Developmet Good Goverace for Medicies programme (of WHO) Iteratioal Moetary Fud Milleium Developmet Goal Medicies Trasparecy Alliace Miistry of Health No-govermetal orgaizatio Uited Natios Developmet Programme Uited States Agecy for Iteratioal Developmet World Health Orgaizatio Fightig Corruptio i the Health Sector: Methods, Tools ad Good Practices 5

8 EXECUTIVE SUMMARY UN Photo/Eva Scheider Several quatitative ad qualitative studies highlight the fact that the burde of corruptio i the health sector impacts the poor most heavily, give their limited access to resources. Poor wome, for example, may ot get critical health care services simply because they are uable to pay iformal fees: a recet study by Amesty Iteratioal o materal health i Burkia Faso foud that oe of the primary causes of the deaths of thousads of pregat wome aually (icludig durig childbirth) is due to corruptio by health professioals. Further evidece from the Iteratioal Moetary Fud (IMF) shows that corruptio has a sigificat, egative effect o health idicators such as ifat ad child mortality, eve after adjustig for icome, female educatio, health spedig, ad level of urbaizatio. Corruptio lowers the immuizatio rate of childre ad discourages the use of public health cliics. I may coutries, its pervasiveess impedes improvemet i health outcomes ad therefore is a serious barrier to the achievemet of the Milleium Developmet Goals (MDGs). This study highlights where ad how corruptio is a threat i the health sector, ad how it ca be diagosed ad tackled. Some of the commo corrupt practices i the health sector idetified iclude abseteeism, theft of medical supplies, iformal paymets, fraud, weak regulatory procedures, opaque ad improperly desiged procuremet procedures, diversio of supplies i the distributio system for private gais ad embezzlemet of health care fuds. Each of these practices aloe represets a major challege i may developig coutries. 6 Fightig Corruptio i the Health Sector: Methods, Tools ad Good Practices

9 EXECUTIVE SUMMARY Effective itervetios addressig such vulerabilities eed to be desiged so that health goals are more likely to be achieved. This study provides examples of ati-corruptio itervetios that ca help policy makers ad practitioers to determie what may be most appropriate for their situatio. For example, the public postig of medical supply prices ca help prevet collusio; regular exteral ad iteral audits ca help esure budgets are allocated ad spet appropriately; ad citize scorecards ca help decisio makers idetify where potetial problems lie. Stad-aloe ati-corruptio itervetios caot elimiate all risks, however. Istead, what is eeded is a multiproged approach that icludes a variety of supportig itervetios maistreamed across sectors. The study cocludes with some cosideratios for UNDP staff ad others workig o health-related projects. The followig 10 key lessos are idetified ad discussed: Health policy goals should iclude ati-corruptio cosideratios. There is o oe size fits all approach to combatig corruptio i the health sector. More tha oe ati-corruptio itervetio should be employed to deal with oe risk. Prioritizatio is essetial: based o evidece, govermets ad others ivolved i health projects ad programmig should prioritize areas of the health system that are most susceptible to corruptio ad implemet appropriate itervetios. It is importat to work with other sectors. Prevetio is the best strategy: therefore, it is best ot to wait for corruptio to happe before begiig to deal with it. Numerous empirical diagostic tools should be employed. Parters with experiece i implemetig ati-corruptio strategies ad tactics should be idetified for techical support. Broad participatio i health policy ad plaig helps. Good behaviour should be rewarded, ad bad behaviour puished. Fightig Corruptio i the Health Sector: Methods, Tools ad Good Practices 7

10 EXECUTIVE SUMMARY UN Photo/Sophia Paris 1.1 Purpose of report Commissioed by the Democratic Goverace Group of the Uited Natios Developmet Programme (UNDP), this study is a review of corruptio assessmet tools ad ati-corruptio itervetios relevat for the health sector 1. Its iteded audiece is UNDP staff as well as health policy makers ad others who have a iterest i how corruptio ca have a impact o the health sector. This study aims to serve as backgroud for further work by UNDP to develop a methodology to maistream ati-corruptio iitiatives i the health sector. The amout of existig kowledge that is relevat ad related to corruptio (icludig examples from outside of the health sector) ad health systems stregtheig is extesive. This study therefore seeks to summarize critical kowledge ad provide limited examples ad refereces that illumiate some of the commo themes ad itervetios. 1 The defiitio of corruptio used i this study is the abuse of etrusted positio for private gai. 8 Fightig Corruptio i the Health Sector: Methods, Tools ad Good Practices

11 1. SETTING THE CONTEXT: BACKGROUND AND OVERVIEW 1.2 Methodology ad structure of study The study is based o a selectio of maily public policy reports ad research o health ad corruptio relevat to developig coutries. The documets were draw from a iitial body of literature icluded i the terms of referece as well as a literature search usig health ad corruptio as the search term. Commoly cited studies from this iitial pool of resources were the icluded, as well as documets suggested by members of a advisory committee. The cosultat has draw heavily o a umber of iformative studies, most of which were published i the past five years. Several otable studies are listed below. All are recommeded for those seekig further kowledge about issues related to health ad corruptio: Via, Savedoff & Mathise ; Lewis & Pettersso ; Via ; Cohe et al ; Lewis ; ad Di Tella & Savedoff (2001) 7. The study is orgaized as follows: summaries of the impact of corruptio o developmet ad how ad why the health sector is susceptible to corruptio (Sectios 1.4 through 1.5); examples of existig iteratioal health sector diagostics ad iteratioal iitiatives (Sectio 2); aalysis of specific corruptio risks i the health sector, alog with good practice examples ad tables outliig relevat ati-corruptio itervetios (Sectio 3); ad key lessos from the study that may help UNDP staff ad others egaged i health policy (Sectio 4). Limitatios There are a umber of study limitatios importat to ackowledge at the outset. First, the study is based o documets ad health policy research that are publicly available (with a few exceptios); because of resource ad time restraits, it does ot iclude richer cotextual iformatio that could 2 Via, T., Sayedoff, W. & Mathise, H. (2010) Aticorruptio i the Health Sector: Strategies for Trasparecy ad Accoutability, Kumaria Press, West Hartford, CT (USA). 3 Lewis, M. & Pettersso, G. (2009), Goverace i health care delivery: raisig performace. World Bak Policy Research Workig Paper Via, T. (2008). Review of corruptio i the health sector: theory, methods ad itervetios. Health Policy ad Plaig, 23(2), Cohe, J., Mrazek, M., & Hawkis, L. (2007). Corruptio ad pharmaceuticals: stregtheig good goverace to improve access i Campos, J. E., & Pradha, S., eds., The May Faces of Corruptio: Trackig Vulerabilities at the Sector Level. World Bak, Washigto, DC (USA). 6 Ibid. 7 Di Tella, R. & Savedoff, W., eds., (2001). Diagosis Corruptio: Fraud i Lati America s Public Hospitals. Lati America Research Network, Iter-America Developmet Bak, Washigto, DC (USA). Fightig Corruptio i the Health Sector: Methods, Tools ad Good Practices 9

12 1. SETTING THE CONTEXT: BACKGROUND AND OVERVIEW be gaied by probig key iformats. Secod, the empirical evidece to back up what itervetios work best ad why is limited. Subsequet coutry case studies by UNDP coutry ad regioal offices will help build much eeded empirical data documetig which itervetios may work most effectively for health outcomes. 1.3 Global recogitio of the impact of corruptio o huma developmet The impact of corruptio o huma developmet is a icreasigly importat focus area for the Uited Natios ad others 8. For example, the Uited Natios Covetio agaist Corruptio (UNCAC), which was adopted by the UN Geeral Assembly i October 2003 ad came ito force i 2005, raised the importace of fightig corruptio worldwide. UNDP is the lead agecy o democratic goverace i the UN system. The agecy has bee egaged i ati-corruptio work sice the early 1990s, withi its madate of fightig corruptio to improve goverace. 9 This iitiative, which is supported through UNDP s Global Thematic Programme o Ati-Corruptio for Developmet Effectiveess (PACDE), will help regioal, atioal ad local govermets implemet ati-corruptio iitiatives. Other UN agecies ad iteratioal, fiacial istitutios are also egaged i ati-corruptio work. The World Health Orgaizatio (WHO) Medicies Strategy icluded corruptio as a priority issue ad led to the lauch of its Good Goverace for Medicies (GGM) programme. The Uited Natios Childre s Fud (UNICEF) recogizes the relatioship betwee child mortality ad corruptio ad has liked its promotio of the rights of the child to good goverace. The Uited Natios Populatio Fud (UNFPA) ad UN Wome (formerly UNIFEM) are helpig to publicize the likage betwee geder ad corruptio. I the health sector, wome are more affected by corruptio give their eed for more specialized ad geerally more frequet health care services. Also, the World Bak s Public Resource ad Ecoomic Maagemet Group is the cetral clearighouse for its istitutioal ati-corruptio work. Aother core iitiative is the U4 Ati-Corruptio Resource Cetre 10, which is fuded by a umber of doors ad is a repository of iformatio o health ad corruptio for developmet specialists ad policy makers The developmet commuity is icreasigly recogisig the importace of implemetig good goverace projects to achieve health goals. Two examples are the UNDP project o Stregtheig Ethics ad Itegrity for Good Goverace i the Health Sector of Mogolia ad the Basel Istitute of Goverace research project Goverace of Health Systems, which examies goverace iputs, processes ad outcomes i Tajikista ad the Uited Republic of Tazaia. 9 Followig the UN resolutio A/RES/51/59 adopted o 28 Jauary See 11 U4 Ati-Corruptio Resource Cetre doors iclude Norad (Norway), DFID (Uited Kigdom), CIDA (Caada), GTZ (Germay), MiBuZa (the Netherlads), SIDA (Swede), BTC (Belgium) ad AusAID (Australia). 10 Fightig Corruptio i the Health Sector: Methods, Tools ad Good Practices

13 1. SETTING THE CONTEXT: BACKGROUND AND OVERVIEW 1.4 Corruptio, health ad the Milleium Developmet Goals The Milleium Developmet Goals (MDGs) 12 cosist of eight global developmet objectives that member-states have pledged to achieve by The eight goals three of which (umbers 4, 5 ad 6) are health-specific are listed below. Each goal has specific measures that idicate progress: Eradicate extreme poverty ad huger Achieve uiversal primary educatio Promote geder equality ad empower wome Reduce child mortality Improve materal health Combat HIV/AIDS, malaria ad other diseases Esure evirometal sustaiability Create a global partership for developmet Corruptio i the health sector is a reflectio of the structural challeges i the health care system as well as where it takes place withi the health care sector. The achievemet of the MDGs is cotiget o a umber of coditios icludig the presece of good goverace, which util recetly was little discussed i relatio to them 13. I 2009, however, UN Secretary-Geeral Ba Ki-moo highlighted the impact of corruptio o the MDGs. He emphasized that corruptio ca kill developmet ad may very well impede efforts to achieve the MDGs 14. Thus, desigig MDG actio plas that effectively itegrate goverace ad ati-corruptio itervetios is critical for achievig desired goals. This is supported by evidece. A aalysis by Trasparecy Iteratioal i 2010 showed that icreasig trasparecy, accoutability ad itegrity i 48 coutries has a robust correlatio to better outcomes i health, educatio ad water. 15 This fidig holds true irrespective of a coutry s wealth or how much it speds i a specific sector. 1.5 How ad why the health sector is susceptible to corruptio Corruptio i the health sector is a reflectio of the structural challeges i the health care system as well as where it takes place withi the health care sector. Amog the key reasos for corruptio i the health sector are weak or o-existet rules ad regulatios, over-regulatio, lack of accoutability, low salaries ad limited offer of services (i.e., more demad tha supply). The scale of corruptio also varies: it may be petty (as with bureaucratic or admiistrative corruptio that takes place at 12 The MDGs directly related to health are umbers 4, 5 ad 6. Other MDGs also are idirectly related to health yet are oetheless importat for the sector. For example, oe target uder MDG 8 specifies that i cooperatio with pharmaceutical compaies, provide access to affordable essetial drugs i developig coutries. 13 For a comprehesive overview, see Wagstaff, A., & Claeso, M. (2004). The Milleium Developmet Goals for health: risig to the challeges. World Bak, Washigto, DC (USA). 14 UN Secretary-Geeral s speech o the Iteratioal Ati-Corruptio Day, 9 December Olie: docs/2009/sgsm12660.doc.htm. 15 See Trasparecy Iteratioal (2010). The ati-corruptio catalyst: realisig the MDGs by 2015, Berli, Germay, p. 1. Fightig Corruptio i the Health Sector: Methods, Tools ad Good Practices 11

14 1. SETTING THE CONTEXT: BACKGROUND AND OVERVIEW the implemetatio level where the people (recipiets of services) iteract with public officials) or grad (corruptio at a higher level, otably at the policy level). Whatever the reaso or type, there is little doubt that corruptio hurts health. Several quatitative ad qualitative studies illustrate how the burde of corruptio impacts the poor most heavily give their limited ability to meet demads imposed by corruptio. For example, poor ad margialized idividuals ca be deied access to ecessary care if paymets are required for health care services 16. I Bulgaria, high-icome urbaized patiets were more likely to make iformal paymets ad thus receive care they eeded i cotrast to low-icome patiets 17. A recet study by Amesty Iteratioal o materal health i Burkia Faso foud that oe of the primary cause of the deaths of thousads of pregat wome aually (icludig durig childbirth) is due to corruptio by health professioals. Poor wome may ot get critical health care services simply because they are uable to pay iformal fees 18. Further evidece comes from a Iteratioal Moetary Fud (IMF) report showig that corruptio has a sigificat, egative effect o health idicators such as ifat ad child mortality, eve after adjustig for icome, female educatio, health spedig, ad level of urbaizatio 19. Corruptio lowers the immuizatio rate of childre; ca prevet the provisio of ecessary treatmet, particularly for the poor; ad discourages the use of public health cliics 20. The two clear ad related coclusios are that corruptio hurts health outcomes ad it is the poor who are affected the most. As oted i Diagram 1 below, the health sector is susceptible to corruptio for a umber of reasos related to its orgaizatio. First, it is a complex sector, eve more so tha may others. Ucertaity prevails withi the sector: it is ot possible to kow who will get sick or whe, ad therefore it is ofte challegig to predict what supplies ad services are eeded, whe they are eeded, ad i what quatities. It is also a sector that has asymmetric iformatio, with sigificat iformatio imbalaces betwee providers ad patiets ad suppliers ad providers. For example, physicias prescribe medicies to patiets ad patiets assume that they are beig prescribed the right drug for their coditios. However, physicias may prescribe a particular product because a pharmaceutical compay is offerig him or her a icetive to do so or that particular product may be recommeded by developers of atioal health guidelies for the same reaso, which has othig to do with its effectiveess or safety. I additio, a large umber of stakeholders with limited ad/or idirect accoutability exist throughout the sector ad they iteract i complex ways 21. Health professioals should be accoutable to regulatory bodies, but the eforcemet of stadards ad sactios for deviatios 16 Lewis, M. (2000). Who is payig for health care i Easter Europe ad Cetral Asia? Iteratioal Bak for Recostructio/World Bak Publicatios, Washigto, DC (USA). 17 Ibid., quoted from Balabaova, D. (1999). Iformal paymets for health care i Bulgaria, observatory case study. Lodo School of Ecoomics, Lodo, UK. 18 See 19 Gupta, S., Davoodi, H. & Tiogro, E. (2000). Corruptio ad the provisio of health care ad educatio services, IMF Workig Paper 00/116, Appedix Table 9, p Azfar, O. & Tugrul, G. (2005). Does corruptio affect health ad educatio outcomes i the Philippies?. Available at Social Sciece Research Network: 21 Savedoff, W. & Hussma, K. (2006). Why are health systems proe to corruptio?. Global Corruptio Report, Trasparecy Iteratioal. 12 Fightig Corruptio i the Health Sector: Methods, Tools ad Good Practices

15 1. SETTING THE CONTEXT: BACKGROUND AND OVERVIEW from stadards are sometimes limited or o-existet due to limited fiacial ad huma resources. Furthermore, regulatory agecies are ot always impartial ad ca be iappropriately iflueced by those they are charged with regulatig. Fially, i the health sector the distictio betwee corruptio ad iefficiecy is ofte difficult to discer due to poor maagemet/ admiistratio 22. Aother challege is that although the issue of accoutability is a relatively ew area of equiry i the health sector, desired health gais whether liked to the MDGs or ot may be hidered or obstructed completely uless efforts are made to improve accoutability ad trasparecy ad uderstad how to prevet corruptio withi the health system,. Diagram 1 below provides a framework for the aalysis of risks ad actors that ca help aticorruptio actors uderstad the mai issues ad desig the right respose strategies. Diagram 1. Core areas of health sector ad corruptio risks Source: Hussma, K., How-to-ote: Addressig corruptio i the health sector. A DFID Practice Paper, November Olie: 22 Lewis, M. (2006). Goverace ad corruptio i public health care systems. Workig Paper 78, Ceter for Global Developmet, Washigto, DC (USA) Fightig Corruptio i the Health Sector: Methods, Tools ad Good Practices 13

16 2. DIAGNOSTIC TOOLS RELEVANT FOR ASSESSING THE HEALTH SECTOR S VULNERABILITY TO CORRUPTION 23 UN Photo/G Pirozzi This sectio discusses some key diagostic/assessmet methodologies that doors, govermets ad o-govermetal orgaizatios (NGOs) ca use to assess the health sector s vulerability to corruptio. Ideally diagostics ca help practitioers ad policy makers desig appropriate aticorruptio strategies. The tools idetified as relevat for corruptio ad the health sector fall ito two categories. Those such as the WHO ad World Bak risk assessmet tools described i detail i Sectios 2.1 ad 2.2 are desiged to idetify ay weak poits i a give health sector (ad i the cases below focus specifically o the pharmaceutical sector). Other tools, such as Trasparecy Iteratioal s Corruptio Perceptios Idex ad household surveys, are desiged more specifically to measure the level of corruptio i a coutry at the atioal, regioal or local levels. However, because the latter tools rely o perceptios they should be used i combiatio with other tools to esure their validity. Both types of methodologies have their stregths i terms of helpig to uderstad how corruptio affects the health sector ad where ati-corruptio itervetios might be eeded. All of the tools are importat as they provide bechmark stadards agaist which itervetios ca be measured i 23 I additio to iitiatives ad programmes metioed i this sectio, it is worthwhile to also refer to accoutability assessmets developed by UNDP for Mogolia, the Basel Istitute o Goverace, the World Bak, etc. 14 Fightig Corruptio i the Health Sector: Methods, Tools ad Good Practices

17 2. DIAGNOSTIC TOOLS RELEVANT FOR ASSESSING THE HEALTH SECTOR S VULNERABILITY TO CORRUPTION time, however imperfectly. (Aex 1 of this report icludes a overview of key tools to idetify, track ad measure corruptio risks ad corruptio, icludig the tools discussed i greater detail below.) 2.1 WHO s Good Goverace for Medicies programme As a core part of its Good Goverace for Medicies (GGM) programme lauched i 2004, WHO has developed a assessmet tool to idetify areas i the pharmaceutical sector that are vulerable to corruptio 24. The GGM programme relies o two core strategies. The first is a top-dow discipliebased strategy that seeks to help govermets establish ati-corruptio laws ad improve legislatio ad regulatio goverig the pharmaceutical sector. The secod is a bottom-up valuesbased strategy that aims to help govermets build istitutioal itegrity through the promotio of ethical practices. Implemetatio occurs i three phases: Phase I: atioal assessmet of the level of trasparecy ad potetial vulerability to corruptio of the atioal pharmaceutical system through the implemetatio of a assessmet istrumet (described below ad the focus of this review). Phase II: developmet of a atioal GGM framework through a cosultatio process ivolvig key stakeholders. Oce officially adopted, the GGM framework documet usually icludes a ethical framework ad code of coduct, regulatios ad admiistrative procedures, collaboratio mechaisms with other good goverace ad aticorruptio iitiatives, whistleblowig mechaisms, ad sactios for corrupt acts. Phase III: implemetatio of the atioal GGM programme. This icludes the traiig of govermet officials ad health professioals, as well as commuicatios ad advocacy campaigs. The GGM assessmet istrumet was based o a earlier diagostic developed i 2002 for the World Bak s work i the Costa Rica health sector25. The World Bak methodology has also bee applied i Macedoia ad served as the basis for a Uited States Agecy for Iteratioal Developmet (USAID) study of Bulgaria s health system i The atioal assessmet udertake through Phase I of the GGM ca potetially examie up to eight core fuctios: medicies registratio, licesig ad ispectio of pharmaceutical establishmets, promotio, cliical trials, selectio, procuremet, ad distributio. The ed result is a baselie to moitor the coutry s progress over time i terms of goverace i the pharmaceutical sector (e.g., level of accoutability, trasparecy i the various processes i the pharmaceutical sector). Baselie data is a commo goal of may of the diagostics that seek to uderstad potetial weakess to corruptio or level of corruptio i the health sector. 24 WHO Assessmet Istrumet WHO/EMP/MAR/2009.4, Measurig trasparecy i the public trasparecy sector. Olie: www. who.it/medicies/areas/policy/goodgoverace/assessmetistrumetmeastraspeng.pdf. 25 Cohe, J., Cercoe, J., & Macaya, R. (2002). Improvig trasparecy i pharmaceutical systems: stregtheig critical decisio poits agaist corruptio: a case study of Costa Rica. Huma Developmet Network, Lati America ad Caribbea Regio, World Bak, Washigto, DC (USA). Fightig Corruptio i the Health Sector: Methods, Tools ad Good Practices 15

18 2. DIAGNOSTIC TOOLS RELEVANT FOR ASSESSING THE HEALTH SECTOR S VULNERABILITY TO CORRUPTION A miimum of two atioal assessors are resposible for the assessmet. They should be from credible orgaizatios, be idepedet of the Miistry of Health (MoH) ad the private sector, ad have good kowledge of the coutry s pharmaceutical sector. For this process to work effectively, govermet support is vital. Iformatio foud o govermet public websites ad other relevat sources are used to check the availability ad dissemiatio of guidelies ad procedures. The documet aalysis is backed up by iterviews with key iformats. At least 10 key iformats are iterviewed for each core fuctio of the pharmaceutical sector or util saturatio is reached. The iformats represet the various stakeholders: the govermet, public hospitals, private sector (pharmacies, compaies, wholesalers ad maufacturers), professioal associatios, civil society, ad o-govermetal ad iteratioal orgaizatios. This helps to esure differet perspectives are represeted ad a comprehesive overview of the sector is prepared. Biary yes/o ad ope-eded questios are used. I some cases, the key iformats may be asked to justify some of their aswers with evidece. Oce all the iformatio is compiled, aswers are scored ad coverted to a simple 1 to 10 scale represetig the vulerability of the decisio poit to corruptio from miimum to maximum potetial. The atioal assessors aalyse the results ad prepare a report that icludes recommedatios based o the fidigs that are preseted to govermet officials ad validated i atioal ad regioal workshops by key stakeholders. The value of a atioal assessmet is based o ad reflects the system s actual structure, particularly the mechaisms to prevet uethical practices ad the admiistrative procedures to measure trasparecy ad accoutability. It also provides a opportuity to examie how differet stakeholders uderstad ad make use of existig procedures ad mechaisms i the pharmaceutical sector. The atioal assessmet also idicates flaws with existig policies ad procedures. The dowside of this assessmet istrumet is that it is time-cosumig to implemet ad there is a risk of acquirig iformatio that is flawed give that some key iformats may feel threateed by the questios ad aswer them accordig to what they perceive is the right aswer rather tha the true aswer. The GGM framework is the defied through atiowide cosultatio with key stakeholders. This process icludes developig ethical frameworks ad codes of coduct, regulatios ad admiistratio procedures, collaboratio mechaisms with other good goverace ad aticorruptio iitiatives, whistleblowig mechaisms, ad sactios for breaches. Lastly, the applicatio of ew admiistrative procedures for icreased trasparecy ad accoutability ad leadership i this area are developed. The assessmet istrumet has bee applied i over 26 coutries to date ad some of the reports are publicly available o the GGM website 26. It is a good startig poit for a more comprehesive ivestigatio of the pharmaceutical sector s vulerability to corruptio. However, the tool is limited isofar as the key iformats may be reluctat to reveal the real level of corruptio. The tool also demads sufficiet kowledge of the local pharmaceutical ad health sector ad requires govermet buy-i to esure access to public officials. 26 See (accessed 24 August 2010). 16 Fightig Corruptio i the Health Sector: Methods, Tools ad Good Practices

19 2. DIAGNOSTIC TOOLS RELEVANT FOR ASSESSING THE HEALTH SECTOR S VULNERABILITY TO CORRUPTION Based o atioal assessmets udertake to date, drug promotio is ofte idetified as the fuctio most vulerable to corruptio, while distributio is ofte the strogest or most trasparet of all fuctios studied 27. The studies geerally illumiate that there is a uiform lack of access to public iformatio about the pharmaceutical sector (e.g., regardig regulatios, legislatio ad writte procedures). Also, i may coutries there is either a lack of coflict of iterest policies or poor implemetatio of them, as well as a lack of selectio criteria for decisio makers (such as persos ivolved i the drug selectio process) i the pharmaceutical sector. The limited access stems from the fact that such iformatio did ot exist i some cases, while i others it was ot made available to the public 28. Sice its iceptio, the GGM programme has had a positive impact o pharmaceutical systems i may of the 26 coutries where it has bee implemeted. Natioal drug procuremet practices have improved, pharmaceutical legislatio ad regulatios have bee revised to esure better goverace i the sector ad to stregthe pharmaceutical systems, ad more trasparet procedures for pharmaceutical licesig ad registratio procedures are i place ad publicly available o Miistry MoH websites. Aex 2 cotais specific coutry examples of outcomes from the GGM programme from coutries i either Phase II or Phase III World Bak Framework for Rapid Assessmet i the Pharmaceutical Sector The World Bak Framework for Rapid Assessmet i the Pharmaceutical Sector is a diagostic tool that aims to help policy makers ad developmet specialists orgaize iformatio about the pharmaceutical sector 30. The dowside of this tool is that it demads assimilatio of a lot of varied iformatio pertaiig to the pharmaceutical sector ad is thus rather time-cosumig to implemet eve if the perso usig the tool has sigificat experiece i the pharmaceutical sector of the coutry uder study. The advatage of this tool is that it helps to orgaize iformatio which ca serve as a bechmark exercise agaist which itervetios i the pharmaceutical sector ca be measured. The assessmet tool ca be used as a stad-aloe mechaism or as part of a overall aalysis of coutry health systems. The mai areas covered are the followig: the pharmaceutical market, drug policy ad regulatio, public ad private drug expediture, drug pricig, purchasig, procuremet, reimbursemet, service delivery ad logistics, idustry ad trade, ad the ratioal use of drugs. A World Bak Workig Paper publicatio details how this assessmet tool has bee applied i a variety of differet coutries ad related outcomes 31. Geeral fidigs from the assessmets iclude the domiat role of the private sector i the provisio of pharmaceuticals, ieffective drug regulatio ad a lack of cosumer power. 27 It should oted, however, that the assessmet istrumet does ot cover the etire distributio chai. Thus the impact of this positive fidig regardig distributio is somewhat limited. 28 Kohler, J. & Bagdadhi-Sabetti, G. (forthcomig). Good goverace for pharmaceuticals i WHO World Medicie Situatio. 29 The results i the aex are from WHO GGM programme, A iovative approach to prevet corruptio i the pharmaceutical sector, backgroud paper for World Health Report 2010 (i preparatio). 30 See Diack, et al, Assessmet of goverace ad corruptio i the pharmaceutical sector: lessos leared from low- ad middleicome coutries, HNP discussio paper. World Bak Huma Developmet Network, Washigto, DC (USA). 31 Ibid. Fightig Corruptio i the Health Sector: Methods, Tools ad Good Practices 17

20 2. DIAGNOSTIC TOOLS RELEVANT FOR ASSESSING THE HEALTH SECTOR S VULNERABILITY TO CORRUPTION 2.3 USAID methodology to test for corruptio i the health sector A good example of USAID s work i this area is based o a study of corruptio i the Bulgaria health system completed i The project used a framework of trasparecy, accoutability, prevetio, eforcemet ad educatio (TAPEE) as istitutioal requiremets of itegrity to examie key areas i the coutry s health care system. I particular, the project examied drug selectio i the public health system ad hospital drug procuremet. Its methodology focused o processes ad was qualitative (focus groups ad key iformat iterviews) ad quatitative (a survey of hospitals across the coutry). Over 30 semi-structured iterviews with key iformats were held with represetatives from the govermet ad the private sector. The quatitative part of the project was the survey of the drug purchasig practices of 148 hospitals. Data were based o suppliers reports regardig corruptio, doctors ad urses reports regardig corruptio, audit reports, ad procuremet prices. USAID also has produced a ati-corruptio assessmet hadbook that icludes a diagostic for the health sector 33. It provides some key questios for provisios of services by frot-lie health workers; health care fraud; procuremet ad maagemet of equipmet of supplies; regulatio of quality i products, services, facilities ad professioals; educatio of health professioals; ad hirig ad promotio. The health sector diagostic ca be used with others (such as oe focusig UN Photo/Olivier Chassot 32 Iris Ceter for USAID (2005). Goverace i Bulgaria s pharmaceutical sector: a sythesis of research fidigs. Iris Ceter, Baltimore, MD (USA). 33 USAID (2009), Ati-corruptio assessmet hadbook. 18 Fightig Corruptio i the Health Sector: Methods, Tools ad Good Practices

21 2. DIAGNOSTIC TOOLS RELEVANT FOR ASSESSING THE HEALTH SECTOR S VULNERABILITY TO CORRUPTION o procuremet) provided i the hadbook. It aims to help the user ask the right questios whe coductig a assessmet i a coutry. The diagostic is limited because it does ot allow for a comprehesive examiatio of the risks 34. However, it ca be used as a guide for key iformat questios ad as a startig poit for further data collectio. 2.4 Iteratioal parterships: the example of MeTA The Medicies Trasparecy Alliace (MeTA) is a multi-stakeholder alliace led by the UK Departmet for Iteratioal Developmet (DFID) ad with the participatio of the World Bak ad WHO. It examies issues related to drug prices, quality, availability, promotio, trasparecy ad accoutability, ad multi-stakeholder relatioships. MeTA aims primarily to improve access to ad affordability of medicies, ad the alliace operates uder the assumptio that lack of access to essetial medicies is a result of weak goverace ad a lack of trasparecy i the selectio, regulatio, procuremet, distributio ad promotio of medicies. MeTA uses a large arseal of diagostic tools to gather iformatio. Such tools may iclude a pharmaceutical sector sca; review of data availability about price, registratio ad policies o promotio; ad a stakeholder mappig. It also uses the WHO/HAI pricig methodology, which measures medicie price, availability, affordability ad compoet costs 35. Priority iformatio sought icludes the quality ad registratio status of medicies, availability of medicies; price of medicies; ad policies, practices ad data o the promotio of medicies. Also ivestigated is the specific policy cotext as well as how supply chai operatios work, affordability of medicies, access ad their ratioal use. MeTA is curretly operatig i seve coutries globally: Ghaa, Jorda, Kyrgyzsta, Peru, the Philippies, Ugada ad Zambia 36. All seve MeTA pilot coutries have set up multi-stakeholder groups kow as coucils that have agreed o work plas that iclude proposals to geerate ad disclose iformatio relatig to price, quality, availability ad promotio of medicies. Coutries set their ow priorities i each area ad they focus o iformatio relatig to the prices i the chai. However, there is growig recogitio of the eed to go beyod pricig issues. MeTA itervetios have to date resulted i i) icreased participatio i policy dialogue (Philippies); ii) the detectio of sub-stadard drugs (Ghaa, Kyrgyzsta); iii) improvemets i the drug selectio process (Jorda); ad iv) pricig ad other trasparecy measures (Peru, Ugada, Zambia). This sectio focuses o core areas of the health sector that are at particular risk for corruptio: providers (Sectio 3.1), govermet regulators i the pharmaceutical market (Sectio 3.2), procuremet of pharmaceuticals ad medical supplies (Sectio 3.3), distributio ad storage of drugs (Sectio 3.4), ad payers (Sectio 3.5). Each core area icludes a problem aalysis, evidece of the risk, ad example(s) of good practice. Possible itervetios for each area are icluded i tables at the ed of this documet. 34 See 35 World Health Orgaizatio ad Health Actio Iteratioal (2008). Measurig Medicie Prices, Availability, Affordability ad Price Compoets (2d ed.). Geeva, Switzerlad. 36 See Ollier, E. (2010). Evaluatio of the medicies trasparecy alliace: phase ad Medicies Trasparecy Alliace (2010). Affectig chage: the MeTA aual review Fightig Corruptio i the Health Sector: Methods, Tools ad Good Practices 19

22 3. CORRUPTION RISKS IN THE HEALTH SECTOR AND SELECT INTERVENTIONS UN Photo/Stato Witer 3.1 Health care providers This sub-sectio examies corruptio amog health care providers such as physicias, urses ad pharmacists. Petty corruptio associated with health providers icludes abseteeism (ot showig up for work yet claimig a salary), theft (of medical supplies or pharmaceuticals), ad demad for iformal paymets for services that are supposed to be free. Petty corruptio of this sort has a direct impact o the poor by deyig them access to services ad thereby jeopardizig their health Abseteeism Problem aalysis ad evidece As i other public sectors such as educatio, abseteeism i the health sector is a commo occurrece i developig coutries. I Argetia it was foud to be the most commo form of 20 Fightig Corruptio i the Health Sector: Methods, Tools ad Good Practices

23 3. CORRUPTION RISKS IN THE HEALTH SECTOR AND SELECT INTERVENTIONS corruptio amog doctors ad urses i public hospitals 37. A survey i Costa Rica foud that more tha two-thirds of doctors ad urses idicated high levels of abseteeism i their hospital 38. Extesive abseteeism ca result i lower volume of health care, poor quality of care, ad icreased costs to the health system 39. Yet abseteeism may ot always be perceived as corruptio. Studies have poited out that it ca be uderstood as a meas of survival or a copig mechaism associated with low salaries ad the eed for more tha oe source of employmet for livelihood. A UNDP study o Mogolia oted that most respodets perceived the primary cause of corruptio i the health sector was ideed due the low wage of doctors ad health workers 40. But eve though salary icreases were later implemeted, they were isufficiet measures agaist corruptio i the log term. This suggests multiple factors are at play which ca create opportuities for corruptio ad that it caot be attributed to oe variable 41. Petty corruptio has a direct impact o the poor by deyig them access However, low salary levels do ot sufficietly explai why corruptio may happe at the level of service provider. The reasos for abseteeism are more their health. complex: they may iclude a lack of motivatio, poor quality of health worker educatio, lack of qualificatios or uderstadig of oe s ow role/ resposibilities as a health worker, parallel accoutability structures, ad a lack of merit-based hirig practices. to services ad thereby jeopardizig Good practice examples A study of health workers i four Peruvia hospitals foud that physicias with permaet cotracts ad good job security were more likely to be abset tha physicias uder temporary cotracts. This suggests that accoutability (from employer to employee) may be oe way to help reduce abseteeism ad improve performace. 37 Schargrodsky, E., Mera, J., & Weischelbaum, F. (2001). Trasparecy ad accoutability i Argetia s hospitals i Di Tella, R. & Savedoff, W., eds., (2001). Diagosis Corruptio: Fraud i Lati America s Public Hospitals. Lati America Research Network, Iter- America Developmet Bak, Washigto, DC (USA). 38 Savedoff W. (2007). Trasparecy ad corruptio i the health sector: a coceptual framework ad ideas for actio i Lati America ad the Caribbea. Iter-America Developmet Bak, Health Techical Note. 39 Lewis & Petterso De Jaegere, S. & Filey, S. (2009). Mappig accoutability i the health sector ad developig a sectoral assessmet framework, UNDP missio report. 41 Nordberg, C., & Via, T. (2008). Corruptio i the health sector. U4 Brief 10, Chr. Michelse Istitute, Berge, Norway. Fightig Corruptio i the Health Sector: Methods, Tools ad Good Practices 21

24 3. CORRUPTION RISKS IN THE HEALTH SECTOR AND SELECT INTERVENTIONS Theft of drugs ad medical supplies Problem aalysis ad evidece Theft of drugs ad medical supplies by health care professioals is commo globally. I Veezuela, approximately two-thirds of hospital persoel surveyed were aware of theft of medical supplies ad medicatios. Similarly, i Costa Rica, 71 percet of doctors ad 83 percet of urses reported that equipmet or materials had bee stole i their hospital 42. Oe study i Ugada foud that the resale of drugs represeted the greatest sigle source of icome for health care persoel 43. Theft has bee foud to icrease whe the potetial beefit from theft is high, whe the probability of detectio is low, ad whe the expected pealty is mior 44. Good practice example The ivolvemet of citizes as watchdogs of the public good ca detect corruptio i provider services. For example, i Bolivia, local health directorates (which icluded local govermet officials ad citize represetatives) were set up to oversee most health facilities 45. Citize scrutiy of health care services ad provisios ca act as a deterret to corrupt actios Iformal paymets Problem aalysis ad evidece Why people ask for iformal paymets ad why people are willig to pay for them are importat questios to cosider. It is well kow that iformal paymets for medical services are more commo i low-icome coutries tha high-icome coutries, which suggests barriers to services for patiets with limited resources 46. A study of iformal paymets i the Uited Republic of Tazaia foud that patiets commoly make iformal paymets for better health care services (i other words, patiets do ot always perceive them as bribes). Health workers i Tazaia took advatage of the populatio s willigess to pay for services by deliberately creatig shortages i order to gai 42 Di Tella, R. & Savedoff, W. (2001). Shiig light i dark corers i Di Tella, R. & Savedoff, W., eds., (2001). Diagosis Corruptio: Fraud i Lati America s Public Hospitals. Lati America Research Network, Iter-America Developmet Bak, Washigto, DC (USA). 43 Ferriho, P. & Va Lerberghe, W. (2002). Maagig health professioals i the cotext of limited resources: a fie lie betwee corruptio ad the eed for moolightig. World Bak Publicatios, Washigto, DC (USA). 44 Jaé, M., & Paravisii, D. (2001). Wages, capture, ad pealties i Veezuela s public hospitals i Di Tella, R. & Savedoff, W., eds., (2001). Diagosis Corruptio: Fraud i Lati America s Public Hospitals. Lati America Research Network, Iter-America Developmet Bak, Washigto, DC (USA). 45 Lewis, M., & Pettersso, G. (2009). Goverace i health care delivery: raisig performace. World Bak Policy Research Workig Paper Nordberg, C., & Via, T. (2008). Corruptio i the health sector. U4 Brief 10, Chr. Michelse Istitute, Berge, Norway. 22 Fightig Corruptio i the Health Sector: Methods, Tools ad Good Practices

25 3. CORRUPTION RISKS IN THE HEALTH SECTOR AND SELECT INTERVENTIONS surplus paymets from patiets 47. I a study o public hospitals i Lati America, most fees paid for public health services were foud to be for illegal charges 48. Whether iformal paymets are viewed as a accepted part of health care services or as a form of corruptio, the impositio of a tax o public health care services that should be free of charge has a egative impact o health care provisio. 49 The ed result is that poor people will be deied access to health services. Good practice examples I Hugary, the itroductio of a official co-paymet was iteded to decrease iformal paymets, but it was ot sufficiet o its ow to chage the behaviour of patiets payig iformally 50. Official co-paymets could be complemeted by aother itervetio such as performace-based fiacig (PBF) to help create icetives for better behaviour. PBF is most likely to work well whe there is strog political ad maagemet support, flexibilities to make chages whe eeded to maximize efficiecies, ad strog health iformatio ad reportig system 51. Performace-based fiacig has recetly bee implemeted i Rwada, amog other places 52. As part of a UNDP project i Mogolia, hospitals have begu awardig performace bouses to promote better service delivery ad ethical behaviour Mæstad, O., & Mwisogo, A. (2007). Iformal pay ad the quality of health care: lessos from Tazaia. U4 Brief 9, Chr. Michelse Istitute, Berge, Norway. 48 Di Tella, R. & Savedoff, W. (2001). Shiig light i dark corers i Di Tella, R. & Savedoff, W., eds., (2001). Diagosis Corruptio: Fraud i Lati America s Public Hospitals. Lati America Research Network, Iter-America Developmet Bak, Washigto, DC (USA). 49 Rose, R. (2006). Corruptio is bad for your health: fidigs from Cetral ad Easter Europe, i Global Corruptio Aual Report: Corruptio ad Health. Trasparecy Iteratioal, Berli, Germay. 50 Baji, P., Pavolova, M., Gulasci, L. & Groot, W. (2010). Short-term effects of the itroductio of official patiet fees o iformal paymets: the case of Hugary. Presetatio, ECHE 2010, Helsiki, Filad 51 For more o outcomes of PBF, see Eldridge, C. & Palmer, N. (2009), Performace-based fiacig: some reflectios o the discourse, evidece ad uaswered questios, Health Policy ad Plaig 24: See USAID (2008). Corruptio assessmet of Rwada health sector. 53 Lkhagvasure, N. (2009). Itegrity i the health sector: Mogolia project assessmet. UNDP, New York, NY (USA). Fightig Corruptio i the Health Sector: Methods, Tools ad Good Practices 23

26 3. CORRUPTION RISKS IN THE HEALTH SECTOR AND SELECT INTERVENTIONS Box 1. Ati-Corruptio Participatory Moitorig (ACPM) i Armeia The implemetatio of the Ati-Corruptio Participatory Moitorig (ACPM) project i Armeia aimed to assess the impact of ati-corruptio iitiatives ad measures i the health care sector through commuity moitorig. The effort cosisted of a three-tiered moitorig system that tracked ad evaluated systemic issues, corruptio risks ad maifestatios of corruptio through four itertwied ad complemetary aspects: quality of access to services, fiaces ad shadow moetary circulatios, rights ad legality, ad admiistratio ad fuctios. While commuity moitorig priciples are well kow, the project first eeded to develop specific tools to esure quality cotrol, such as guidelies o resposibilities of a commuity group s members, orms of ethics, ad groud rules ad istrumets for coductig observatios, expert iterviews, focus groups ad i-depth iterviews. Commuity groups egaged to carry out the moitorig were thus equipped with the ecessary tools ad kowledge to udertake the effort, eve if some of them had o previous relevat experiece. The moitorig was carried out from April to October 2007 i Yereva, the capital, ad 10 other tows ad cities i differet regios of the coutry. A total of 22 outpatiet cliics ad hospitals were reviewed. The project outputs described the baselie situatio i the health care sector, i particular corruptio risks ad maifestatios i various aspects ad levels of health care system, accordig to fuctioal categories (huma resources, drugs, medical techologies ad fiacial issues). O this basis, recommedatios for systemic chages were developed ad commuicated to the resposible State authorities ad the Prime Miister s Office. I the ed, the majority of the project recommedatios were accepted ad icluded i the ew atioal ati-corruptio strategy. Source: the%20ati-corruptio%20participatory%20moitorig%20coducted%20i%20the%20health%20 ad%20educatio%20sectors%20by%20civil%20society%20ati-corruptio%20groups%5b1%5d.pdf Fraud Problem aalysis ad evidece A average of 5.59 percet of aual global health spedig is lost to fraud, which is a itetioal deceptio that ca lead to a uwarrated beefit to the perso perpetuatig the fraud 54. Based o WHO estimates that global health care expediture is about US$4.7 trillio, this traslates ito about US$260 billio lost globally to fraud ad error. 54 Europea Healthcare Fraud ad Corruptio Network (2009). The fiacial costs of health care fraud 24 Fightig Corruptio i the Health Sector: Methods, Tools ad Good Practices

27 3. CORRUPTION RISKS IN THE HEALTH SECTOR AND SELECT INTERVENTIONS Fraud i the health care system icludes the pocketig of user fees by a service provider or the overchargig of a health isurace agecy by a physicia. I a hospital, it could ivolve the diversio of patiet fees or collusio betwee a hospital admiistrator ad a purchasig aget. For istace, i Liberia the coutry s Geeral Auditig Commissio foud that accoutig irregularities by staff i the Miistry of Health ad Social Welfare accouted for as much as US$4 millio i uaccouted fuds 55. Good practice examples Istitutioal checks ad balaces such as the divisio of fuctios betwee cashiers ad accoutats ca help cotrol agaist fraud. The compariso of actual ad expected reveue ad regular iteral ad exteral audits are recommeded measures to prevet fraud. The Iter-America Developmet Bak (IDB) coducted a exteral audit of public hospitals i Bogota, Colombia. This exteral review provided Bogota s Secretariat of Health with evidece that fraud was takig place, ad i respose measures were take to reduce theft ad improper billig i hospitals 56. This example shows how trasparecy ad auditig tools are effective measures to fight fraud. UN Photo/Eva Scheider 55 See 56 Savedoff W. (2007). Trasparecy ad corruptio i the health sector: a coceptual framework ad ideas for actio i Lati America ad the Caribbea. Iter-America Developmet Bak, Health Techical Note, p. 11. Fightig Corruptio i the Health Sector: Methods, Tools ad Good Practices 25

28 3. CORRUPTION RISKS IN THE HEALTH SECTOR AND SELECT INTERVENTIONS Table 1. Select itervetios to improve provider performace 57 Itervetio Type Commet Performace-based fiacig Maagerial Fiacial rewards have helped to esure better performace. Domai of atioal or regioal govermet depedig o health system structure. Wage icreases Maagerial Works oly if other measures are applied alog with it such as tough sactios for breaches of professioal coduct ad match market rates. Domai of local or atioal govermet depedig o health system structure. Legislatio that makes maagers legally resposible for actios of subordiates Prosecutig or establishig admiistrative sactios for idividual breaches Itroducig or improvig iteral cotrol mechaisms Itroducig ad eforcig a code of coduct for public officials ad professioals that specifies expectatios ad also requires public officials to disclose their assets 3 Coduct exteral reviews icludig uaouced visits to health facilities ad evaluatio of services by cliets ad beeficiaries Maagerial Accoutability/ oversight Accoutability/ oversight Maagerial ad trasparecy Accoutability/ oversight May help deter corruptio by esurig that moitorig of practices is more effectively eforced. Domai of atioal govermet. Helps to set a example but also demads a well-fuctioig judiciary system 1. This eeds to be iitiated at the facility level but supported by the atioal govermet. This ca help miimize theft of medical supplies i hospitals ad public health cliics, icludig oversight from maagemet 2. Needs to be doe at the facility level. Requires oversight ad support from maagemet systems Domai of atioal, regioal or local govermet. 57 Referereces i this table: 1. Nordberg, C., & Via, T. (2008). Corruptio i the health sector. U4 Brief 10, Chr. Michelse Istitute, Berge, Norway, p Ibid. p Ibid. 26 Fightig Corruptio i the Health Sector: Methods, Tools ad Good Practices

29 3. CORRUPTION RISKS IN THE HEALTH SECTOR AND SELECT INTERVENTIONS Itervetio Type Commet Set up a secure ati-corruptio hotlie for citizes ad professioals Moitor job performace ad esure performace expectatios; stadardize job descriptios; ad implemet ad eforce trasparet rules, behaviour stadards, ad merit-based promotio policies 4 Formalize user fees with exemptio schemes for the poor Accoutability/ oversight Maagerial Trasparecy Needs to be liked to adequate follow up, feedback ad whistle-blower protectio. Domai of atioal, regioal or local govermet. Facility level resposibility Demostrated as effective i Albaia, Cambodia ad Kyrgyzsta. Icreased paymets for facility, supplemeted staff salaries, helped i purchase of supplies ad to phase out door support. Also eeds a strog public educatio pla 5. Domai of atioal govermet. 3.2 Govermet regulators i the pharmaceutical market This sectio focuses o the role of govermet i the regulatio of the pharmaceutical market ad, more specifically, the selectio of drugs 58. The pharmaceutical selectio process ivolves the registratio ad market authorizatio of drugs i a pharmaceutical market; this govermet process also specifies which drugs are icluded i a public formulary ad thus are subject to reimbursemet policies. Drug registratio ad market authorizatio are the resposibility of atioal drug agecies. Ufortuately, these agecies are ofte poorly fuded ad have limited staff ad istitutioal capacity. If the legislative ad regulatory eviromets are weak ad there is a lack of trasparecy ad accoutability i the processes, suppliers may bribe govermet officials to register their drugs without the requisite iformatio, or govermet officials may deliberately delay the registratio process to solicit a illegal paymet or to favour aother supplier. This ca create opeigs i the market for couterfeit ad substadard medicies. 57 Refereces i this table: 4. Lewis, M., & Pettersso, G. (2009). Goverace i health care delivery: raisig performace. World Bak Policy Research Workig Paper Miller, K. & Via, T. (2010). Strategies for reducig iformal paymets i Via, T., Savedoff, W. & Mathise, H. (2010). Aticorruptio i the Health Sector: Strategies for Trasparecy ad Accoutability, Kumaria Press, West Hartford, CT (USA), p This sectio is based o prior work that the cosultat did o the topic. See Cohe, J., Mrazek, M., & Hawkis, L. (2007). Corruptio ad pharmaceuticals: stregtheig good goverace to improve access i Campos, J. E., & Pradha, S., eds., The May Faces of Corruptio: Trackig Vulerabilities at the Sector Level. World Bak, Washigto, DC (USA). Fightig Corruptio i the Health Sector: Methods, Tools ad Good Practices 27

30 3. CORRUPTION RISKS IN THE HEALTH SECTOR AND SELECT INTERVENTIONS WHO defies a couterfeit medicie as oe which is deliberately ad frauduletly mislabelled with respect to idetity ad/or source. Couterfeitig ca apply to both braded ad geeric products ad couterfeit products may iclude products with the correct igrediets or with the wrog igrediets, without active igrediets, with isufficiet active igrediets or with fake packagig. 59 Regulatio of health sector goods ad services is a core fuctio of govermet. Govermets are resposible for esurig that health professioals are licesed properly ad that health Problematically, the medicies used to treat some of the most prevalet diseases of the world, such as malaria, tuberculosis ad bacterial ifectios, are the most commoly couterfeited 60.All of the above poit to the extreme health risks that are associated whe couterfeit ad fake medicies are available i a pharmaceutical market due to lack of good goverace ad weak health systems. A key fuctio i the pharmaceutical selectio process is whether drugs that are registered ad have received market approval should actually be available o a drug formulary. Risks i the selectio process iclude kickbacks from suppliers ad payoffs so that drugs o the formularies are ot ecessarily appropriate for the health eeds of the populatio or cost-effective. A USAID study o corruptio i the pharmaceutical system i Bulgaria foud that the atioal drug formulary had istaces of the selectio of ewer (usually more expesive) pharmaceutical agets ad the exclusio of older agets that were equally effective i treatig the relevat coditio ad also comparatively cost-effective 61. products are safe ad effective. Essetial drug lists ca prevet corruptio i the drug selectio process because they usually iclude drugs that are reviewed by WHO as ecessary for most commo diseases. But the use of a essetial drug list must be accompaied by other ati-corruptio iitiatives further alog i the drug supply chai. For example, i the Balkas the dosage specified for a product i the essetial drugs list was set up so that a local maufacturer could wi the procuremet bid See WHO website: 60 Picock, S. (2003). WHO tries to tackle problem of couterfeit medicies i Asia. British Medical Joural 327, (7424), Iris Ceter for USAID (2005). Goverace i Bulgaria s pharmaceutical sector: a sythesis of research fidigs. Iris Ceter, Baltimore, MD (USA). 62 Cohe, J., Mrazek, M., & Hawkis, L. (2007). Corruptio ad pharmaceuticals: stregtheig good goverace to improve access i Campos, J. E., & Pradha, S., eds., The May Faces of Corruptio: Trackig Vulerabilities at the Sector Level. World Bak, Washigto, DC (USA). 28 Fightig Corruptio i the Health Sector: Methods, Tools ad Good Practices

31 3. CORRUPTION RISKS IN THE HEALTH SECTOR AND SELECT INTERVENTIONS Good practice examples WHO has sice 1977 has published a Essetial Drugs List that ca be used as a guidelie for coutries. Each editio establishes a limited list of priority medicies; icluded are commo diseases alog with the pharmaceutical products that are most effective ad affordable for most coutries. Trasparecy helps prevet corruptio i the drug selectio process. The Govermet of Mogolia has developed a olie public database for drug registratio. The database has reduced the umber of uregistered drugs i the market as well as helped expedite the registratio process. Eve whe coutries do ot have the resources or the size to justify a full-scale drug agecy, assessig the quality, safety ad efficacy of the drugs eterig their markets is possible without comprehesive testig. For example, a applicat product may already have market authorizatio through a recogized drug agecy of aother coutry (e.g., the Uited States Food ad Drug Admiistratio or the Europea Medicies Agecy). I such cases, some coutries may accept the documetatio submitted to these agecies as sufficiet. If documetatio is ot available, the coutry may out-source the required testig to a third-party laboratory or may egage i its ow testig 63. Table 2. Select itervetios to improve govermet regulator fuctio 64 Itervetio Type Commet Set up a well resourced idepedet drug agecy Esure registratio ad marketig approval procedures are applied uiformly, are curret for all suppliers, ad are publicly available through a govermet website Esure that the regulatory agecy publicly provides justificatio for decisios Maagerial Trasparecy Trasparecy Needs to be doe by atioal govermet. Nigeria s registratio guidelies were updated as part of a aticorruptio strategy 1. Domai of atioal govermet. This icludes the regular publishig o a govermet website of drug registratio ad market authorizatio decisios. The process should be complemeted by a formal appeals process. Domai of atioal govermet. 63 Ibid., p Refereces used i this table: 1. Ibid., p. 41. Fightig Corruptio i the Health Sector: Methods, Tools ad Good Practices 29

32 3. CORRUPTION RISKS IN THE HEALTH SECTOR AND SELECT INTERVENTIONS Itervetio Type Commet Require that staff of regulatory agecy ad ay supplemetal committee members ivolved i registratio ad market approval decisios sig a coflict of iterest documet that is publicly dissemiated Istitute a body to maage coflicts of iterest. Trasparecy Accoutability/ oversight Public dissemiatio of coflict of iterest should also be part of this strategy. Domai of atioal govermet. Must iclude a process for reportig ad reviewig coflicts of iterest ad determiig appropriate course of actio. Such a process should esure that idividuals with real or apparet coflicts of iterest are ot ivolved i decisio-makig. Domai of atioal govermet Implemet ad sustai ogoig market surveillace of drugs with a complemetary public educatio campaig to help educate cosumers about how to idetify a couterfeit product 2. Accoutability/ oversight Iclude radom batch testig ad reportig streams for users ad patiets so that ay potetial problems are idetified. I Azerbaija, for example, drugs that passed govermet ispectio were give a hologram sticker so that they were easily idetifiable. Domai of atioal govermet. 3.3 Procuremet of pharmaceuticals ad medical supplies 65 Problem aalysis ad evidece The goal of procuremet for drugs or medical supplies is to esure that the right quatity of a product is purchased with the right quality at a cost-effective price. Procuremet may take place at the atioal level of govermet or it may be decetralized ad take place at the facility level. There is o clear evidece about which approach is less proe to corruptio. It is ot the procuremet level that matters but rather how the procuremet process is set up. Procuremet of publicly fuded drugs is particularly susceptible to corruptio because drug volumes are typically large ad the cotracts are usually quite lucrative; this motivates some actors 64 Refereces used i this table: 2. Ibid., p This sectio is based o Cohe, J., Mrazek, M., & Hawkis, L. (2007). Corruptio ad pharmaceuticals: stregtheig good goverace to improve access i Campos, J. E., & Pradha, S., eds., The May Faces of Corruptio: Trackig Vulerabilities at the Sector Level. World Bak, Washigto, DC (USA). 30 Fightig Corruptio i the Health Sector: Methods, Tools ad Good Practices

33 3. CORRUPTION RISKS IN THE HEALTH SECTOR AND SELECT INTERVENTIONS to udertake corrupt actios. Specificatios may be maipulated to favour oe supplier; suppliers may bribe procuremet officials to gai advatage i the procuremet teder process; overpaymet of products may happe; ad procuremet of products may occur whe there is o justifiable health reaso for it. Procuremet of publicly fuded drugs is particularly susceptible to corruptio because drug volumes are typically large ad the cotracts are usually quite lucrative; this motivates some actors to udertake I Albaia, for example, istaces of corruptio i pharmaceutical procuremet icluded corrupt actios. private fiacial iterests determiig what drugs to procure for the public health system, kickbacks or bribes that eabled bidders to gai access to cofidetial iformatio, ad use of direct procuremet istead of competitive biddig without soud justificatio 66. Procuremet fraud is particularly risky i hospitals as almost all capital expeses ivolve procuremet ad ofte time ad techical expertise is limited 67. Box 2. World Bak ad corruptio i procuremet: health projects i Idia The World Bak s Detailed Implemetatio Review of Idia FY icluded a broad-based review of procuremet practices i five World Bak health projects that icluded procuremet. Fraud ad corruptio were foud i all projects ad icluded collusio, bribery ad maipulated bid prices, deficiet civil works certified as complete, broke or damaged equipmet certified as compliat with specificatios, uder-delivery of services, iadequate project audit ad cotrol systems 68. Ati-corruptio itervetios are ow i place. They iclude procuremet audits, commuity oversight ad moitorig, commuity social cards ad social audits, olie publicatio of all procuremet processes, more rigorous terms for NGO ad cotract awards, ad procuremet audits. Two compaies, Nestor Pharmaceuticals Ltd. ad Pure Pharma Ltd., both of which were foud guilty of collusive behaviour uder the Reproductive ad Child Health Project I i Idia, were also barred from participatig i World Bak procuremet teders for a set period of time. 66 Via, T. (2003). Corruptio i the health sector i Albaia. USAID/Albaia Civil Society Corruptio Reductio Project. 67 Via, T. (2006). Corruptio i hospital admiistratio. Trasparecy Iteratioal, Berli, Germay. 68 World Bak Group (2008), Aual itegrity report: protectig developmet s potetial. Fightig Corruptio i the Health Sector: Methods, Tools ad Good Practices 31

34 3. CORRUPTION RISKS IN THE HEALTH SECTOR AND SELECT INTERVENTIONS Good practice examples Procuremet procedures ad systems should guaratee that the drugs purchased are of high quality ad meet iteratioal stadards because products ca vary substatially i formulatio ad bioavailability, depedig o the supplier. Whe this differece is therapeutically sigificat, regular chages i suppliers ca have cosequeces for product quality. Eve whe ew products are completely equivalet i cotet ad effect, chages i a dosage form ca be problematic, requirig patiet ad provider reeducatio. Effective quality assurace systems iclude the selectio of reliable suppliers usig existig mechaisms such as the WHO Certificatio Scheme o the Quality of Pharmaceutical Products Movig i Iteratioal Commerce; establishig a programme of product defect reportig; ad performig targeted quality cotrol testig. The selectio of suppliers with a prove record of providig high-quality products ca cotribute to quality assurace, so log as the appropriate checks are i place. Pricig trasparecy i procuremet helps to curb price gougig ad overpaymet for products, ad ca be fairly iexpesive to implemet. Oe example i this regard is the public postig of medical supplies purchased by public hospitals by the city govermet of Bueos Aires, Argetia. Authorities iformed all purchasig maagers of the city govermet s decisio to post prices; as a result, prices fell withi the first few moths of this itervetio i aticipatio of price reportig. But the price declie did ot stick, thereby suggestig the lack of stayig power of this iitiative ad the eed for complemetary itervetios such as the impositio of sactios for uethical behaviour. USAID s Supply Chai Maagemet System (SCMS) creates a procuremet system (i lie with US govermet federal acquisitio guidelies) that publicly lists teders ad price iformatio 69. E-procuremet as doe i the Chilea procuremet system is ofte cited as a effective tool to prevet corruptio i drug procuremet. Through the use of electroic biddig ad iformatio dissemiatio about procuremet procedures ad results, corruptio has bee curbed substatially. These ati-corruptio itervetios helped eve more whe a wide rage of suppliers competed for each product so that price competitio was fostered ad opportuities for collusio reduced 70. Researchers at Bosto Uiversity i the Uited States have developed two potetial trasparecy tools to help drug purchasers (e.g., govermets ad NGOs) limit corruptio i procuremet 71. The first tool is the high price outlier aalysis, which examies each atiretroviral drug (used to treat HIV ifectio) ad allows users to assess whether prices paid are excessively higher tha the global distributio of prices paid 69 Via, T. (2010). Prevetig drug diversio through supply chai maagemet. U4 Brief 4, Chr. Michelse Istitute, Berge, Norway 70 See Cohe, J., & Motoya, J. (2001). Usig techology to fight corruptio i pharmaceutical purchasig: lessos from the Chilea experiece. World Bak Istitute, Washigto, DC (USA). 71 Waig, B., & Via, T. (2010). Trasparecy ad accoutability i a electroic era: the case of pharmaceutical procuremet i T. Via, Prevetig drug diversio through supply chai maagemet. U4 Brief 4, Chr. Michelse Istitute, Berge, Norway. 32 Fightig Corruptio i the Health Sector: Methods, Tools ad Good Practices

35 3. CORRUPTION RISKS IN THE HEALTH SECTOR AND SELECT INTERVENTIONS for the same product. This tool ca be used iterally to idetify where problems may exist i the procuremet process ad the followed up with case studies to detail more iformatio about the procuremet process. The secod tool allows for the compariso of prices paid i a coutry to the global media prices paid for idetical products. The researchers bechmarked 90 coutries ad poit out that coutries should aim to have most of their procuremets fall ito the 25th to 50th percetile. This would idicate that their products are at the same level or below global media prices. Table 3. Select itervetios to improve drug ad equipmet suppliers: procuremet 72 Itervetio Type Commets Esure clear policy o quatificatio methodology for supplies Esure that closig date of all procuremet bids is adhered to; that all bids are recorded; ad that all awards ad adjudicatio decisios are made by the procuremet committee or teder board Publish all procuremet teder bids ad results of cotract awards olie Trasparecy Trasparecy ad maagerial Trasparecy Limits idividual discretio ad approval by a ubiased expert committee. Depedig o procuremet locatio, will be domai of atioal, regioal or local govermet or health care facility This sets ito place clear criteria for the procuremet process. Domai of atioal, regioal, local govermet or health care facility. Publicly postig prices paid for drugs or other supplies ca help esure that prices are trasparet ad prevet price maipulatio. Domai of atioal, regioal, local govermet or health care facility. Use electroic biddig where possible Trasparecy Ca be doe at ay level i the health care system where procuremet is takig place 72 Refereces used i this table: 1. Available at cfm (accessed 24 August 2010). Fightig Corruptio i the Health Sector: Methods, Tools ad Good Practices 33

36 3. CORRUPTION RISKS IN THE HEALTH SECTOR AND SELECT INTERVENTIONS Itervetio Type Commets Prequalify suppliers (e.g., through the WHO Prequalificatio Programme) Maagerial Helps to icrease likelihood of credible suppliers. Domai of atioal, regioal, local govermet or health care facility. Moitor prices of supplies Trasparecy This helps ucover hidde costs caused by poor product quality, poor supplier performace or short shelf life. Domai of atioal, regioal, local govermet or health care facility. Check prices agaist iteratioal bechmarks Use iteratioal guidelies for health supply procuremet practices Madate regular reportig of key procuremet performace idicators Commissio expert committee with oversight over all procuremet Accoutability/ oversight Maagerial Accoutability/ oversight Accoutability/ oversight Maagemet Scieces for Health s Iteratioal Drug Price Idicators Guide 1 ad Bosto Uiversity tools cited i Sectio 3.3 ca help with price comparisos. Domai of atioal, regioal, local govermet or health care facility. For example the World Bak, Stadard Biddig Documet for the Procuremet of Health Sector Goods (May 2004) ad WHO Operatioal Priciples for Good Pharmaceutical Procuremet (1999). Domai of atioal, regioal, local govermet or health care facility. Domai of reportig will deped o where procuremet takes place. Broad-based participatio is a effective ati-corruptio tool. Domai of atioal, regioal, local govermet or health care facility. Provide techical assistace ad traiig of procuremet officers 2 Maagerial Procuremet officers should ideally sig a cotract to remai i their positios for a set amout of years. This ca be reiforced particularly by doors if fudig is provided to help build up procuremet capacity. Domai of atioal, regioal, local govermet or health care facility. 72 Refereces used i this table: 2. Nordberg, C., & Via, T. (2008). Corruptio i the health sector. U4 Brief 10, Chr. Michelse Istitute, Berge, Norway. 34 Fightig Corruptio i the Health Sector: Methods, Tools ad Good Practices

37 3. CORRUPTION RISKS IN THE HEALTH SECTOR AND SELECT INTERVENTIONS 3.4 Distributio ad storage of drugs 73 Problem aalysis ad evidece Poor storage coditios ca lead to losses either through the mismaagemet of pharmaceuticals (leadig to their expiratio) or plai corruptio (theft of medicies). Shipmets ca be stole at may poits i the delivery system, icludig by port persoel, crime sydicates that orgaize large-scale thefts from warehouses, ad by drivers alog the delivery route. Eve if drugs reach their iteded destiatio, govermet officials ad health facility workers may steal them for their ow use or profit. It is usurprisig that drug diversio icreases health care costs, give that medicies ca accout for about betwee 10 ad 30 percet of recurret health budgets i low-icome coutries 74. Thus, stock loss obviously has a impact o a populatio s access to medicies. Icetives for diversio may be more of a risk i the distributio ad storage of expesive medicies such as atiretroviral drugs. Large-scale commitmet to treatmet puts pressure o health officials to sped fuds rapidly, which meas there is less time to moitor the supply chai or provide sufficiet cotrols o the supply 75. Good practice examples The US Presidet s Emergecy Pla for AIDS Relief (PEPFAR) ad the related Supply Chai Maagemet System (SCMS) are good examples of supply chai maagemet that icreases accoutability ad oversight i drug delivery by separatig fuctios. I these models, private suppliers are cotracted by the public sector to deliver drugs to specific poits i the health system. PHD, a compay based i South Africa 76, has a cotract with the govermet to deliver drugs to govermet ad private-sector service delivery poits. It has 9,000 delivery ad supplies products from 30 maufacturers. Services iclude secure warehousig, ivetory maagemet, ad drug distributio to idividual wholesalers, retailers, hospitals, cliics, ad physicias offices across South Africa. 73 This sub-sectio is based o Cohe, J., Mrazek, M., & Hawkis, L. (2007). Corruptio ad pharmaceuticals: stregtheig good goverace to improve access i Campos, J. E., & Pradha, S., eds., The May Faces of Corruptio: Trackig Vulerabilities at the Sector Level. World Bak, Washigto, DC (USA). 74 Via, T. (2010). Prevetig drug diversio through supply chai maagemet. U4 Brief 4, Chr. Michelse Istitute, Berge, Norway, p Iformatio draw from Via, T. (2010). Prevetig drug diversio through supply chai maagemet. U4 Brief 4, Chr. Michelse Istitute, Berge, Norway. 76 See (accessed 24 August 2010). Fightig Corruptio i the Health Sector: Methods, Tools ad Good Practices 35

38 3. CORRUPTION RISKS IN THE HEALTH SECTOR AND SELECT INTERVENTIONS Table 4. Select itervetios to improve drug ad other equipmet supplies: distributio 77 Itervetio Type Commet Keep track of shipmets i real time to detect diversio across the etire distributio ad storage system through the use of computerized ad automated iformatio systems Create systems for electroic moitorig of trasport vehicles ad checkig of ivetory (each batch) Implemet a public expediture trackig survey (PETS) to validate delivery ad fiacig of drugs Implemet physical facility protectio ad security measures icludig hirig of security staff, screeig of all employees prior to employmet (the aually) for credit history ad crimial record, aual polygraphs, ad surveillace Madate ad eforce separatio of work force ad fuctios Ivolve civil society groups i moitorig drug delivery systems Ru regular risk aalyses for trasportatio ad delivery Create health boards that are charged with distributio ad regular moitorig of stocks at the facility level Accoutability/ oversight Accoutability/ oversight Accoutability/ oversight Maagerial Maagerial Accoutability/ oversight Accoutability/ oversight Accoutability/ oversight Optimal systems use bar codig ad scaers or radio-frequecy idetificatio (RFID) techology. May be a higher cost itervetio. Also relevat to other areas i health sector. A core compoet but ofte overlooked. At PHD i South Africa, warehouses are divided ito three uits, each of which has separate physical areas, persoel policies, ad operatig procedures. Ivolvemet of civil society orgaizatios (CSOs) as watchdogs of the public good is a low-cost ad effective itervetio. The risk of theft durig trasport ad delivery is reduced through risk aalysis of delivery routes with accompayig appropriate measures. Health board members must be screeed well for o potetial coflict of iterest. 77 Govermet domai will deped o which level(s) of govermet (atioal, state/provicial or muicipal) is ivolved i overseeig the distributio of medicies. 36 Fightig Corruptio i the Health Sector: Methods, Tools ad Good Practices

39 3. CORRUPTION RISKS IN THE HEALTH SECTOR AND SELECT INTERVENTIONS 3.5 Health budgets Problem aalysis ad evidece Health budgets, like all other areas of public sector fiacig, may be subject to corruptio if oversight is lackig. Budget maagemet systems are limited i may developig coutries i particular; i such cotexts, moitorig of budgets is difficult, critical data are missig ad fiacial iformatio o expeditures may be flawed. The budget formulatio process is ofte a area of weakess ad vulerable to iterest politics. Some importat steps have bee take to improve such situatios: most otably, health budgets i may developig coutries ow beefit from support provided by global istitutios ad fiacig mechaisms such as the as the GAVI Alliace ad the Global Fud to Fight AIDS, TB ad Malaria. Budget processes ad correspodig vulerabilities to corruptio will differ depedig o the extet to which a budget is maaged at the atioal level ad/or is supported by traditioal bilateral programmes or global iitiatives. This differetiatio should be cosidered whe determiig what measures are most appropriate to employ to prevet corruptio. Door fiacig ca be highly vulerable to corruptio. Two mai reasos are that fudig from that source may be cosiderably higher tha a atioal health budget ad have a shorter time period for disbursemet. With shorter timelies, moitorig of disbursemets may ot take place or be isufficiet. Also, door fudig may be more difficult to track whe it is coverted ito local currecy; a similar challege may occur because trasactios are ofte cash-based i resource-poor settigs (ad thus less easy to track) 78. Zambia is a case of door fudig for health that was subject to corruptio. The coutry is the recipiet of a large umber of door fuds for health, may of which were pooled through a sector-wide approach (SWAp) 79. Eve though Zambia s high potetial for corruptio was well kow, doors did ot take ecessary measures to esure that sufficiet ati-corruptio ad good goverace processes were i place prior to the gratig of fuds. I 2009, Zambia s Ati-Corruptio Commissio foud that high-level officials i the Miistry of Health ad Social Welfare had embezzled US$1.4 millio. The officials were paid as cosultats for workshops that did ot take place 80. As soo as corruptio was discovered i the health sector, door support, which represeted half of the atioal health budget, was froze, which led to a disruptio i health care services. Followig the corruptio scadal, a umber of measures were advocated by doors. They iclude esurig trasparecy i budgetary decisios, stregtheig fiacial maagemet systems, madatig regular fiacial reports ad audits, ad prioritizig follow-up to esure govermets implemet audit recommedatios. 78 Semrau, K., Scott, N., & Via, T. (2010). Embezzlemet of door fudig i health projects i Via, T., Prevetig Drug Diversio Through Supply Chai Maagemet. U4 Brief 4, Chr. Michelse Istitute, Berge, Norway. p See for more iformatio about SWAps. 80 For more iformatio see Pereira, J. (2009). Zambia aid effectiveess i the health sector, Actio for Global Health. Fightig Corruptio i the Health Sector: Methods, Tools ad Good Practices 37

40 3. CORRUPTION RISKS IN THE HEALTH SECTOR AND SELECT INTERVENTIONS Good practice examples The govermet ad doors have set up a social cotrol fud i Colombia. Uder terms of the fud, citizes moitor fudig for key sectors icludig health. It is estimated that as much as US$5.4 millio would otherwise have bee lost due to corruptio 81. Sector expediture trackig surveys ca help to idetify potetial budget leakages as well as how well moey is beig spet. Oe importat caveat, however, is that the trackig of overall health expeditures is ofte challegig because there are multiple sources ad mechaisms for fudig 82. It is useful to kow what fuds are beig used i the health sector (core budget, door, etc.) to esure their cosistecy i disbursemet ad fiacial maagemet alog with appropriate spedig at the cliic ad hospital levels 83. Table 5. Select itervetios to improve payer performace 84 Itervetio Type Commets Apply ad eforce IMF s Revised Code of Good Practices o Fiscal Trasparecy (2007) 1. Implemet Public Expediture ad Fiacial Accoutability (PEFA) framework. Iitiate ad sustai public expediture trackig surveys ad public expediture reviews Audit istitutios or ati-fraud uits Trasparecy Accoutability/ oversight Accoutability/ oversight Accoutability/ oversight Role of atioal govermet to set as a stadard. Doors could also esure this is icluded i health developmet projects. PEFA idicators relevat to the health sector are: i) aggregate expediture compared to origial approved budget; ii) effectiveess of payroll cotrols; ad iii) availability of iformatio o resources received by service delivery uits 2. Commoly used by istitutios like the World Bak to determie if public fudig is reachig its objective. A good example of a idepedet audit istitutio is the UK Couter Fraud Service, which aims to protect the Natioal Health Service from fraud ad corruptio Trasparecy Iteratioal (2010). The ati-corruptio catalyst: realisig the MDGs by 2015, Berli, Germay, p See Azfar, O., & Gurgur, T. (2006). Local-level corruptio hits health service delivery i the Philippies, from Trasparecy Iteratioal Aual Report. 83 Lewis, M., & Pettersso, G. (2009). Goverace i health care delivery: raisig performace. World Bak Policy Research Workig Paper The itervetios outlied i Table 5 are from Lewis, M., & Pettersso, G. (2009). Goverace i health care delivery: raisig performace. World Bak Policy Research Workig Paper Refereces used i this table: 1. The maual ca be dowloaded from the IMF s website: (accessed 25 August 2010). 2. Lewis, M., & Pettersso, G. (2009). Goverace i health care delivery: raisig performace. World Bak Policy Research Workig Paper Gee, J. (2006). Fightig fraud ad corruptio i Britai s Natioal Health Service. Trasparecy Iteratioal, Berli, Germay. 38 Fightig Corruptio i the Health Sector: Methods, Tools ad Good Practices

41 3. CORRUPTION RISKS IN THE HEALTH SECTOR AND SELECT INTERVENTIONS Itervetio Type Commets Use atioal health accouts (NHAs) Icrease public participatio i the budget process Establish a system for citize scorecards Promote ad ehace budget moitorig by NGOs Trasparecy Trasparecy Accoutability/ oversight Trasparecy NHAs measure ad track the use of total health care expeditures i a coutry. Some key observers argue that the eed for trasparecy for NHAs makes it a aticorruptio tool if implemeted regularly 4. Broad-based participatio is a effective tool. Effective meas of checkig health service delivery. Allows for greater scrutiy of govermet budget ad icreases public awareess. Implemet performace-based budgetig Esure traiig of core staff i relevat areas, such as fiacial maagemet, budgetig, accoutig, ad risk maagemet Improve iteral cotrol through better oversight, audits ad streamlied processes. Use quatitative service delivery surveys (QSDS) 6. Maagerial Maagerial Accoutability/ oversight Accoutability/ oversight Helps to esure ethical behaviour. Ca be eforced by maagemet i the health sector as well as doors if health projects cotai a traiig compoet. Domai of doors ad the govermet. Recommeded cotrols iclude segregatio of duties, comparig actual ad expected reveue, iteral/exteral audits, ad ivestig i fraud cotrol 5. Ivestigates the efficiecy of public spedig ad the associated icetive structure. Simplify reportig systems Maagerial By keepig reports simple there is less chace of hidig iformatio. Outsource disbursemet of fuds to a idepedet thirdparty Accoutability/ oversight To be effective, this step also demads appropriate safety measures such as trasparecy, regular reportig, etc. 84 Refereces used i this table: 4. Lewis, M., & Pettersso, G. (2009). Goverace i health care delivery: raisig performace. World Bak Policy Research Workig Paper Semrau, K., Scott, N., & Via, T. (2010). Embezzlemet of door fudig i health projects i Via, T., Prevetig Drug Diversio Through Supply Chai Maagemet. U4 Brief 4, Chr. Michelse Istitute, Berge, Norway. 6. See for example: Fightig Corruptio i the Health Sector: Methods, Tools ad Good Practices 39

42 4. TOP TEN LESSONS FROM THIS STUDY UN Photo/Michel Szulc-Kryzaowski The drive to reach the MDGs by 2015 has helped raise awareess amog the global commuity about the eed for ati-corruptio itervetios to be itegral elemets of health sector policy ad plaig. This study has explaied why the health sector is proe to corruptio, provided examples of istaces of corruptio i the health sector, ad discussed select diagostics ad ati-corruptio itervetios. It has also highlighted a set of lessos that may assist ay stakeholder (policy makers, developmet practitioers, citizes, etc.) to desig ati-corruptio itervetios i the health sector. Te of the most importat lessos are summarized below. Lesso oe. There is o oe size fits all approach to mitigatig corruptio i the health sector. Practitioers eed to give careful attetio as to what potetial strategy or strategies would work most effectively i view of the specific risks idetified by use of diagostics. Lesso two. More tha oe ati-corruptio itervetio should be employed to deal with oe risk. For example, wage icreases may help to curb the likelihood of abseteeism, but they are likely to be more effective whe there are systems i place to documet absetee rates ad whe sactios for absece are imposed. 40 Fightig Corruptio i the Health Sector: Methods, Tools ad Good Practices

43 4. TOP TEN LESSONS FROM THIS STUDY Lesso three. Prioritizatio is key: govermets ad others ivolved i health projects ad programmig should prioritize areas of the health system that are most susceptible to corruptio ad implemet appropriate itervetios. Ofte eve low hagig fruit ca produce sigificat ati-corruptio impacts. For example, the act of postig medical supply ad pharmaceutical product pricig ca help deter price gougig. The idetificatio of priority areas is particularly importat whe resources are scare. Lesso four. It is importat to work with other sectors. Corruptio caot be curbed i the health sector without the ivolvemet of other critical sectors, such as ifrastructure ad fiace. Lesso five. Health policy goals should iclude ati-corruptio cosideratios. Ivestmets i health may be wasted uless ati-corruptio strategies are built ito all health projects. Prevetative itervetios ca protect ivestmets made. Lesso six. Prevetio is the best strategy: therefore, it is best ot to wait for corruptio to happe before begiig to deal with it. Oe of the biggest failigs i the health sector is the implemetatio of ati-corruptio itervetios oly after corruptio is suspected or cofirmed. Regular moitorig of the health sector for discrepacies i stadards is vital. Lesso seve. Numerous empirical diagostic tools should be employed. Give the complexity of the health sector, more tha oe diagostic tool may be of value to esure accurate iformatio. This also requires proper measurig ad re-measurig. Regular check-ups ca measure how effectively ati-corruptio strategies are workig i a give poit i the health care system. Lesso eight. Parters with experiece i implemetig ati-corruptio strategies ad tactics should be idetified ad cotacted for techical support. This study has idetified a umber of NGOs, iteratioal developmet istitutios, research groups ad experts ivolved i implemetig aticorruptio strategies ad tactics i the health sector. Lesso ie. Broad participatio i health policy ad plaig helps. Ivolvig NGOs, citizes ad desigated experts i health budgetig, moitorig, ad cosultig, as a few examples, ca help heighte trasparecy ad lesse the likelihood of corruptio. Lesso te. Good behaviour should be rewarded, ad bad behaviour puished. This ca be doe by settig up appropriate icetive structures that help promote adherece to good behaviour, such as performace-based fiacig. It is also importat to sactio those idividuals who are egaged i corrupt activities where possible. This seds a importat message that corruptio is ot tolerated. There is a growig body of evidece documetig which ati-corruptio strategies work i the health sector. What is eeded, however, is more iformatio about the impact ati-corruptio strategies have o health outcomes, who should be ivolved i the process, which coditios are most likely to achieve successes, ad how to sustai positive results. Also of importace is the eed to uderstad whether good practices are trasferable ad if ot, why? What should be doe at the local, regioal or atioal level to miimize the risk of corruptio i the health sector? This study ideally will help set ito motio empirical work i respose to these questios ad more. Fightig Corruptio i the Health Sector: Methods, Tools ad Good Practices 41

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47 REFERENCES Uited Natios, Web page o the Milleium Developmet Goals. Olie: milleiumgoals/ (accessed 31 August 2010). Uited Natios Developmet Programme (2007). Goverace for sustaiable huma developmet. UNDP Policy Documet, New York, NY (USA). Uited Natios Geeral Assembly, Iteratioal Coveat o Ecoomic, Social ad Cultural Rights (1966). Uited Natios Treaty Series, Vol. 993, p. 3. Olie: html (accessed 3 August 2010). Uited Natios Secretary Geeral (2009). Speech o Iteratioal Ati-Corruptio Day. Olie: ww.u.org/news/press/docs/2009/sgsm12660.doc.htm (accessed 1 August 2010). Uited States Agecy for Iteratioal Developmet (2009). Ati-corruptio assessmet hadbook. Olie: hadbook/idex.html (accessed 2 August 2010). Via, T. (2003). Corruptio i the health sector i Albaia. USAID/Albaia Civil Society Corruptio Reductio Project. Olie: (accessed 2 August 2010). Via, T. (2006). Corruptio i hospital admiistratio. Trasparecy Iteratioal, Berli, Germay. Via, T. (2008). Review of corruptio i the health sector: theory, methods ad itervetios. Health Policy ad Plaig, 23(2), Via, T. (2008). Trasparecy i health programmes. U4 Brief 9, Chr. Michelse Istitute, Berge, Norway. Via, T. (2010). Prevetig drug diversio through supply chai maagemet. U4 Brief 4, Chr. Michelse Istitute, Berge, Norway. Via, T., Sayedoff, W. & Mathise, H. (2010) Aticorruptio i the health sector: strategies for trasparecy ad accoutability, Kumaria Press, West Hartford, CT (USA). Wagstaff, A., & Claeso, M. (2004). The Milleium Developmet Goals for health: risig to the challeges. World Bak, Washigto, DC (USA). Waig, B., & Via, T. (2010). Trasparecy ad accoutability i a electroic era: the case of pharmaceutical procuremet i T. Via, Prevetig drug diversio through supply chai maagemet. U4 Brief 4, Chr. Michelse Istitute, Berge, Norway. Wazaa, A. (2000). Physicias ad the pharmaceutical idustry: is a gift ever just a gift? Joural of the America Medical Assosicato 283, World Bak cocept ote o medicies procuremet, iteral documet, 18 May World Bak, Web page o Goverace & Ati-Corruptio. Olie: WBSITE/EXTERNAL/WBI/EXTWBIGOVANTCOR/0,,meuPK: ~pagePK: ~piPK: ~theSitePK: ,00.html (accessed 4 August 2010). World Bak Group (2008). Aual Itegrity Report: Protectig Developmet s Potetial. Olie: (accessed 5 August 2010). Fightig Corruptio i the Health Sector: Methods, Tools ad Good Practices 45

48 REFERENCES World Health Orgaizatio (.d.), Web page o Medicies. Olie: policy/goodgoverace/documets/e/idex.html (accessed 24 August 2010). World Health Orgaizatio (2009). Measurig trasparecy i the public pharmaceutical sector: assessmet istrumet. Olie: AssessmetIstrumetMeastraspENG.PDF (accessed 27 July 2010). World Health Orgaizatio ad Health Actio Iteratioal (2008). Measurig Medicie Prices, Availability, Affordability ad Price Compoets (2d ed.). Geeva, Switzerlad. World Health Orgaizatio GGM Programme (i preparatio). A iovative approach to prevet corruptio i the pharmaceutical sector. Backgroud paper for World Health Report Fightig Corruptio i the Health Sector: Methods, Tools ad Good Practices

49 ANNEX 1. OVERVIEW OF KEY TOOLS TO IDENTIFY, TRACK AND MEASURE CORRUPTION RISKS AND CORRUPTION Area Issue Tools to idetify ad track problems Geeral Budget Ad Resource Maagemet Idividual Providers Iformal Paymets Corruptio Perceptios & Experiece Cross-cuttig Budget processes Payroll leakages I-kid leakages Job purchasig Health worker abseteeism Iformal paymets Perceptios of Corruptio Experiece with corruptio Vulerability to corruptio assessmets Value chai aalysis Sectoral accoutability assessmet Aalysis of goverace i health care systems Public Expediture ad Fiacial Accoutability (PEFA) idicators Focus groups ad iterviews with public officials, recipiet istitutios, ad civil society Public expediture trackig surveys ad reviews Household surveys Focus groups with public officials ad health workers Public expediture trackig surveys Quatitative service delivery surveys Facility surveys Focus groups with public officials, recipiet istitutios, ad health workers Official admiistrative records combied with facility surveys Iterviews with public officials ad former officials Goverace ad ati-corruptio coutry diagostic surveys Quatitative service delivery surveys Surprise visits Direct observatio Facility records Focus groups or iterviews with facility heads ad patiets Household surveys (e.g., World Bak livig stadards measuremet surveys ad demographic ad health surveys) Facility exit surveys ad score cards Focus groups/iterviews with providers/patiets ad health staff Goverace ad ati-corruptio coutry diagostic surveys (World Bak) Goverace ad ati-corruptio coutry diagostic surveys (World Bak) Natioal level perceptio surveys by CSOs ad others AfroBarometer, LatiBarometer, EuroBarometer, atioal experiece-based surveys Patiet satisfactio surveys ad report cards Focus group surveys /studies Source: Hussma, K (2010). Adapted from Lewis, M., & Pettersso, G. (2009). Goverace i health care delivery: raisig performace. World Bak Policy Research Workig Paper Fightig Corruptio i the Health Sector: Methods, Tools ad Good Practices 47

50 ANNEX 2. SELECT RESULTS FROM WHO S GOOD GOVERNANCE FOR MEDICINES (GGM) PROGRAMME Lebao The Phase I assessmet recommeded that the atioal Good Maufacturig Practices (GMP) be updated give they had ot bee revised sice As a result, a atioal GMP committee was formed i 2008, ad it revised the GMP stadards i The Miistry of Health (MoH) recetly adopted the GGM framework to iclude a atioal code of coduct, compilatio of regulatios ad admiistrative procedures, mechaisms for collaboratio with other good goverace ad aticorruptio iitiatives, whistleblowig mechaisms ad sactios for breaches of stadards. Malaysia Outcomes from the GGM iclude the developmet of public promotioal activities to icrease awareess o the potetial of corruptio i the pharmaceutical sector. There is also more publicly available iformatio about the pharmaceutical legislatio ad process available o the MoH website. Moldova The Natioal Medicies Agecy is leadig the implemetatio of actios related to the GGM icludig workig with pharmacists to correct ay regulatory gaps, ad writig stadard operatig procedures for each fuctio that the assessmet istrumet deemed as weak. The MoH has sice approved a guide for pharmaceutical procuremet, a code of ethics for health professioals, ad moitorig of drug promotio. Mogolia Sice Phase I there have bee more trasparet procedures i the MoH ad regulatios as well as the developmet of guidelies such as atioal stadards o drug registratio. Also, geeral priciples for pharmacies ad for drug procuremet agecies have bee reviewed ad updated. I collaboratio with UNDP, the MoH ad the Pharmaceuticals ad Medical Devices Departmet set up a olie registratio system to improve licesig ad moitorig of drugs ad medical devices. Philippies The Govermet of the Philippies has developed a techical maual for good goverace dealig with the registratio, selectio ad procuremet of medicies. I August 2008, the govermet lauched a GGM awards system, i collaboratio with MeTA (Medicies Trasparecy Alliace). It ecourages local govermet uits, atioal health facilities or the private sector to develop iovative iitiatives that provide models for good goverace. Thailad There has bee a icrease i the umber of public hospitals that have adopted best practices i medicies procuremet. The hospitals have established a pooled purchasig scheme with a agreed list of medicies ad suppliers, resultig i more cost-effective procuremet. The atioal pharmaceutical laws ad regulatios have bee reviewed to assess whether they reflect curret best practice. Commuicatio with the public has icreased through the use of media, brochures ad websites. Miutes from the Natioal Medicie Committee meetigs are ow publicly available ad the topic of good goverace has bee added to the curriculum of 15 faculties of pharmacy. The Natioal Health Assembly is also focused o policy issues such uethical drug promotio ad curbig the ifluece of pharmaceutical compaies o medical doctors. 48 Fightig Corruptio i the Health Sector: Methods, Tools ad Good Practices

51 ANNEX 3. CITED PARTNERS FOR HEALTH AND ANTI-CORRUPTION Basel Istitute o Goverace: Europea Healthcare Fraud & Corruptio Network: Medicies Trasparecy Alliace (MeTA): Poverty Reductio ad Ecoomic Maagemet (PREM) etwork, World Bak: www1.worldbak. org/prem Supply Chai Maagemet System (SCMS): Trasparecy Iteratioal: UK Couter Fraud Service: WHO Good Goverace for Medicies (GGM) programme: html Fightig Corruptio i the Health Sector: Methods, Tools ad Good Practices 49

52 ANNEX 4. PROPOSED TERMS OF REFERENCE FOR COUNTRY CASE STUDIES ON ANTI-CORRUPTION IN THE HEALTH SECTOR Backgroud Corruptio i the health care sector exacerbates ay existig challeges health systems may face ad limits access of the populatio, particularly the poor ad vulerable, to essetial health care services. Absece of rules ad regulatios, lack of accoutability, low salaries ad limited offer of services (i.e., more demad tha supply) are amog the key reasos for corruptio i the health sector. The type of corruptio foud i the health sector is a by-product of the structure of the health care system ad its locatio withi it (for example, drug procuremet collusio or payig bribes to health professioals for public health services). The scale of corruptio is either petty (iformal paymets levied o public health services) or grad (the maufacture of couterfeit medicies for wide distributio), both types have adverse impacts o health care outcomes. Despite the widespread recogitio of the importace of addressig corruptio to meet health goals, such as the MDGs, there is ot a large body of empirical evidece which documets good practices. Objective The field research will ivestigate select corruptio risks i the health sector, ad what ati-corruptio itervetios have bee applied at the local ad/or atioal levels to address risks. Attetio will be give to what factors help ad/or hider ati-corruptio itervetios. Methodology First step: documet review Documets that are relevat to corruptio ad/or health specific to the coutry uder ivestigatio should be compiled ad aalysed for key themes. These may iclude reports from UN agecies, govermets, doors, civil society orgaizatios (particularly Trasparecy Iteratioal), academia ad the media. Commo themes, particularly areas of stregths ad weakess i the health sector, should be idetified. The purpose of this step is to provide backgroud iformatio o the health sector ad to uderstad why a ati-corruptio itervetio was warrated. Target areas iclude: health professioals, drug supply ad distributio, fiace, ad budget allocatio. Secod step: idetify priority ati-corruptio itervetios Based o the fidigs from the documet aalysis, ati-corruptio itervetios i priority areas may be idetified for further examiatio by coductig semi-structured iterviews with key iformats. Here, questios relevat for the health sector ad corruptio ca be draw from documets such as the USAID Ati-Corruptio Assessmet Hadbook ad the WHO Measurig Trasparecy i the Public Pharmaceutical Sector. Third step: key iformat iterviews Key iformats i the health sector should be idetified that would be kowledgeable about the aticorruptio itervetio ad the health sector i geeral. These may iclude represetatives from the Miistries of Health, Fiace, ad Justice, ati-corruptio istitutios, hospitals, pharmaceutical compaies, local drug maufacturers ad wholesalers, commuity health care facilities, iteratioal 50 Fightig Corruptio i the Health Sector: Methods, Tools ad Good Practices

53 ANNEX 4. PROPOSED TERMS OF REFERENCE FOR COUNTRY CASE STUDIES ON ANTI-CORRUPTION IN THE HEALTH SECTOR developmet agecies, doors, NGOs, media, ad patiets. The sowball techique (askig a key iformat for his/her suggestio about who to iterview) may also be helpful here. Questios for key iformats may be based o existig documets to esure appropriateess to the ati-corruptio itervetio ad health care sector target area. Questios should also iclude geeral oes such as: Why was the ati-corruptio itervetio iitiated? What was your role i the ati-corruptio itervetio? What fuctio or fuctios i the health sector is/are a target(s)? What specific corruptio risks were addressed? What type of approach was used i this ati-corruptio itervetio? Who participated i the itervetio (e.g., atioal govermet, local govermet, UN agecy, door)? What other sectors were addressed as part of this ati-corruptio itervetio? What are the results of the ati-corruptio itervetio? What evidece ca back it up? What have bee the eablig ad hiderig factors of the ati-corruptio itervetio s results? How were costraits dealt with? What sustaiability mechaisms were built ito the ati-corruptio itervetio? Have these bee effective? What lessos ca be draw from the ati-corruptio itervetio? Ca this itervetio be repeated? If so, how? Fourth step: mappig risks ad ati-corruptio itervetios Based o the documet aalysis ad key iformat iterviews, map corruptio risks i the health sector. Aalyse each risk ad try to assess whether the risk for corruptio is high or low. I additio to mappig corruptio risk, map ati-corruptio itervetio as below. Iformatio for each aticorruptio itervetio should iclude: Health fuctio Corruptio risk Legth of itervetio Results Success/failure factors Hiderig/fosterig factors Eablig policy ad cotext characteristics Sustaiability of itervetio Fightig Corruptio i the Health Sector: Methods, Tools ad Good Practices 51

54 ANNEX 4. PROPOSED TERMS OF REFERENCE FOR COUNTRY CASE STUDIES ON ANTI-CORRUPTION IN THE HEALTH SECTOR Fifth step: fial product The case study should address each step listed i the above focusig particularly o good practices, as well as a aalysis about the geeralizability of the fidigs. It should be limited to o more tha 30 pages. Team compositio: Team leader: solid experiece i the area of corruptio ad developmet ad experiece i preparig policy documets Fiace specialist: strog backgroud i health fiacig Procuremet specialist: kowledge of operatioal issues related to health supplies Health specialist: expertise of health system issues ad strog kowledge of the structure ad fuctios of the health system uder ivestigatio Qualitative methods specialist: experiece i compilig iformatio from documet aalysis ad coductig key iformat iterviews as well as preparig case studies Research assistat: experiece with project maagemet ad good orgaizatioal skills 52 Fightig Corruptio i the Health Sector: Methods, Tools ad Good Practices

55 ANNEX 5. CASE STUDIES FROM UGANDA, MALAWI AND TANZANIA: MAPPING GOOD ANTI-CORRUPTION PRACTICES IN SUB-SAHARAN AFRICA Objectives ad Methodology This aex presets the fidigs, coclusios, lessos ad recommedatios o good aticorruptio practices i the health sector i sub-sahara Africa. Specific case studies are draw from Malawi, Tazaia ad Ugada, which like most others i the regio have faced goverace challeges i the health sector that have cotributed to high levels of corruptio i various subsectors icludig drugs supply ad maagemet, huma resource maagemet, ad procuremet. The three coutries are all implemetig oe or more good goverace ad ati-corruptio programmes i the health sector that are discussed elsewhere i this report. Documets reviewed icluded reports from UN agecies, govermets, doors, civil society orgaizatios, academia ad the media. Commo themes, particularly areas of stregths ad weakess i the health sector, were idetified. The purpose of this step was to provide backgroud iformatio o the health sector ad to uderstad why a ati-corruptio itervetio was warrated. Target areas icluded health professioals, drug supply ad distributio, fiace, ad budget allocatio. The study was somewhat limited i scope give that it was largely desk-based ad there is a paucity of iformatio olie (especially updated iformatio). It is key that this process be take forward later o through i coutry assessmets ad evaluatios of idetified case studies. Additioal questios relevat for the health sector ad corruptio ca be draw from documets such as the USAID Ati-Corruptio Assessmet Hadbook ad the WHO Measurig Trasparecy i the Public Pharmaceutical Sector should. Key iformats i the health sector should iclude represetatives from the Miistries of Health, Fiace, ad Justice as well as ati-corruptio istitutios, hospitals, pharmaceutical compaies, local drug maufacturers ad wholesalers, commuity health care facilities, iteratioal developmet agecies, doors, NGOs, media, ad patiets. 2. Ugada Case Study: Icreasig Public Awareess ad Debate o Corruptio i the Health Sector through the Stop Stock-outs Campaig 2.1 Itroductio Accordig to the Third Progress Report o MDGs i Ugada (prepared by the Miistry of Fiace, Plaig ad Ecoomic Developmet i 2010), Ugada is ot o track to meet the health-related MDGs. Progress toward achievig several of the health targets, icludig those related to child ad materal mortality, access to reproductive health, ad the icidece of malaria ad other diseases, have progressed slowly. Ifat mortality remais at 85 per 1,000 live births while materal mortality is at 435 per 100,000 live births ad it is estimated that 16 wome die daily due to materal complicatios. After decliig for years, adult HIV prevalece has stabilized at about 6.4 percet, ad aual ew ifectios have rise amog older age groups ad those that are married/cohabitatig. 85 These cases studies were commissioed by UNDP ad prepared by AVID Developmet Ltd. i March The desk research was coducted by Alle Asiimwe with assistat from Ashaba Ahebwa ad Victor Agaba. Fightig Corruptio i the Health Sector: Methods, Tools ad Good Practices 53

56 ANNEX 5. CASE STUDIES FROM UGANDA, MALAWI AND TANZANIA: MAPPING GOOD ANTI-CORRUPTION PRACTICES IN SUB-SAHARAN AFRICA World Bak / Yosef Hadar Rapid populatio growth at 3.2 percet per aum cotiues to place stress o the health system while the global fiacial ad ecoomic meltdow is likely to result i reduced developmet assistace to Ugada. Compoudig these challeges is a heavily uderfuded health sector i compariso to what is eeded for implemetig the Natioal Health Policy (NHP) ad Health Sector Strategic Pla (HSSP), ad achievig the targets outlied i the MDGs. Govermet budget expediture i the health sector curretly stads 11.6 percet (FY 2008/09), a level still below the Abuja target of 15 percet. Fudig gaps for idividual health service provisio with per capita expediture are at US$25 (of which oly US$7 is from govermet source) compared to HSSP II target of US$28 ad WHO target of US$40. I the 2009/10 budget, pharmaceutical supplies icludig medical drugs were allocated 301 billio Ugada shilligs (US$105 millio), which accouted for 47 percet of the total budget allocatio to the health sector. Oly 2 percet of the health sector budget is apportioed to Moitorig ad Evaluatio. 2.2 Corruptio i the health sector A big portio of the amout allocated to drugs ad supplies is however wasted through leakages ad pilferage; accordig to oe aalysis, a estimated 22.3 billio shilligs (US$7.9 millio) was lost i FY 2006/07 (Bjorkma ad Sveso). As a result, access to essetial medicies ad supplies i Ugada icludig ati-malarials, atiretroviral drugs (ARVs), cotraceptives, gloves ad mama kits remais low. Curretly, there is a umet eed of 41 percet for cotraceptives (UBOS- UDHS, 2006) ad it has bee reported that 300 people die daily of malaria-related complicatios. Accordig to the Public Expediture Review (PER) o the health sector i 2008, the availability of drugs is the most sigificat determiat of whether people atted public health facilities. 54 Fightig Corruptio i the Health Sector: Methods, Tools ad Good Practices

57 ANNEX 5. CASE STUDIES FROM UGANDA, MALAWI AND TANZANIA: MAPPING GOOD ANTI-CORRUPTION PRACTICES IN SUB-SAHARAN AFRICA There is lack of credible data o distributio ad use of essetial medicies but several studies idicate high levels of drug leakage ad massive stock-outs. The 2008 PER o the health sector oted that data o drugs released by the Natioal Medical Stores (NMS) explaied oly 7 percet of the data o drugs received by facilities while the Fiacial Maagemet Programme (FINMAP) Review (November 2009) foud low levels of recordig ad stock updates i all health facilities visited. I the recet past, the health sector has bee hit by a wave of high-profile corruptio scadals ivolvig the direct pilferage of drugs ad misuse of resources. Millios of dollars have bee lost resultig i the suspesio of fudig from global iitiatives such as the Global Fud to Fight AIDS, Tuberculosis, ad Malaria ad the GAVI Alliace. Ivestigatios ad prosecutios of accused officials are ogoig; however, follow-up ad eforcemet remai weak. Withi districts ad at health facilities, corruptio is largely maifested through bribes ad iformal paymets for services ad drugs; pilferage ad misuse of health facilities ad equipmet; ad abseteeism. For example, abseteeism across the sector is aroud 40 percet i all facilities, ad ears 50 percet for midwives ad urses Risks that exacerbate iefficiecies ad corruptio i the health sector The existig policy ad istitutioal framework 87 for drugs maagemet leds itself to potetial overlaps ad duplicity ad potetially provides opportuity ad a coducive eviromet for mismaagemet, corruptio ad pilferage Difficulties i trackig drugs amog the MoH, districts ad health cetres 88 Weakesses i procuremet plaig (e.g., some procuremets were ot approved by the cotract committees, ad irregularities i the procuremet of ARVS) Icosistecies i drug storage ad distributio (e.g., regardig trasportatio of drugs, recocilig of ledgers, collectio of drugs from districts by health cetres) Drug shortages ad stock-outs, iadequate storage facilities ad expired drugs Poor supervisio ad moitorig The impact icludes wastage of medical equipmet ad massive stock-outs of essetial drugs, vaccies ad cotraceptives. Empty medicie cupboards are the orm ad vaccie stocks are ot updated by health cetres. Millios of Ugadas are still uable to access essetial medicies i govermet health facilities ad Ugada s efforts to meet its commitmets to improvig the health rights of its citizes are hampered. I some cases, drug stock-outs have resulted i the loss of lives e.g., where drugs are ot accessible to treat diseases like malaria. 86 Ugada Miistry of Health, Ugada Service Provisio Assessmet Survey Drugs maagemet has a broad et work of iterdepedet istitutioal etities icludig the Miistry of Health, the Natioal Medical Stores (NMS), the Natioal Drug Authority (NDA), the Miistry of Fiace, Plaig ad Ecoomic Developmet, local govermets, private-sector orgaizatios, door orgaizatios, third party programmes (such as the Global Fud ad PEPFAR), ad NGOs. Also of relevace are existig policies, laws ad regulatios icludig the Public Procuremet ad Disposal of Public Assets Act of 2003 (PPDA), 88 Audit by the Office of the Auditor Geeral i the maagemet of health programmes i the health sector (March 2009). Fightig Corruptio i the Health Sector: Methods, Tools ad Good Practices 55

58 ANNEX 5. CASE STUDIES FROM UGANDA, MALAWI AND TANZANIA: MAPPING GOOD ANTI-CORRUPTION PRACTICES IN SUB-SAHARAN AFRICA 2.4 Ogoig reforms I a bid to ehace drugs maagemet ad miimize leakages, the Govermet of Ugada i November 2009 cetralized all medicies fudig i the Natioal Medical Stores (NMS). Fuds for the purchase of drugs are ow chaelled directly from the Miistry of Fiace, Plaig ad Ecoomic Developmet (MoFPED) to NMS as opposed to the previous system of chaellig fuds directly to the districts ad health facilities. This traslates to 75 billio shilligs (US$27 millio) beig trasferred to NMS for FY 2009/10, a amout that has icreased to 110 billio shilligs (US$39 millio) i the FY 2010/11 FY. A review of recommedatios by previous studies 89 idicates that cetralizatio of fudig ad procuremet for drugs ad essetial medicies supplies has bee a logstadig recommedatio that may address some of the cocers i the sector. Several studies/reviews 90 of NMS have highlighted key challeges ad costraits that affect its effective performace ad cotribute to the existig goverace weakesses. NMS has bee ewly restructured ad is uder ew maagemet; evertheless, it has made commitmets to addressig gaps ad to a zero policy o corruptio. Iteral reforms 91 are uder way with a ew priority product list of 256 items developed, a operatioal maual revised, ad a pricig survey udertake to revisit overpriced items. Proposals are uder way to establish a list of essetial drugs ad items that must be available at each Health Cetre II ad III, icludig ati-malarials, cotraceptives, drugs ad mama kits. NMS iteds to pilot delivery of drugs dow to the lower level sub-district health cetres, ulike the curret policy of delivery to the district level. It NMS has also developed a procuremet policy ad processes maual, with required modificatios expected to address specific peculiarities of procuremet of drugs ad to reduce bottleecks i implemetig the regulatios ad provisios of the Public Procuremet ad Disposal of Public Assets Act of 2003 (PPDA) act. The revised maual was submitted to PPDA for accreditatio i February The Medicies Trasparecy Alliace (MeTA) is workig through a multi-stakeholder group (the MeTA Coucil 92 ) to implemet a work pla aimed at brigig iformatio ito the public domai e.g., o the cost of medicies at poit of etry ad recogitio of essetial drugs. MeTA is also udertakig a pricig survey for drugs i Ugada ad mappig the medicie supply chai. Loopholes, however, still exist i the value chai as evideced by the various studies, audits ad media reports. 89 Icludig the techical review of NMS by Euro Health Group Cosultats (May 2004) ad a World Bak study (August 2006) o the role of NMS i the public ad private health care system i Ugada. 90 Icludig the NMS Task Force Report (2008); ad a USAID-supported assessmet of warehouses, distributio ad maagemet iformatio (October 2007). 91 NMS Progress Report (July-December 2009). 92 The MeTA Coucil comprises represetatives from the MoH, the private sector (icludig pharmaceutical compaies), the Natioal Drug Authority, the Pharmaceutical Society of Ugada, ad civil society groups icludig the Ugada Natioal Health Users Orgaisatio (UNCHCO), HEPS ad the Ugada Protestat Medical Bureau. Also ivolved are developmet parters such as the World Bak ad WHO. 56 Fightig Corruptio i the Health Sector: Methods, Tools ad Good Practices

59 ANNEX 5. CASE STUDIES FROM UGANDA, MALAWI AND TANZANIA: MAPPING GOOD ANTI-CORRUPTION PRACTICES IN SUB-SAHARAN AFRICA 2.5 Massive stock-outs i health facilities Despite these reforms, health cetres at all levels cotiue to face massive stock-outs of essetial medicies. These medicies were origially defied by the World Health Orgaizatio (WHO) 93 as those which satisfy the eeds of the majority of the populatio ad therefore should be available at all times, i adequate amouts, i appropriate dosage forms ad at a price the idividual ad commuity ca afford. Exactly which medicies are regarded as essetial remais a atioal resposibility but ufortuately corruptio greatly iterferes with this process. Whe a pharmacy (i a medical store or health facility) temporarily has o medicie o the shelf, it is kow as a stock-out. It may affect oe medicie or may medicies, or i the worst case, all medicies. A stock-out ca be documeted at oe poit i time or over a period of days, weeks or moths. Whe there is good stock maagemet systems i place, the stock-out duratio will be miimal or, ideally, ever. I Ugada, it is ot clear what percetage of stock-outs are a result of corruptio or poor maagemet. I 2010 the health miister said the followig: Oly 26 percet of public facilities were able to get through the last year without a stock-out of ay of the six sector tracer medicies.factors rage from iadequate fiacig for medicies, low levels of appropriately skilled huma resources for health i the health facilities ad more especially low maagemet capabilities at the differet levels ad iefficiecies The Stop Stock-outs campaig: ivolvig the public i oversight The Stop Stock-outs campaig is a regioal campaig i six coutries i Africa icludig Keya, Madagascar, Malawi, Ugada, Zambia ad Zimbabwe aimed at edig stock-outs of essetial medicies i public health facilities. At the regioal level, the campaig is spearheaded by Health Actio Iteratioal (HAI)-Africa ad Oxfam ad supported by other stakeholders such as MeTA, the Ope Society Foudatios ad atioal civil society orgaizatios (CSOs). I Ugada, the campaig was coordiated by a cosortium of five CSOs (HEPS Ugada, AGHA, AIDE, ACFODE, ad NAFOPAHU) 95 ad lauched i March 2009 for oe year. 96 The Stop Stock-outs campaig was crafted as a public media campaig aimed at puttig the issue oto the atioal ageda. Based o iformatio geerated from previous studies udertake by cosortium members 97, a baselie was established o the availability ad affordability of medicies i public health facilities ad i the private sector, icludig missio hospitals. The aalysis idicated that certai specific ad commoly used medicies were available oly a average of 50 percet of the time i public health 93 See 94 Excerpt from a speech by the-miister of Health Stephe Malliga at a pharmaceutical policy optios workshop supported by USAID i Kampala, 15 April The Coalitio for Health Promotio ad Social Developmet i Ugada (HEPS), the Actio Group for Health, Huma Rights ad HIV/ AODS (AGHA), the Natioal Forum for People Livig with HIV/AIDS i Ugada (NAFOPHANU), Actio for Developmet (ACFODE) ad the Alliace for Itegrated Developmet ad Empowermet (AIDE). 96 The campaig though lauched for a period of oe year cotiues to ru. The Ushiadi website- is still operatioal showig status of stock-outs i the differet coutries 97 HEPS had udertake umerous studies from 2005 o the availability ad affordability of medicies ad the data were cotaied i its quarterly progress reports Fightig Corruptio i the Health Sector: Methods, Tools ad Good Practices 57

60 ANNEX 5. CASE STUDIES FROM UGANDA, MALAWI AND TANZANIA: MAPPING GOOD ANTI-CORRUPTION PRACTICES IN SUB-SAHARAN AFRICA facilities. The comparable figure i the private sector was more tha 70 percet, but the drugs were more expesive i that sector ad thus ot affordable to may. The campaig was started with a series of capacity buildig workshops for CSOs ad the media workig o health-related issues. The traiig was essetial i simplifyig health issues ad creatig uderstadig amog CSOs ad media of medicies-related issues ad moitorig. I additio, clear, simple ad well defied messages were crafted to be used i media advocacy. Followig the traiig, the cosortium udertook a Pill Check Week 98. This ivolved a spot check of medicie stock-outs i public health facilities. It was carried out i 11 of the coutry s 81 districts, each of which was represeted by oe govermet facility. The check covered 10 key essetial medicies ad foud that stock-outs, especially of paediatric preparatios ad ati-malarials, were still a major problem. 99 After visitig the various cliics ad pharmacies, activists reported their results usig mobile phoes through structured, coded text messages (SMS) that were uploaded o a website called Ushahidi, which meas testimoy i Swahili 100. The website used Google Maps to show specific locatios of up to 250 stock-outs of essetial medicies. Based o the results of the Pill Check Week, the Ugada coalitio issued a press statemet ad called upo the Ugada Govermet to: 101 Give fiacial ad operatioal autoomy to NMS, the atioal medicies procuremet ad supply agecy Istall civil society represetatio o the board of NMS. Ed corruptio i the medicie supply chai Stop theft ad diversio of essetial medicies Take a proactive role i stregtheig the watchdog role of accoutability mechaisms such as Parliamet, the Ispectorate of Govermet (IGG), the Directorate of Public Prosecutios (DPP) ad CSOs by meaigfully ivolvig them i decisio makig ad moitorig the delivery of health care ad use of resources for health Provide a dedicated budget lie for essetial medicies Fulfil commitmets to sped 15 percet of the atioal budget o health care Provide free essetial medicies at all public health istitutios The Ugada campaig used a variety of approaches largely aimed at icreasig public awareess ad geeratig debate o key issues relatig to drugs stock-outs. These approaches have icluded the use of publicity materials like t-shirts, baers, fact sheets, fliers ad policy briefs ad idetifyig champios icludig a local artist ad female Member of Parliamet. Press statemets ad cofereces, public rallies, radio talk shows ad media articles were used to geerate public debate i the media. 98 The Pill Check Week took place i all five of the Africa coutries participatig i Stop Stock-out campaigs ad used a Google map to idetify where the stock-outs were a reality. Olie: 99 See The Pill Check Week took place i Jue Ushahidi is a website that was first developed to map reports of violece i Keya after the post-electio fallout at the begiig of Olie: See 58 Fightig Corruptio i the Health Sector: Methods, Tools ad Good Practices

61 ANNEX 5. CASE STUDIES FROM UGANDA, MALAWI AND TANZANIA: MAPPING GOOD ANTI-CORRUPTION PRACTICES IN SUB-SAHARAN AFRICA Box 1. Use of Frotlie SMS 102 FrotlieSMS is free ope source software that turs a laptop ad a mobile phoe ito a cetral commuicatios hub. Oce istalled, the programme eables users to exchage text messages with large groups of people through mobile phoes. It was ivaluable to the Stop Stock-outs campaig by ecouragig the public to voluteer iformatio o the status of drugs i health cetres because it is so easy ad affordable to use. Frotlie SMS was used durig the Pill Check Week campaig where SMS text messages were set by data collectors o the status of stock-outs of essetial medicies. The messages were received o phoes i Malawi, Keya, Ugada ad Zambia where computers ruig Frotlie SMS processed ad validated the data before sedig it to a Ushahidi iterface to be visualized o the Web. After visitig cliics ad pharmacies, activists reported their results usig their mobile phoes through structured, coded text messages that were uploaded o Ushahidi. Data were reflected o a map o the website showig specific locatio of up to 250 stock-outs of essetial medicies. 2.7 Achievemets of the campaig ad lessos idetified 103 The Stop Stock-outs campaig was iitially iteded for oe year startig from March 2009, but was reewed i July 2010 ad cotiues to ru to date because of its successes. The campaig has bee widely reported i the media icludig radio, televisio, prit ad iteret. It has prompted resposes from wide sectios of society ad geerated public debate o medicie stock-outs, their causes ad possible solutios. Articles ad stories cotiue to appear regardig medicie stockouts i public health facilities, icludig about arrests ad prosecutio of health workers caught stealig drugs. The campaig also attracted the attetio of the key govermet agecies. For istace, NMS respoded to the media reports with a statemet ad persoel were cited i ewspaper articles explaiig the causes of stock-outs (icludig the challeges); may also blamed other players, particularly health facilities, for delayed orders. Members of the Social Services Committee of Parliamet made a uaouced visit to NMS to ascertai the stock levels ad causes of stock-outs. The campaig is also credited with cotributig to ifluecig the govermet s decisio to cetralize procuremet ad distributio of drugs uder NMS ad limit the resposibility of district govermets for procuremet of drugs. O 31 August 2009, Parliamet passed the atioal budget, approvig a separate budget lie for NMS for the first time ever. This meas that moey for medicies will o loger go through the MoH. It is expected that the decisio will reduce bureaucracy ad fragmetatio ad icrease resources for medicie procuremet o a timely basis. I October 2009, the Presidet s Office aouced the establishmet of the Medicies ad Health service Delivery Moitorig Uit of State House, with a madate to ivestigate ad curb theft of 102 See ad Iterview with Rosette Mutambi, executive director of HEPS, who coordiated the CSO cosortium that developed ad implemeted the Stop Stock-Outs campaig i Ugada Fightig Corruptio i the Health Sector: Methods, Tools ad Good Practices 59

62 ANNEX 5. CASE STUDIES FROM UGANDA, MALAWI AND TANZANIA: MAPPING GOOD ANTI-CORRUPTION PRACTICES IN SUB-SAHARAN AFRICA medicies i govermet hospitals ad ehace smooth delivery of medicies ad health services to the people of Ugada. Several medical practitioers ad officials (icludig doctors, ursig aides, cliical officers) have bee arrested, maily those at a low level i the drugs supply chai. A report preseted by the Medicies Uit i September 2010 stated that some 5 billio shilligs (US$1.77 millio) worth of stole drugs had bee recovered. As may as 80 cases have bee brought to court to date across the coutry, with at least five covictios secured so far. Overall, the Stop Stock-outs campaig has raised more awareess about the right to health ad to access essetial medicies i Ugada ad icreased public participatio i the health system. The public are becomig more active i debatig the issues, reportig stock-outs ad holdig istitutios to accout while the govermet is respodig to the campaig i a positive way ad chages are takig place at policy ad implemetatio level. Lessos idetified: The Stop Stock-Outs campaig was a cocerted effort of several stakeholders. The capacitybuildig workshop (supported by MeTA) at the start of the campaig was critical i creatig uderstadig amog CSOs ad the media of medicies-related issues ad establishig bechmarks for moitorig. The cosortium relied o existig data ad iformatio by the members ad by the MoH which was used to create sufficiet material ad evidece for the campaig. The MeTA Coucil (a cosortium of stakeholders i the health sector) was used as a platform to provide iput ad debate materials used for the campaig, thereby ehacig stakeholder support. This support helped build success for the campaig. The cosortium of CSOs also worked through its etworks at the commuity level i various commuities (icludig Kiseyi ad Kawempe), thereby ehacig commuity owership of the campaig. By usig clear, simple, well defied ad cosistet messages, the cosortium was able to simplify health related issues ad edear the local populatio to the campaig. Through use of simple ad affordable social media tools such as text messagig, CSOs were able to get the public egaged i idetifyig gaps ad fightig corruptio i the drugs supply chai. The public support garered through the campaig was critical i propellig duty bearers to iitiate reforms to address the pilferage of drugs. The eed to ehace the effectiveess of the campaig especially i followig up ad sactioig cases of corruptio was oted. Existig laws are weak, leadig to poor or ieffective sactios for those that are arrested ad covicted, while the capacity of law eforcemet officers to ivestigate ad prosecute drug related crimes is also limited. I additio, strog leadership ad political will are eeded to eforce maagemet ad istitutioal reforms that will miimize iefficiecies ad reduce opportuities for corruptio ad theft of drugs. 60 Fightig Corruptio i the Health Sector: Methods, Tools ad Good Practices

63 ANNEX 5. CASE STUDIES FROM UGANDA, MALAWI AND TANZANIA: MAPPING GOOD ANTI-CORRUPTION PRACTICES IN SUB-SAHARAN AFRICA UN Photo/Eva Scheider 3. Malawi Case Study: Measurig Levels of Trasparecy ad Vulerability i the Health System through the Good Goverace for Medicies Programme 3.1 Itroductio Malawi s health idicators are overall extremely poor. Life expectacy declied from 48 to 39 years betwee 1990 ad 2000, maily as a result of AIDS. Materal mortality is shockigly high ad has worseed sice 1990, suggestig a sigificat declie i the overall health ifrastructure ad ability to deliver accessible emergecy obstetric services. Achievig the MDGs i Malawi is a major challege i the face of icreasig levels of poverty. Sixty-five percet of the populatio is uable to meet their daily utritioal eeds. Fertility rates are high ad the HIV/AIDS epidemic has icreased demad for health services, while reducig the health sector capacity. Access to health services is modest ad skewed i favour of o-poor ad urba populatios. Oly 54 percet of the rural populatio has access to a health facility withi five kilometres. Oly 10 percet of all health facilities have the capacity to deliver the essetial health package. Frot-lie health services suffer from lack of drugs, poor staff-cliet relatios, ad poor quality diagosis ad treatmet. Public services are free of charge at the poit of delivery, but out-of-pocket expediture accouts for 26 percet of total health spedig, with the poorest households spedig up to 10 percet of their aual cosumptio o health care. The poor have the greatest burde of ill health ad are the least likely to access health services DFID Programme Memoradum, Improvig health i Malawi: a sector-wide approach icludig essetial health package ad emergecy huma resources programme (2005/ /11). Olie: Fightig Corruptio i the Health Sector: Methods, Tools ad Good Practices 61

64 ANNEX 5. CASE STUDIES FROM UGANDA, MALAWI AND TANZANIA: MAPPING GOOD ANTI-CORRUPTION PRACTICES IN SUB-SAHARAN AFRICA 3.2 Corruptio i the health system Malawi has i the past bee raked as a highly corrupt coutry ad corruptio has bee a major problem i drugs procuremet ad the supply chai. The World Bak assessed the risk as high whe it coducted a Coutry Procuremet Assessmet Review i 2004, followig a procuremet capacity assessmet of the Miistry of Health (MoH) ad Cetral Medical Stores i December Box 1. Goverace risks ad challeges i the health system i Malawi Chroic uder fudig of the health sector leadig to provisio of poor quality services Iefficiet procuremet ad distributio systems Uethical practices that iclude corruptio ad pilferage Cosistet shortage of essetial drugs ad medical supplies at service delivery poits Limited pharmaceutical maufacturig base ad over-depedece o the importatio of medicies from foreig maufacturers Iadequate capacity of the Pharmacy, Medicie ad Poisos Board to eforce legislatio ad regulatios relatig to cotrol of medicies i Malawi High poverty rates ad high costs of quality drugs lead the poor to seek cheaper ad ofte usafe optios 3.3 Ogoig reforms: Malawi has i the last decade itroduced greater fiscal disciplie ad fiduciary reforms. A ew public procuremet system is beig implemeted. Doors are supportig govermet plas to istitutioalize political reform i the hope that stroger istitutios will make backslidig more difficult. Fiacial maagemet ad procuremet procedures have bee developed for the sectorwide approach (SWAp), offerig safeguards while simultaeously buildig capacity at cetral ad district levels. These iclude time-boud fiacial maagemet ad procuremet improvemet plas, a commitmet to fill accoutat vacacies, idepedet fiacial ad procuremet audits, ad log-term techical assistats with metorig, maagemet ad supervisory resposibilities 105. Several strategies have bee desiged, especially by developmet parters, to improve the operatios of the health system ad to combat corruptio i the sector. I December 2004 DFID agreed to provide 100 millio (US$158 millio) to the Govermet of Malawi to support the health sector over a period of six years (2005 through 2011). DFID is poolig its cotributio to the SWAp i health with the World Bak ad some other bilateral parters. Other bilateral doors ad the Global Fud support the health sector through project fudig. 105 See 62 Fightig Corruptio i the Health Sector: Methods, Tools ad Good Practices

65 ANNEX 5. CASE STUDIES FROM UGANDA, MALAWI AND TANZANIA: MAPPING GOOD ANTI-CORRUPTION PRACTICES IN SUB-SAHARAN AFRICA 3.4 Assessig vulerability i the health system through the Good Goverace for Medicies programme I implemetig the Good Goverace for Medicies (GGM) programme at coutry level, two strategies 106 were idetified to fight corruptio: Disciplie-based strategy: establishig ati-corruptio laws, as well as legislatio ad regulatio for the maagemet of the pharmaceutical sector. Values-based strategy: buildig istitutioal itegrity through the promotio of moral ad ethical practices. A three-phase approach was idetified by WHO as follows 107 : Phase I: Natioal assessmet of trasparecy ad potetial vulerability to corruptio usig the WHO stadardized assessmet istrumet which focuses o the followig cetral fuctios of the pharmaceutical sector: registratio of medicies ad cotrol of their promotio ispectio ad licesig of establishmets selectio, procuremet ad distributio of essetial medicies cotrol of cliical trials Phase II: Developmet of a atioal framework for promotig Good Goverace for Medicies i the public pharmaceutical sector. Oce the assessmet is doe, defiig the basic compoets of the GGM framework will be udertake through a atiowide cosultatio process with key stakeholders. These compoets might iclude: a ethical framework ad code of coduct, regulatios ad admiistrative procedures, collaboratio mechaisms with other good goverace ad ati-corruptio iitiatives, whistleblowig mechaisms, sactios for reprehesible acts ad a GGM implemetig task force. Phase III: Implemetig the atioal Good Goverace for Medicies programme, a effort that icorporates a fully-itegrated istitutioal learig process i the applicatio of ew admiistrative procedures for icreased trasparecy/accoutability ad the developmet of leadership capabilities. 106 WHO (2010), Good goverace for medicies: curbig corruptio i medicies regulatio ad supply. Olie: medicies/areas/policy/goodgoverace/encurbigcorruptio4may2010.pdf. 107 Ibid. Fightig Corruptio i the Health Sector: Methods, Tools ad Good Practices 63

66 ANNEX 5. CASE STUDIES FROM UGANDA, MALAWI AND TANZANIA: MAPPING GOOD ANTI-CORRUPTION PRACTICES IN SUB-SAHARAN AFRICA Table 3. GGM Three-step approach 108 MoH clearace Phase I Phase II Phase III Natioal trasparecy assessmet Assessmet report Developmet of a atioal GGM programme GGM framework officially adopted Implemetatio of atioal GGM programme GGM itegrated i the MoH pla 3.5 Implemetatio of GGM Phase I ad II i Malawi 109 Malawi was the first Africa coutry to start implemetig the GGM programme. Two govermet officials were omiated as well as two assessors from the local Maagemet Scieces for Health (MSH) office. They were traied o the trasparecy assessmet methodology i March 2007, after which a atioal assessmet was udertake to assist i measurig the level of corruptio i the pharmaceutical sector. This etailed a assessmet of the level of trasparecy ad potetial vulerability to corruptio i a few key fuctios i the health sector i.e., medicies registratio, cotrol of medicie promotio, ispectio of establishmets, selectio of essetial medicies, ad procuremet of medicies. A assessmet report ad recommedatios were prepared ad adopted by a atioal workshop i July I May 2008, the Malawi MoH authorized WHO to publish the report; the report was formally lauched i July The assessmet showed that key fuctios of the pharmaceutical sector i Malawi are very vulerable to corruptio, maily because of a umber of lapses i the good goverace for medicies mechaisms. The fuctios foud most vulerable to corruptio i Malawi s pharmaceutical sector were drug promotio, followed by drug selectio, procuremet ad registratio 110. Assessig the level of trasparecy ad potetial vulerability to corruptio is ot a ed i itself but rather the begiig of a log process iteded to geerate good goverace i the pharmaceutical sector. Followig the adoptio of the report at the highest levels of govermet, a atioal GGM team was omiated by the MoH, resposible for i) the developmet ad fializatio of the framework documet i cosultatio with all key stakeholders ad ii) the overall maagemet, coordiatio ad evaluatio of the GGM programme. The report authorizes the GGM team to implemet ad promote good goverace i the pharmaceutical sector. GGM traiig for Phases II ad III was orgaized to kick-start implemetatio Ibid. 109 WHO Good Goverace for Medicies programme progress report, February Olie: uploads/2009/11/s16218e1.pdf. 110 WHO (2008), Measurig trasparecy to improve good goverace i the public pharmaceutical sector i Malawi, p. vii. 111 See 64 Fightig Corruptio i the Health Sector: Methods, Tools ad Good Practices

67 ANNEX 5. CASE STUDIES FROM UGANDA, MALAWI AND TANZANIA: MAPPING GOOD ANTI-CORRUPTION PRACTICES IN SUB-SAHARAN AFRICA 3.6 Achievemets ad lessos from the GGM programme i Malawi The methodology used is key to esure objectivity ad accuracy of iformatio. I Malawi, the atioal assessmet was carried out by idepedet atioal assessors, usig the stadardized WHO assessmet istrumet. The atioal assessors collected iformatio through a combiatio of desk research ad semi structured iterviews with 57 key iformats ad the orgaized ad aalysed the data to geerate the results are preseted i a report. This report showed that Malawi has a dautig task i combatig corruptio ad bribery i the pharmaceutical sector. The study results idicate that geerally the sector suffers from extreme vulerability to corruptio (i.e., a score of 3.36 o a 1.00 to ratig scale). Some key fuctioal areas exhibit very low levels of trasparecy due to poor good goverace mechaisms while other areas barely have ay mechaisms for trasparecy ad good goverace 112. The assessmet came up with key recommedatios iteded to provide guidace i the fight agaist corruptio i the health sector i Malawi. These iclude 113 : The eed for icreased iformatio sharig withi the pharmaceutical sector through traiig ad motivatio of those directly or idirectly ivolved with medicies. The govermet should provide stadard operatig procedures ad guidelies o coflict of iterest (COI) i writte form (icludig procedures to be followed i the process of declarig COI ad clear, simple forms to be completed by those ivolved). These prerequisites should be publicly available ad easily accessible. The govermet should esure the promotio of proper, publicly available ad speedy public tederig procedures for medicies. The govermet should esure that there is improved commuicatio with all istitutios ivolved i medicie registratio, promotio, ispectio, selectio, procuremet ad distributio. As a result of this trasparecy study, the Govermet of Malawi has a better idea of the vulerability areas i the health system ad may be able to idetify effective strategies to stamp out corruptio ad provide better quality health services to the populatio. As part of the reforms, the govermet has begu to put i place mechaisms to esure the availability ad accessibility of essetial drugs ad stregtheig istitutioal capacity for moitorig of drugs distributio ad quality. Followig the successful coclusio of the assessmet stage, GGM traiig for Phases II ad III was orgaized ad is uder way. Lessos idetified iclude the followig 114 : The GGM assessmet/process is ot a oe off but a log term itervetio that requires commitmet at all levels. I Malawi, the process betwee the assessmet i 2007 ad its adoptio i 2009 was legthy ad it is importat to ackowledge that some coutries eed 112 Ibid. 113 Ibid. 114 WHO Good Goverace for Medicies programme progress report, February Olie: uploads/2009/11/s16218e1.pdf. Fightig Corruptio i the Health Sector: Methods, Tools ad Good Practices 65

68 ANNEX 5. CASE STUDIES FROM UGANDA, MALAWI AND TANZANIA: MAPPING GOOD ANTI-CORRUPTION PRACTICES IN SUB-SAHARAN AFRICA more time tha others, depedig o their political situatio ad the availability of huma resources to carry out GGM activities. High-level commitmet ad political buy-i ad owership at the highest levels of govermet is crucial for the success of the programme. I Malawi, the health miister ad presidet ivited WHO to implemet this programme ad took iterest to esure a credible assessmet was coducted. High-level commitmet has proved to be beeficial, ot oly for raisig the profile of such a sesitive programme, but also for esurig its sustaiability. Parterig with atioal ati-corruptio or good goverace bodies is extremely valuable, together with costat commuicatio ad discussio of issues ad staff traiig. I Malawi, the teams udertook a series of traiigs both i-coutry ad elsewhere. UN Photo 4. Tazaia Case Study: Stregtheig Istitutioal Capacity of the Tazaia Food ad Drug Authority through the WHO-HAI Africa Regioal Collaboratio for Actio o Essetial Medicies 4.1 Overview of the pharmaceutical sector The total medicie budget for the Tazaia public sector for the year 2000 was US$14.1 millio, but the aual amout had early tripled by 2008, to US$44 millio. The procuremet, supply ad distributio systems i the public sector are orgaized through the Medical Stores Departmet (MSD), which receives orders from regioal, district ad missio hospitals. Procuremet is doe 66 Fightig Corruptio i the Health Sector: Methods, Tools ad Good Practices