We suggest you start by understanding in detail the different corruption types that you are faced with. You can do this in the following way:

1. Look at the template of the different sector corruption types in our review. Use this as the basis of your identification of the corruption types in your situation.
2. Gather available data. We suggest that you do this first at a macro level, to get a sense of which corruption issues are big or small across the sector, regions and/or countries. Often there is a lot of such macro data publicly available. Then, gather available data at the micro level, local to you.
3. Decide if it would help to do a formal analysis of the corruption types and the levels of corruption risk. This takes time but gives you a thorough baseline for your reforms. It also serves to show the level of danger and damage from corruption to staff and to the public.
4. Consider doing an analysis of the levels of support and opposition that you can expect. This is called a ‘political economy analysis’.
5. Prepare for the later step in which you develop your strategy (Step 4) by thinking about which the best ‘entry points’ are likely to be – certain corruption types, regardless of scale, merit being tackled first because they are the most likely to build momentum and/or enable further reform. This choice of starting point is hugely context dependent.

You can read more guidance on Step 1 here.

Transparency International’s Pharmaceuticals and Healthcare programme (ti-health.org) lists 37 different corruption issues across pharmaceuticals and healthcare, as shown opposite.

There are also other ways you can categorise the corruption types. For example, you could categorise them by the categories of people involved in corruption:

• Insiders– administrative staff, doctors and other healthcare professionals – taking advantage of vulnerabilities in the health system for personal enrichment
• Insiders taking shortcuts to make the system work. These often start out with good intent, such as speeding up the process to get an essential result, like a vital spare part for a hospital scanning machine. But such shortcuts afterwards can easily become avenues of corruption
• Outsiders with have power and influence, who force the above two types of people to be corrupt according to their requirements; up to and including getting them appointed in the first place.
• Supplier companies, including pharmaceutical companies, both national and international
• Patients, because paying a bribe may give them more certainty of outcome, such as achieving a better position on a waiting list or access to an ICU bed. This is ‘sort of’ voluntary, but it is also a form of extortion.

Or you can categorise the issues using a ‘value chain’ perspective. This was done by Savedoff and Grepin (2012), for example, in application to the health system in Ethiopia. See opposite:

Reform measures will always be specific to the particular circumstances. Nonetheless, in order to get ideas and insights, it helps to learn about reforms employed elsewhere and to have a mental model of the type of what sorts of reforms are possible. We recommend you consider each of these ten reform approaches:

1. Functional approaches: improving institutions, public financial management, systems and controls
2. People-centred approaches: building networks and coalitions of supporters
3. Monitoring approaches: strengthen oversight groups and their independence
4. Justice & rule of law approaches: prosecuting, raising confidence, improving laws
5. Transparency approaches: making visible what others wish to keep hidden
6. Integrity approaches: motivating, instilling pride and commitment
7. Whistleblowing approaches: finding safe ways for people to speak up
8. Civil society and media: creating space for external voices
9. Incentives and economic theory approaches: aligning stakeholders and economics
10. Nudge approaches: new science show how small changes can make a big difference

Talking through with colleagues and stakeholders how each of them might work in your environment enables you to ‘circle around’ the problem, looking at different ways and combinations to tackle it. A reform strategy might, for example, consist of some institutional improvement projects, plus strengthening integrity among staff, plus strengthened sanctions and discipline.

You can read more guidance on Step 2 here.

2.1.1 Service delivery and clinical reforms

This is where the anti-corruption work will be most clinically facing. There are likely to be multiple initiatives and reforms going on at any one time to improve service delivery in a national health system. Such work to improve patient outcomes is the core business of any health system, and the corruption aspect will only be one element of this. The way that clinical protocols and pathways operate is very closely linked to the corruption opportunities that they throw up, whether this be for unnecessary procedures, or overtly expensive ones, or pathways that favour one medical group over another, and so on. This is as true in developed country environments as in developing country situations.

Example: Preventing informal payments in Armenia through a child certification programme.  The Health system in Armenia is complex but underfunded, and much of the payment for services comes directly from citizens, of which about 70% are for ‘informal payments’, rather than for official services or payment for medicines. This reform initiative focused on informal payments for child health, and a ‘Child Health State Certification Program’ was designed and implemented. USAID reported as follows: ‘The findings of the quantitative assessment clearly demonstrated that the Child Health State Certificate Program significantly reduced informal payments for paediatric inpatient care for children 0-7 years of age and increased accessibility of care for those who could not afford it previous to the program’ (USAID, 2011).

Example: Reform of clinical pathways and payment system in Vietnam. ‘Researchers from Vietnamese Health Economics Association, a civil society organisation with support from AusAID (Australia), are developing a case-based reimbursement methodology, which they believe can help improve transparency and reduce perverse incentives in the health care delivery process. Case-based payments, established prospectively based on estimated resource needs for standard care, replace fee-for-service reimbursement. Under this kind of payment system, providers no longer have the incentive to use many diagnostic tests or potentially ineffective treatments to maximise revenue. Working in four pilot hospitals, the research team collaborated with facility personnel to develop care pathways for the treatment of three types of cases: pneumonia (medical), normal delivery (obstetrics) and appendicitis (surgery). For each of these cases, the researchers developed criteria for admission and discharge, indications for standard mandatory and other diagnostic tests and imaging, guidance for selection of drugs and criteria for other interventions.’ (Vian, 2012).

Other examples of bribes for service delivery. There are many more analyses from other countries of the small bribes paid to navigate national health systems, and the ways in which the authorities tackled this common problem. There are further examples described by Vian et al (2015), Stepurko et al (2010), Bjorkman and Svensson (2009), Liarapoulos et al (2008), Rispel et al. (2016).

2.1.2 Reforms to non-clinical process

Improving the way that the multiple systems and processes of the health system works is a natural way to reduce corruption: by reducing procedural complexities, streamlining budgeting, automating cumbersome procedures, improving controls, improving the range and reliability of performance indicators, etc., etc. However, be cautious. It is tempting for officials to focus on these types of improvements, because they are technical, can be defined precisely, and are usually relatively non-political. However, there are two problems. First, they can tend to take time to put in place, easily 12-24 months. This is a real issue – the timeline to results will be longer than what you would want to show progress to citizens. Second, there is also a more cynical aspect: the fact that the work takes time allows progress to be proclaimed until sometime after the momentum for change has dissipated. Those opposed to corruption reform can therefore safely support such initiatives, anticipating that they can be slowed down again in 12 months’ time.

Example: Health procurement corruption reform in Ukraine using ProZorro. Ukraine has made excellent cost savings in the health sector (and in other sectors as well) through procurement anti-corruption and transparency reforms.  See “Everyone sees everything; the overhauling Ukraine’s corrupt contracting sector”.

Example: The Open Contracting Partnership. OCP is an excellent multi-country reform initiative measure that is being used by a wide range of countries, from the UK to Mexico to Afghanistan. It starts at the planning stage, and covers tenders, awarding, and implementation of public contracts, including in health.

2.1.3 Improved HMIS

Improved Health Management Information Systems (HMIS) are one of the most crucial technical levers for reducing corruption. This happens both by direct changes, such as by better medicine stock management, and indirectly, by providing reliable data on the performance and relative performance of all parts of the health system. This is at least as much an issue for developed countries as for developing ones, because they are often working with large, cumbersome systems that are too expensive and sometimes too complex to replace. In such cases, simple web-based solutions alongside the old systems to get over some of the worst efficiency and corruption problems may be as much a corruption reform as an efficiency reform. Greece, for example, has made great progress with a Business Information’ portal for health that has been able to circumvent their huge problems with inflexible, complex old systems. Note that the same cautions apply as with the non-clinical improvements already discussed: It is tempting for officials to focus on these types of improvements, because they are technical and tend to take time to put in place, e.g. 12-24 months.

Example: MIS strengthening in Albania, Moldova, Cambodia, Palestine West Bank. USAID has done such improvements, for example, in Albania, Moldova, Cambodia and Palestine West Bank. These systems improved management, administration, and operational efficiencies of hospital and health actors, leading to greater transparency and access to information within the sector. As the USAID 2014 evaluators put it for the Albania project: ‘The systems contribute to anti-corruption by creating greater control over critical data and information and, thus, reducing the opportunity for committing medical fraud’. And for the Cambodia project: ‘The project-supported health informatics team works closely with the hospital improvement program to improve data collection methods, data quality and data use via HIS. Improved data quality reduces the likelihood of corruption by diminishing the ability of individuals to manipulate or falsify records and information.’

2.1.4 Technology reforms

There are multiplying numbers of reforms using new technologies, mobile apps and social media that may also reduce corruption. A recent review identified 15 distinct ways of using technology for good governance activities in LMIC health care. These use cases clustered into four conceptual categories: 1) gathering and verifying information on services to improve transparency and auditability 2) aggregating and visualizing data to aid communication and decision making 3) mobilizing citizens in reporting poor practices to improve accountability and quality and 4) automating and auditing processes to prevent fraud. From Holeman et al (2016). For a review of data mining processes to reduce fraud in health, see Joudaki et al (2015).

2.1.5 Organisation reform of the Ministry

Ministries can easily become corrupted. If the problem is deep rooted, you need to consider also whether changing the mandate and/or structure of the Ministry and/or the health system organisation might reduce the problem more fundamentally.

Example: Health ministry structure in Afghanistan. The health system is fundamentally structured to be operated by international NGOs (like Save the Children and the Aga Khan Foundation), rather than by government. The Ministry is therefore less operational and more geared towards policy and financial control. They still have major corruption problems (See Pyman 2018 Tackling health sector corruption: five lessons from Afghanistan), but they no longer have the larger corruption problems that arising in a post-conflict government bureaucracy

Example: Benefits of Public-Private partnerships in Lesotho, Southern Africa. Lesotho has explored the use of Public Private Partnerships (PPP) to improve health governance and the corruption impact of such reform seems to be beneficial. An independent assessment concluded that ‘Corrupt practices that were described at the government-run hospital (theft, absenteeism, and shirking) were absent in the PPP hospital. In the PPP hospital, anticorruption mechanisms (controls on discretion, transparency, accountability, and detection and enforcement) were described in four management subsystems: human resources, facility and equipment management, drug supply, and security. … The PPP hospital appeared to reduce corruption by controlling discretion and increasing accountability, transparency, and detection and enforcement. Changes imposed new norms that supported personal responsibility and minimized opportunities, incentives, and pressures to engage in corrupt practices. By implementing private-sector management practices, a PPP model for hospital governance and management may curb corruption.’ Vian et al (2017).

2.2.1 Your leadership

Being clear that your team can and will make a difference – can change the organisation’s culture to one with a much lower tolerance of misbehaviour. This sounds so straightforward as to be hardly worth a Chapter heading. But it is important because tackling corruption is not a ‘normal’ thing to be talking about or doing. Being clear that your team can and will make a difference can change the organisation’s culture to one with a much lower tolerance of misbehaviour can inspire people to work with you and to put in much more than ‘normal’ effort.

2.2.2 Building committed supporters

Most people in most organisations hate corruption but feel trapped and disempowered by it. Building a team of officials across the ministry and related agencies who share the vision of what can be achieved with less corruption is therefore a key place to start. Ask someone to open up these discussions across the organisation.

Example: Using a questionnaire to tease out peoples’ opinions. You could use a questionnaire to bring out peoples’ opinions. Here is one example opposite for local government employees from UN Habitat 2006, but it could easily be adapted for health. For each of the ten statements, there are four choices, to register whether you agree (score 1) or disagree (score 4) with the statement, and how strongly. The results indicate to the respondent and to you how big a barrier there may be to tackling corruption and is one way to start the conversation.

2.2.3 Leadership team discussions. This author has been present at such discussions in numerous professional leadership groups, from global companies to health leadership teams, from clean Scandinavian countries to conflict countries. Each of them was initially reluctant to engage in open discussion about corruption. This changes quickly once you make it clear that this is not a taboo subject, and that your purpose in tackling it is not punitive but is constructive, because it will actively improve access and service for your patients. You can do this in round table conversations.

2.2.4 Informal forums. Set up one or more forums where people can come and demonstrate their commitment to your plans. Sometimes people – public officials, citizens, whoever – are ready to help but don’t have a forum around which to congregate. Patients groups and Community groups can provide a powerful voice not only on which corruption issues hurt them most, but also what the solutions can be.

2.2.5 Formal coalitions. Focus your efforts on building a coalition across multiple stakeholders.

Example: Coalitions, politics and success in health reform: the ‘Sin tax’ in the Philippines. A diverse range of partners, including doctors and health-related organisations, led reform against tobacco, via the so-called ‘Sin tax’. This was a classic coalition of parties with different interests and one in which companies were also involved as ‘allies of convenience’, notably British America Tobacco and San Miguel Corporation. The reform coalition included other diverse components, namely:

1. ‘reform entrepreneurs’, activists, experts, policy wonks from the world of civil society, NGOs, and academe;
2. reform ‘champions’ from within the administration, in departments, agencies, and the Office of the President;
3. reform ‘champions’ within Congress;
4. advocacy groups, allied associations, organizations, and pressure groups;
5. media outlets: investigative journalists, reporters, social media and Internet websites.

Read more on the process that led to the Sin Tax

2.2.6 Working in collaboration with civil society. See Section 2.8 later in this section.

2.2.7 Pushing industry to develop & uphold its own integrity standards. To some in the health sector, it may seem perverse to suggest working with the health companies on corruption. Aren’t they the cause of much of it? Indeed, often they are. But they also have the energy and the means to do something about it and in the last ten years, encouraged by tougher anti-corruption laws, larger companies have moved towards active efforts to make sure that they are ‘compliant’ by not being involved in corruption. This shift is not universal: there are many countries of the world where almost none of the national health companies have a meaningful compliance programme. Nonetheless, this shift is welcome news for tackling corruption because solving corruption requires constructive inputs from multiple groups, one of which is the private sector. Here are six things you can consider doing:

Ways of engaging companies in the health industry

2.2.8 Changing the health industry structure to limit corruption There may be a more fundamental issue than simply pressing health companies to engage and do better, which you may or may not be able to address. The issue may be that the structure of the health industry in the country incentivises corruption. There are often hundreds, or thousands, of local manufacturers of drugs who have to sell into the grey market of hospital purchases. Besides often being poorly regulated, this also makes it harder for the larger multinational companies to avoid bribery. China has been a major example of this problem (e.g. leading to the prosecution and punishment of GlaxoSmith Kline), but also of solutions: the Government of China has moved to cut off the licenses of offending local producers (See for example The Economist (2018) China is sprucing up its pharma sector and Cockcroft 2012 pp 33-35).

2.3.1 Strengthen independent monitoring. Monitoring by outside groups is an important part of control against corruption. Patient groups, Community groups round a hospital, specialist health forums, all can be used both as a source of knowledge about the corruption issues and as a good location to seek local solutions. In some countries these are easy to set up, in other countries the opposite is true. Some countries, especially in Latin America, have a very active tradition of citizen engagement, and they are likely to be already active on anti-corruption scrutiny. In other countries, you will need to encourage them, or find ways to support them.

2.3.2 Strengthen regulatory agencies and oversight agencies. Regulatory agencies and oversight agencies are vital parts of the control framework of a health system. However, it is easy for their standards to deteriorate, to become servants of government officials, or even for the agencies to become complicit in condoning corrupt practice. Examining how these independent agencies are functioning, the independence, competence and diversity of their members is important. The opposite problem is also common, that there may be too many such agencies. Their overlaps and organisational confusion simply enable the corruption.

Example: Vietnam health system. The article calls for regulatory and service delivery functions to be split in the Vietnamese health system. There will be endemic corruption until the government realises that it cannot be both a ‘player’ and a ‘referee’ at the same time. Other countries have models similar to the Medical Council model, where a board independent of the Ministry of Health has disciplinary powers over professionals working in Ministry of Health facilities. The following options, based on the three approaches of Vietnam’s anti-corruption strategy, would help: Approach 1: Enhanced administrative oversight; Approach 2: Transparency, citizen monitoring and participation; and Approach 3: Structural policy reform to reduce incentives for corruption’ (Vian et al 2012).

2.3.3 Strengthen Internal audit. Audits and reviews of corruption risks and issues are a powerful way of raising awareness of corruption and deterring wrongdoers. But these control mechanisms are not used in health systems as much as elsewhere. Internal audit has been a low-quality department in many health systems, and often subservient to health system management or to local management. In such situations, you would be better off using an independent group to do the audits.

In other countries and health systems the internal audit function is strong, and so can be used. They signal a change in the culture and show that certain areas of the health system are being targeted.

Example: Health system monitoring in Colombia. In the Colombian health sector, there are currently eleven Internal Control Offices.…‘it is identified as a high-risk sector, as there are many potential entry points for poor service delivery, waste and malpractice, as well as corrupt schemes and conflicts of interest (state capture, public procurement, over-billing, doctor-patient extortion to jump the treatment queue, links between medical professionals and the pharmaceuticals industry, etc.), which makes a strong case for an effective internal audit function.’ (OECD 2017 Colombia report, p131.

Example: Health fraud audit in Calabria, Italy. In Calabria, countless investigations in healthcare have corruption as both a crime and a conspiracy, including mafia infiltration. In his report to the Italian Parliament on 27 February 2009, Renato Brunetta, then Minister of Public Administration and Innovation, showed that Calabria was in first place for corruption in healthcare. Still, much corruption remains hidden; despite the Laws on Checks and Controls, healthcare organisations previously lacked a comprehensive system of control of both administrative and economic performance. (European Commission 2015). Read more 

Example: Internal audit leading transparency and corruption reform in Ukraine. In other sectors, internal audit has developed as the lead group in tackling corruption in that Ministry. One example is in the Defence Sector, where Ukraine has made progress led through the internal audit departments work. See, for example Barynina and Pyman (2012), and ‘The 3^rdline of defence: how audits can help address defence corruption’. She leads that Department and her analysis is of 400 defence audits and reviews, all of which are publicly available.

2.3.4 Strengthen external audits and investigations. Routine external audits have a surprisingly low success rate in detecting and exposing fraud; yet this is an expensive resource, and a potentially powerful one. Carrying out reviews of the quality of external audits is one way to tackle this issue (through broader than health sector alone). Where there is a specific health external audit and investigation agency, making this a priority element of the health anti-corruption initiative can be useful. Such agencies may have been marginalised in the past, and increased focus and resources can invigorate them.

2.3.5 General health fraud audits. This is an established way of understanding the nature of corruption and fraud within a health system. In a review of case studies conducted in 33 organizations from six high income countries, concluded that the ‘percentage loss rate’ due to fraud and abuse in health care ranged between three to ten percent with an average of 5.6% of total health care costs (Rashidian et al 2012). However, the same study found that there are few health fraud audits being carried out in low income countries and even less attention is paid to fraud and abuse related to private insurance organizations.

Example: Cameroon. External investigations have a vital role, and, if there is external donor aid, this is an area where the donors can actively assist. In Cameroon, the GAVI alliance initiated an investigation into massive fraud and misuse of drugs in a Cameroon project in 2009-2011 The result led to a stimulation of reform. Based on these findings, and in consultation with the Ministry of Public Health (MOPH), ‘The case study shows the benefits donor organizations can gain by adopting a transparency and accountability policy: Having a clear policy in place allowed GAVI to implement pre-defined procedures, including the FMA and follow-up investigations, which detected and responded to mismanagement and abuses. The policy was agreed upon beforehand and contained stepwise escalation procedures, which made response actions more transparent and understandable. Although the investigation revealed that government employees were involved in the fraud, which was undoubtedly an embarrassment for the Cameroonian government, they fully supported the investigation and were willing to act on its findings. In addition to providing guidance and support for the detection of misuse of funds, the TAP policy also helps to deter future violations by strengthening financial management support – not only detecting, but also preventing corruption’ (See U4 2013).

2.3.6 Strengthen or establish clinical audit. Clinical audit is an equally powerful and often under-utilised control mechanism. It is defined (Wikipedia) as “a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change“. Clinical audit only entered mainstream health care in the 1990s but is now a standard clinical control mechanism.

2.3.7 Establish a Commission of Inquiry. Sometimes it makes sense to press for a formal Commission of enquiry about the corruption, as a way to publicly address known but unexplored problems. This is a way of raising awareness of the corruption issues in a very visible public forum. It means that there will be huge attention to the health sector and may result in greater momentum for reform. Even if the follow up is subverted, such Commissions can be valuable.

Example: Uganda

A detailed analysis of the rationale and potential benefits of choosing such a reform measure in a country like Uganda has been made by Kirya (2011) in ‘Performing good governance: Commissions of Inquiry and the Fight against Corruption in Uganda’. Here is her overview: ‘The findings suggest that the global anti-corruption framework signified by the good governance agenda is hindered by various factors such as the self-interest of donors, the moral hazard inherent in aid and the illegitimacy of conditionality; all of which contribute to the weak enforcement of governance-related conditionalities.

This in turn causes aid-recipient countries such as Uganda to do only the minimum necessary to keep up appearances in implementing governance reforms. National anti-corruption is further hindered by the government tendency to undermine anti-corruption by selective or non-enforcement of the law, the rationale being to insulate the patronage networks that form the basis of its political support from being dismantled by the prosecution of key patrons involved in corruption. Ad hoc commissions of inquiry chaired by judges, which facilitate a highly publicised inquisitorial truth-finding process, therefore emerge as the ideal way of tackling corruption because they facilitate ―a trial in which no-one is sent to jail. …They also served to appease a public that was appalled by the various corruption scandals perpetrated by a regime that had claimed to introduce ―a fundamental change and not a mere change of guard in Ugandan politics.

Nevertheless, while they enabled the regime to consolidate power by appeasing donors and the public, they also constituted significant democratic moments in Ugandan history by allowing the public – acting through judges and the media – to participate in holding their leaders accountable for their actions in a manner hitherto unseen in a country whose history had been characterised by dictatorial rule.

Example: South Africa Health Market Enquiry. An analysis of the private health care sector in South Africa ‘blew the lid off…. the Competition Commission revealed the results of a four-year investigation into competition within the private healthcare market. The inquiry found a lack of rigorous competition in sectors including pathology, hospital groups, as well as medical aids and administrators.’ For more information, read this article or the provisional report Competition Commission of South Africa 2018.

Example: Queensland Health Payroll System Commission of Enquiry. A similar analysis, though it stated that they found ‘nothing to suggest any form of corruption’. (Queensland 2013, p86)

Example: Uganda Commission of Enquiry. ‘The sum total of the enormous catalogue of flaws, shortcomings, errors, mistakes, and hiccups enumerated and detailed in all the above … adds up to a humongous picture of grand managerial inefficiency and incompetence. … The great losers in this sordid story were the people of Uganda; the international donor community; and, particularly so, the new experiment in Global Fund Public-Private Sector partnership’. The Commission that was very clear in its findings, but with little follow up. For more information, read this article by Cohen 2008 or a later analysis by Sekalalah and Kirya 2015.

2.3.8 Citizen Report Cards. Report Cards are a specific citizen-driven method used to generate information on the quality and efficiency of the public service as perceived by users. There are many examples of their use. To read more see Guidance STEP 2 or more details.

2.4.1 Investigation and prosecution. Prosecution of corrupt health officials or company executives or politicians can jolt the system and show that there is a change of tolerance. Prosecution also responds to the demands of the public. However, prosecutions are high risk: they can be very slow, often many years, to come to court; they can be unpredictable, as powerful individuals find ways to escape prosecution or conviction. Worse, if the judiciary are corrupt, this tends to mean that corruption reform will take decades. Perhaps only Sicily, in Italy, has had success against corruption by a prosecution-led strategy. Whilst prosecution may be a tactical response to public pressure, it is unlikely to be a major part of the strategy.

2.4.2 Exert pressure via discipline, sanctions and penalties. Where prosecution may be too slow or too difficult, more active use of sanctioning, discipline or penalty procedures sends a strong signal of change, that corruption is no longer acquiesced to. Civil and administrative penalties often hold out more hope of impact than prosecution. Examine in detail what disciplining and sanctioning options you have, and how they might be strengthened, or adapted to prioritise corruption cases. Often, the priority is to move a corrupt person from their job – to allow that directorate to improve – and to sanction the individual so that he/she is not simply placed somewhere else in the bureaucracy.

Example: The work of the Health Monitoring Unit (HMU) in Uganda. According to a recent re-analysis of Transparency International’s Global Corruption Barometer (GCB), the bribery rate for health services had halved for service users between 2010 and 2015.  The reduction seems to be the effect of the Health Monitoring Unit (HMU). A highly visible institution with an exceptional degree of support and direction from the president, the HMU developed a strategy to improve accountability in the sector. This included high profile raids. Through highly visible investigations, the HMU seems to have been effective in making health workers in the country significantly more cautious, reducing their willingness to request bribes. Requests for bribes for health services appear to have decreased as a likely consequence of the HMU’s efforts (Peiffer et al 2018).

However, though there have been bribery reductions, the naming and shaming approach has also led to reduced morale among health, because of perceptions that the HMU had unduly harassed many innocent health professionals.

Example: The Global Fund. After several corruption scandals, the Global Fund dramatically toughened up their control and investigation of corruption in the last five years. They have introduced claw-backs and penalties for countries allowing corruption in their grants. Here is their description of current practice: ‘The Global Fund actively manages risk, with embedded procedures including strict controls and monitoring. When a problem is identified by a country team at the Global Fund, it is referred to the Office of the Inspector General, who independently evaluates evidence and decides how to act on it. When an investigation identifies misspent funds, the Global Fund pursues recovery, so that no donor money is lost to fraud. Since 2012, the work of the Office of the Inspector General has been strengthened and expanded. Its staff has grown from 27 to 47 experienced professionals.’

2.4.3 Carry out a legal review. In the 1990s, calling for new laws or new regulations against corruption was the first port of call for reformers. Now most countries have decent laws relating to corruption. Nonetheless, there will still be multiple areas where reform of law is vital and where gaps, overlaps and ambiguities allow the corrupt to escape justice. There will also continue to be new forms of corruption, some of which may start of being legal until pressure builds to criminalise them; and new ways in which the corrupt bend the current laws to their favour, which too will need regulation.

You may have many suggestions from officials on how the laws can be improved. This needs critical review, however. It is normally unwise to plan on making a large number of regulatory changes, as you are likely to get bogged down and thereby seen to be making no progress, so the changes that you will pursue need to be carefully prioritised for effectiveness. Involve outsiders in the review, not just Justice officials: also civil society, or non-government legal experts with knowledge of anti-corruption impacts.

Example: Health law reform in Moldova. The results of a review in the Moldova health system, taken from USAID (214): ‘Creating integrity and ethics through (legal) reform. Working closely with the Moldovan Ministry of Health (MOH), USAID contractor MGTCP drafted laws, policy papers, and recommendations to improve healthcare services across the country.

• The project drafted and submitted to parliament a revised administrative code in order to strengthen the enforcement of the accreditation process of healthcare professionals.
• The most far-reaching legal reforms supported under MGTCP were the government order issued to create corruption reporting systems in all ministries, including MOH, and the whistle blower protection law, which was drafted and submitted to Parliament.
• Legal reforms supported by the program also affected the hiring process in MOH-supported facilities.
• MGTCP supported the MOH in issuing a ministerial order that created a competitive hiring process including objective scoring of candidates.
• MGTCP also worked through the government of Moldova to reform the legal and policy framework in the health sector to improve functionality and monitoring. This included the creation of nine working groups
• This allowed for quick decisions and implementation of key interventions, such as the development of a code of ethics that had not previously existed in Moldova. In collaboration with a specially created MOH working group, MGTCP supported the drafting, editing, and publication of 15,000 copies of the code to medical professionals, including all physicians in the country.
• MGTCP helped reform procurement and bidding processes by creating a government-sponsored integrity pact, which all bidders on public tenders were required to sign.’ USAID 2014 report.

2.4.4 Examine which changes in policy might disrupt corrupt dynamics. It has not been usual for policy to be made explicitly with anti-corruption in mind. This may therefore mean that there are some policy changes that you can make that would have a significant impact. Pay attention to policies that directly or indirectly allow corruption to persist.  Policy can also be captured by corrupt interests, so the challenge is also to scrutinise misuse of current policy.

2.5.1 Identify public service data that needs to be transparent. This is context and sector specific, so you need to brainstorm with colleagues on what data would most show up corruption or improper influence. It can be very simple, such as publishing hospital waiting lists for surgery or publishing how much of the primary school education budget is actually received by each school. The more resistance there is to publishing data, the more likely it is that there is some corruption reason behind it. Examples include Wait lists for surgery (with suitable measures being taken to prevent patient identity), Boards showing the Presence/Absence of clinical staff in the hospital, the Average unit costs of drugs in hospitals, regions or in the country. Also useful are comparisons with international public sources for cost of common drugs (from MSH, MSF, WHO, GFATM etc) so that someone can see if the country is paying above the world market. In all such data cases an important related question is which forum you use to present the data. Is it electronic, or via meetings, or in journals, or to patients’ organisations, or highly visibly, e.g. on boards at the front of the hospital, or in newspapers?

Example: WHO Good Governance in Medicines initiative (GGM). The WHO has created process indicators for transparent and accountable drug promotion practices as part of the Good Governance in Medicines programme. The GGM approach to increasing transparency in public pharmaceutical systems includes three steps: risk assessment, development of a national framework for responding to identified needs and implementation of approaches such as procedures for disclosure and management of conflict of interest, web-based medicines registration and licensing systems, and other interventions. To date, 26 countries are participating in the GGM, including Cambodia, Malaysia, Mongolia and the Philippines.

Example: Transparency measures in seven countries in the Medicines Transparency Alliance. The WHO Medicines Transparency Alliance (MeTA) fostered policy dialogue to bring together government, civil society and private company stakeholders concerned with access issues in health and to promote transparency. An analysis of the effect of this in seven countries (Ghana, Jordan, Kyrgyzstan, Peru, Philippines, Uganda, Zambia) found strong evidence that transparency was enhanced and some evidence to suggest that MeTA efforts contributed to new policies and civil society capacity strengthening, although the impact on government accountability is not clear From Vian et al (2017).

2.5.2 Build transparency into systems and metrics. Good HMIS data is essential for tackling corruption. You need data on relative costs of procedures from one site to another, on stock levels, on costs per patient per diagnosis. Sometimes, getting this data is a ‘normal’ function of upgrading the HMIS to give you that functionality. Often though this is not the case: the official systems are often old, cumbersome and unsuited to any such intelligent query. In which case you have to decide if the problem is worth a separate management information system or application. In one OECD country the Health leadership had exactly this latter problem and, despite huge budget constraints, were able to produce an alternative HMIS that was dramatically more useful than the old, official system. As a result, they were able to scrutinise treatment costs between hospitals that led to a major improvement in performance and reduction in corruption.

Example: Less corruption in the medicines system in Thailand. Thailand participated in a WHO Good Governance for Medicines programme, with a number of significant achievements, such as lower costs for medicines, and national pharmaceutical laws reviewed. Thailand’s Dr Tharathep offers this advice for other countries: “First of all, they should do a medicines situation analysis in their countries, then develop a good governance framework appropriate to their context and environment. The gap between the existing system and the framework should be identified and the strategy should aim to fill the gap…The transparency of the system is one of the crucial activities. For us, the pharmacy information centre has been the best tool for transparency. We have the pharmaceutical products prices from each company who sold their products to the Ministry of Public Health hospitals publicly accessible.” Read more.

2.5.3 Require all engagements by senior public officials be routinely disclosed. If public money is being used, then there should be a presumption that the interactions should be public. Examples include senior public officials having the whole of their daily agenda online (as in the European Commission), or new contracting and procurement that require all contracts, progress reports, tender submissions and so forth to be available online (see Open Contracting Partnership here, for example). The simple way to do this is for the electronic calendars of officials to be available online.

2.5.4 Require that all health budgets, and spending, are disclosed. This is not yet the case in many countries. You need to see the Open Budget Survey to identify countries, here. This authoritative survey shows that even in an uncontroversial sector like health, such data is often not available. Citizens often want to know how much their government spends on a particular service and how that spending is changing over time. Answering this question is not as simple as it sounds. Besides the Ministry of Health, you probably need at least the “functional classification” that organises spending by functions or purposes, as well as spending by state corporations that support health services (such as public insurers or suppliers). If the health system is decentralized, funds to lower levels of government might not be captured under the central Ministry of Health budget or the functional classification of national spending and you would need quantitative and narrative information about such transfers.  The table below from the survey provides a summary of the level of availability of these types of information. While two-thirds of countries surveyed have a basic functional classification, less than half provide any of the other types of information described above.

2.5.5 Consider requiring all internal and external audit reports to be published. Are all external audit reports public? They should be, though many are not. One public analysis suggests that about 85% of external audit reports are made available publicly (Institute of Internal Auditors, 2012). Internal audit reports are more commonly not public: only 10-14% of public sector reports were made public according to the quoted study. There is sometimes justification for non-publication – it can lead to big problems being kept quiet rather than written in the report – but the opposite problem is usually bigger: if the report is not public, it can be buried, and marginalised. It is less difficult and restricting to make internal audit reports public than officials might imagine. In Ukraine, for example, internal audit reports are publicly available (Barynina and Pyman 2012).

2.5.6 Watch out for when transparency does not work as intended. Transparency may be good, but it is not a panacea. Often data and reports are made transparent, but the underlying corrupt behaviour still does not change, especially if the public and NGOs are disinterested in examining and acting on the data. What more do you need to do? The answer is often to encourage civil society to make more use of the newly transparent information. There may also be different understanding of transparency among staff, because transparency means different things to people depending on what level you are in the organisation.

Example: Transparency in US health care means different things to different people. ‘Much research on transparency in global settings has focused on institutional design, such as online performance reports and external budget transparency. Yet, these avenues of research do not help to illuminate how change develops in an organization and the micro organizational social processes which influence policy implementation. Eliciting narratives of transparency in health care organizations can be a tool to gain insight into how to develop and nurture organizational cultures which are favourable to transparency, adapted to particular social, economic, and country contexts. The analysis of this small set of stories suggests potential areas where people may understand transparency differently depending on their organizational position and prior experience. … Narrative analysis focused on stories of transparent and non-transparent behaviour can help researchers gain insight into human conduct and relationships which affect organizational accountability. These insights can, in turn, help in the design of interventions which cultivate a transparency culture and promote good governance. Taken from Vian, 2012.

2.6.1 Improving the integrity of public officials. Creating and maintaining a culture of high integrity behaviour among health professionals and health officials should not be so hard; These are among the most caring groups of people in society. However, powerful social ‘systems’ can be more powerful in driving human behaviour. As quality engineering guru W. Edwards Deming once said: ‘A bad system will beat a good person every time.’ The OECD is increasingly active in working with countries to structure suitable ‘integrity frameworks’ for the nation’s public officials. Recently this has included work in Mexico, Colombia and Thailand, for example.

There are a multitude of ways to press for and to build a high integrity health culture:

• Attention to the basics, e.g. the legality and reality of fair hiring, firing, promoting and disciplining staff
• Having clear standards and codes of conduct for health professionals (doctors, nurses, specialists), health officials, Ministers and regulators
• Having credible internal reporting procedures
• Having mechanisms for identification and resolution of conflicts of interest,
• Regulating conferences and benefits from the pharmaceutical companies, etc
• Investing in integrity training; and in anti-corruption education for staff and officials
• Building the capability of locally-accountable hospital and community oversight bodies
• And, speaking out loudly and clearly against corruption.

There is a useful report Integrity in healthcare organisations from the Netherlands Health System (CEG 2016), which analyses integrity approaches to health care. They analyse five situations where the integrity is most tested in health care organisations: conflicting interests and expectations, dealing with errors, remuneration of administrators, perverse incentives within the system and peer pressure.

Example: Professional integrity for health staff in Australia. Here is an example  of the professional health staff code from Australia.

Example: A structured approach to Integrity Codes in Colombia. Colombia has put considerable effort into developing integrity across its public administration. In relation to Integrity codes and codes of conduct, Colombia has a three-level model, from national, to at-risk positions, to specific Ministries and organisations. If your country has a similar structure, then you will want the health system codes to align with the national level ones. The OECD report on this effort is worth reading (OECD 2017, p67), as are the reports for Mexico and Chile.

2.6.2 Consider the benefits of awareness raising and capacity development. General anti-corruption education for officials and building the capability of oversight and regulatory bodies can be a useful measure, especially if they reach a critical mass of people or officials, and in environments where it is hard or dangerous to have more direct impacts. This is one way to show that at least something is happening, however modest.

2.7.1 Encourage complaints mechanisms. These mechanisms are vital in identifying and calling out corruption and the challenge is to find a way to make them effective. Civil society has often shown that it can be a more honest and independent way of checking performance and/or being a trusted place that complainants speak with. Today, many complaint systems are actually run by NGOs for this reason. Besides feeling confident to make the complaint to someone, the other half of the complaint system is assurance that there will be prompt and accountable complaint investigation. There needs to be a range of sanctions (fines, loss of contract renewal) which can be implemented without going to the judiciary. This second part of the system has worked badly in many public health systems. In some it is just because of budget pressure. But in others it is more corrupt, being driven by the interests of professional groups, such as doctors or health officials, to protect themselves by ensuring that complaints do not get concluded.

So, making an effective complaint system can be more about making changes to the power balances within the health system than about the technicalities. Sometimes, a solution has been for a top official to take the complaints directly and personally. For example, in another sector, the top official made himself personally available all day every Monday to hear complaints from citizens.

2.7.2 Be open and public about the depth of the corruption. Do not underestimate the effect that you and senior colleagues can have just by speaking openly and publicly about the corruption problems. When the head of the World Bank spoke about corruption in 1996, after years of silence, the effect was huge. Countries such as Estonia and Georgia have had considerable success. particularly in the earlier years of their reforms, they made it publicly clear that curbing corruption was the top mission of the government. It was clear that the government would stand or fall by their success in tackling corruption, and this gave them greater credibility with the public; though more recently, some of the progress is being undone in Georgia.

After you have reviewed the specific corruption types and identified reform measures, you can develop an overall strategy. Because curbing corruption is about changing the status quo, so you need to be thinking about how to build support, how to spread the benefits, how to bring opponents on board or how to outflank them. This is where judgement and political skill are important. You also need to think carefully as to which combination of measures and management is likely to result in the most impact within the limited resources and time available. We suggest that you develop an overall strategy – in collaboration with those who can also own it with you – in the following way:

1. Thinking through objectives and what impact you really want to achieve
2. Challenging yourselves by considering strategic opposites and different entry points
3. Flexibility – preparing yourselves to be wrong
4. People, politics and skill – where and how to build support
5. Implementation – setting up a sound programme
6. Maximising supportive structures across government & stakeholders.
7. Choices in high corruption environments

You can read more guidance on Step 3 here.

Review what international sector efforts are active in tackling corruption in your sector. They may be sources of knowledge, ideas, support and assistance in the development of your initiative. Sector-specific organisations include:

• Professional sector associations (many have an ‘anti-corruption working group’ or similar forum);
• Initiatives and programmes targeted on building integrity, raising transparency and reducing corruption in the sector;
• Multilateral organisations associated with the sector (e.g. World Health Organisation). They too may have anti-corruption knowledge and capability.

Non-sector-specific organisations also have sector knowledge. These include:

• Multilateral economic organisations such as World Economic Forum, IMF and OECD; among these,
• OECD has a large group focused on public integrity and anti-corruption.
• There are multiple stand-alone initiatives focused on issues such as beneficial ownership transparency, or access to information.
• Multilateral development organisations, like the World Bank, UNDP and U4, can hold valuable sector knowledge and expertise, whether or not you are based in a developing country.

The Health Systems Governance Collaborative express the need from a helpful historical perspective: Back in 2007, the WHO proposed a six building blocks’ framework to categorize and analyse health systems . In this framework, health system governance was defined as: “Ensuring strategic frameworks exist and are combined with effective oversight, coalition-building, attention to system design and accountability”. Then on their website, this group says ‘First, we must admit that for the past decade, we have paid much attention to the first part of this definition: “ensuring strategic policy frameworks exist”….. Secondly, without denying the critical importance of policy-making capacity and strategic planning processes in the health sector, we must also acknowledge the need to examine more closely the latter part of the governance definition put forward by WHO in 2007: “effective oversight, coalition-building, system design and accountability”. Much less has happened in this respect in the recent past, although some authors in the health system literature have ventured this less travelled route: a recent systematic review identifies 16 frameworks for health systems governance published between 1994 and 2014, but only five of them have been applied in practice and only three considered governance at multiple levels of the health system. When travelled, the route therefore remains vastly theoretical; it is difficult to grasp what are the concrete actions that could benefit health system governance and improve health system performance.