Corruption and the Corruption and the Health Sector Health Sector - - PowerPoint PPT Presentation

Corruption and the Corruption and the Health Sector Health Sector

Lessons from Albania Lessons from Albania

Taryn Vian, Assistant Professor of Taryn Vian, Assistant Professor of International Health International Health

Boston University International Health Grand Rounds Boston University International Health Grand Rounds Presentation Presentation June 13, 2003 June 13, 2003

Outline Outline

• Corruption

Corruption as a as a health issue health issue

• Background

Background on Albania and anti

• n Albania and anti-
• corruption activities

corruption activities

• Scope of work

Scope of work

• Assessment Methods

Assessment Methods

• Findings

Findings

• Recommendations

Recommendations

Corruption is a Health Issue Corruption is a Health Issue

• Abuse of

Abuse of public or entrusted public or entrusted power power for private gain for private gain

• Students should be

Students should be prepared prepared

• Corruption is universal, but

Corruption is universal, but effects effects are are worse worse in lower in lower-

• income and transitional countries

income and transitional countries

• Corruption =

Corruption = cause cause of under

• f under-
• development, not just effect

development, not just effect

“Something is wrong in societies where corruption takes

• ver….We should not lose this sense of moral violation.

But as we reflect on questions of why, we should also do

• ur best on questions of how. We should not yield to the

temptation to escape from the hardest and most ethically loaded problems on the grounds there is nothing we can do about them. …With regard to corruption, policymakers and citizens are not helpless. There are things we can do about even this most difficult of

• problems. At least this practical and normative

assumption should drive more of our work on the problems of the poorer nations.”

Robert Klitgaard, Controlling Corruption, 1988 (p. 210)

Background Background

• 3.1 million

3.1 million

• Isolated prior to

Isolated prior to 1991, pyramid 1991, pyramid scheme collapse scheme collapse in 1997 in 1997

• $1,200 GDP (PPP

$1,200 GDP (PPP adjusted) adjusted)

• Muslim

Muslim

MSI and ACAC MSI and ACAC

• USAID/Albanian Civil Society

USAID/Albanian Civil Society Corruption Reduction Project Corruption Reduction Project

• Albanian Coalition Against

Albanian Coalition Against Corruption Corruption (ACAC) (ACAC)

• Citizen Advocacy Office

Citizen Advocacy Office

• Press Coverage

Press Coverage

• Working Group on Procurement

Working Group on Procurement

Scope of Work Scope of Work

• Assess

Assess vulnerabilities vulnerabilities

• Identify

Identify partners and activities partners and activities for reducing vulnerability to for reducing vulnerability to corruption corruption

• Share lessons

Share lessons learned through a learned through a workshop workshop

Methods Methods

Vulnerability Assessment Vulnerability Assessment Method 1 Method 1

• Inherent

Inherent risk risk

• f corruption
• f corruption
• Control

Control environment environment

• Existing

Existing safeguards safeguards

Klitgaard Assessment Tasks Klitgaard Assessment Tasks

• Disaggregate

Disaggregate the types of the types of corruption corruption

• Determine the

Determine the scope scope and and seriousness seriousness of each type

• f each type
• Identify the

Identify the beneficiaries beneficiaries and the and the losers losers

Klitgaard, Controlling Corruption, 1988

More Assessment More Assessment Challenges: Challenges:

• How to talk about corruption

How to talk about corruption

• Avoid the “

Avoid the “C C-

• word

word” ? ” ?

• Forward

Forward-

• looking

looking— —improving improving incentives, not pointing fingers incentives, not pointing fingers

• Start with a

Start with a vulnerability ranking vulnerability ranking exercise exercise

Vulnerability Ranking

Procurement of goods and services Pharmaceutical promotion Drug distribution & sale Health regulation Education of health professionals Personnel management & informal payments Budget and financial management

Citizen Voice & Choice Management Tools

(for hierarchical control)

Strategies

Information Appropriate Discretion (+/-) Incentives & Consequences

(including detection & sanctions)

Findings Findings

Types of Corruption

Leakage of official fee revenue, overcharging patients Budgeting, pricing Bribes or influence used in drug registration and licensing/control of quality of drugs; lack of standards or regulatory control of public and private facilities Regulatory systems Theft from public facilities for resale in private sector Distribution and storage of drugs Private financial interests affecting decisions of what to procure; collusion among bidders; kickbacks or bribes that allow certain bidders access to confidential procurement information during the selection process; low quality performance that has no repercussions; use of direct procurement rather than competitive, without good reason Procurement of drugs and medical equipment Financial influence used by private companies or pharmacies to get drugs added to reimbursement lists; illegal financial relationships between public doctors and private pharmacies;

• ver-prescription for financial gain

Drug selection and use Informal payments; private practice during public work hours; absenteeism; over-utilization due to financial incentives; favoritism in personnel appointments and hiring Provision of services by frontline health workers, personnel management

Types of Corruption Likely in Albania Activity

Informal Payments Informal Payments

Informal Payments Informal Payments

• Some

Some previous studies previous studies, more , more data available to analyze (LSMS, data available to analyze (LSMS, Abt Abt data) data)

• A wide

A wide spectrum of opinion spectrum of opinion on

• n

acceptability acceptability

• Little appreciation of

Little appreciation of negative negative impacts impacts of informal payments

• f informal payments

Frequency of Informal Payments In Selected Countries in Eastern Europe and Central Asia

Frequency of Informal Payments in Selected Countries

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Armenia (1999) Vietnam (1992) Albania (2000)* Poland (1998) Azerbaijan (1995) Kyrgyz Republic (1996) Russian Federation (1997) Moldova (1999) Tajikistan (1999) Slovak Republic (1999) Latvia (2000) Albania (1996)* Bulgaria (1997)

Source: All data except the second Albania study are from Maureen Lewis, Who is Paying for Health Care in Eastern Europe and Central Asia? (Washington, DC: World Bank,2000). Data points for Albania are from:World Bank, Albania: Growing Out of Poverty 1997 (data from 1996, cited in Lewis’s paper), and World Bank, Albanian Public’s Perceptions of the Health Care System September 2000 (data from 2000).

Informal Systems Informal Systems

Acceptable Corruption

Most payments are after service is delivered Gifts are a cultural practice Salaries are too low Staff demand payment before If you can’t pay you may die Some docs have 3 houses

Here, there is the mentality Here, there is the mentality that you have to give a that you have to give a reward to someone who gives reward to someone who gives you service. For example, you you service. For example, you give a tip to the barber who give a tip to the barber who serves you. So much more serves you. So much more grateful you must be to the grateful you must be to the doctor who saves you. doctor who saves you.

Participant Participant Health and Corruption Workshop, Tirana, 3/03 Health and Corruption Workshop, Tirana, 3/03

The informal payment system is so accepted that doctors leave at the end of the day and turn to each

• ther to ask “How much did you

make today?” Although patients are reluctant to complain to the doctors, they will get angry and disillusioned when they leave the facility, and they lose confidence in the system.

Participant Health and Corruption Workshop,Tirana, March 2003

Informal Payments

• Patients who receive unnecessary interventions merely to increase

staff’s compensation

• Patients who cannot afford fees but feel obliged to pay (may not seek

care, or may sell assets to have cash to pay under-the-table)

• Patients who try to get free care (may be refused or get lower quality

care)

• Government (loss of control over health care policy, creation of

private system operating in a “shell” of public sector) Losers

• Almost all levels of staff (payments may be shared when given to

doctor, or patients may pay each staff member directly)

• Well-connected individuals (may not be asked to pay because of

relationships)

• Patients who can afford to pay (feel safer, more likely to get quality

service)

• Government (less pressure for health reforms by health personnel)
• Surgeons (make most money)

Beneficiaries No consensus. A lot of recent, negative press and some vocal critics; however, many people feel the payments are fair since health personnel are so poorly paid, and there is a direct quid-quo-pro Seriousness Pervasive, estimated 89% of inpatients and 80% of outpatients make the payments (WB 2000) versus 20% as measured four years earlier Scope

A successful experiment A successful experiment

• Tirana Maternity Hospital

Tirana Maternity Hospital

• 2001:

2001: strengthened formal payment strengthened formal payment system, increased revenues from system, increased revenues from 900K to 2,590 K ( 900K to 2,590 K (Leks Leks) )

• Increased doctors’ salaries 4x, others

Increased doctors’ salaries 4x, others too too

• Patient education: no other payments

Patient education: no other payments needed needed

• Suggestion boxes, exit interviews for

Suggestion boxes, exit interviews for monitoring monitoring

• Results: increased utilization; some

Results: increased utilization; some evidence of decreased informal evidence of decreased informal payments payments

Recommendations Recommendations

Criteria for Strategies Criteria for Strategies

• Who?

Who?

• ACAC (e.g. Citizens Advocacy Office,

ACAC (e.g. Citizens Advocacy Office, ACAC ACAC-

• sponsored grantees)

sponsored grantees)

• USAID collaborating agencies

USAID collaborating agencies working on other health issues working on other health issues

• Government officials

Government officials

• Technical capacity

Technical capacity

• Government

Government commitment commitment

Citizen Voice & Choice (C) Management Tools (M)

Strategies

Information (I) Appropriate Discretion (D) Incentives & Consequences (I&C)

Strategies Strategies

• Citizen Voice & Choice (C)

Citizen Voice & Choice (C) Local health

Local health boards, complaint offices, exit options, boards, complaint offices, exit options, shown to decrease informal payments and shown to decrease informal payments and procurement prices in Bolivia procurement prices in Bolivia

• Information (I)

Information (I) Increase accountability,

Increase accountability, probability of detection. When people know probability of detection. When people know they are watched, they are less likely to they are watched, they are less likely to abuse system. Evidence from price abuse system. Evidence from price reporting system in Argentina. reporting system in Argentina.

Strategies Strategies

• Incentives & Consequences (I&C)

Incentives & Consequences (I&C)

Increase likelihood corruption will be detected and Increase likelihood corruption will be detected and sanction, and increase benefits of staying clean. sanction, and increase benefits of staying clean. Provider payment systems Provider payment systems

• Appropriate Discretion (D)

Appropriate Discretion (D) Reduce

Reduce discretion where it is being abused, increase discretion where it is being abused, increase discretion where it permits earlier detection of discretion where it permits earlier detection of corruption, rewards for good behavior. Evidence corruption, rewards for good behavior. Evidence from Colombia. from Colombia.

• Management Tools (M)

Management Tools (M) Reinforce

Reinforce hierarchical control systems. Internal financial hierarchical control systems. Internal financial control systems, performance auditing, drug control systems, performance auditing, drug inventory systems. Evidence from Latin America. inventory systems. Evidence from Latin America.

Anti-Corruption Strategies

Gov’t Commit- ment

High Low

Implementation Capacity

Citizen representatives

• n committees (EDL, drug

reimbursement, hospital management) (C) Clear documentation of procurement results (I) Statements condemning informal payments (I) Disseminate pricing Information

(I)

Citizen Advocacy Office for Health (C) Consumer guides to health laws & system

(I)

Promote awareness on informal pmts (I) Develop performance standards, management tools (M) Increase provider compensation and link pay to outputs (I&C) Strengthen & enforce regulatory systems (I&C, D) Trend analysis of drug margins, prices, and affordability (I) Research and analysis of data on informal payments

(I)

Citizen lobbying & advocacy for changes in policies (C) Strong Low

Citizens Advocacy Office (CAO) Citizens Advocacy Office (CAO) for Health Concerns for Health Concerns

• CAO is popular and has dealt

CAO is popular and has dealt with hundreds of complaints with hundreds of complaints

• Help for worst abuse cases

Help for worst abuse cases

• More data, operational details to

More data, operational details to help with planning reforms, help with planning reforms, advocating legal changes advocating legal changes

Citizens on Committees Citizens on Committees

• How to promote citizen voice

How to promote citizen voice through committees & local through committees & local health boards health boards

• Not currently developed, though

Not currently developed, though some models being tested some models being tested

• Volunteerism?

Volunteerism?

Research Research

• Research

Research evidence that health evidence that health reforms do reduce informal payments reforms do reduce informal payments

• Evaluation of

Evaluation of Tirana Maternity’s Tirana Maternity’s intervention intervention to fight corruption to fight corruption

• Study and analysis of

Study and analysis of culture and culture and corruption corruption in Albania, toward in Albania, toward development of informational development of informational messages, support messages, support

Awareness on Informal Awareness on Informal Payments Payments

• Health professionals

Health professionals and and citizens citizens

• Discuss

Discuss results of studies, surveys results of studies, surveys

• Case studies, videotapes of focus

Case studies, videotapes of focus groups, exit surveys (what patients groups, exit surveys (what patients see, what motivates them). Use to see, what motivates them). Use to analyze vulnerabilities analyze vulnerabilities. Asymmetrical . Asymmetrical information? Preferences? Culture? information? Preferences? Culture?

• Leadership role of doctors

Leadership role of doctors in in preventing abuses, promoting preventing abuses, promoting reforms reforms

Conclusion Conclusion

• Assessment methods

Assessment methods need to need to consider health reform progress. consider health reform progress. Consider presenting issues, Consider presenting issues, strategies for reaction strategies for reaction

• Health reform

Health reform is not a panacea. is not a panacea. Information and citizen voice Information and citizen voice strategies can be pursued while strategies can be pursued while health reforms are developed. health reforms are developed.

Conclusions Conclusions

• Strategies must be evaluated

Strategies must be evaluated, , corruption perception surveys of corruption perception surveys of health staff & household surveys health staff & household surveys may be helpful may be helpful

• More coordination is needed

More coordination is needed between between health and democracy health and democracy (anti (anti-

• corruption) programs

corruption) programs, , resources are available to share resources are available to share