Transparency in the Health Sector USAID Technical Exchange August 19, 2009

1. Transparency in the Health SectorUSAID Technical ExchangeAugust 19, 2009 Management Systems International Presentation by Taryn VianBoston University School of Public Health

2. Agenda • Overview and definitions • Mainstreaming strategies in health sector • Case examples • Comments from panel and discussion

3. What is corruption? • “Abuse of entrusted authority for private gain.” • (USAID Anticorruption Strategy 2005) Logo from a Moldovan NGO working on anti-corruption

4. Corruption: a Global Issue

5. Informal Payments Stealing drugs Lack of transparency No accountability for results Absenteeism Selling posts Over-payment of supplies (kickbacks) Embezzlement of user fees Theft and diversion Spending on “pet” projects Linking Governance to Health Systems Strengthening

6. Government-wide strategies needed for anticorruption (rule of law, judicial reform...) Sector-specific strategies enhance effectiveness: address specific problems leadership and public opinion more supportive links to health systems strengthening Mainstreaming AC & good governance strategies

7. Framework of corruption in the health sector - social norms - moral/ethical beliefs - attitudes - personality monopoly discretion rationalization abuse of power for private gain accountability citizen voice opportunity toabuse transparency - wages/incentives - pressure from clients enforcement pressures toabuse • Health care system and structure • Insurance • Payer-provider split • Role of private sector, etc. • Type of abuse • Hospital construction • Procurement • Informal payments, etc. • Resources • High or low incomes • Donor dependence, influx of funding (Vian T. 2008. Review of Corruption in the Health Sector, Health Policy & Planning 23:83-94)

8. Understanding the Problem • Step 1: describe and measure • Step 2: examine the drivers (opportunities, rationalizations, pressures) • Step 3: consider levers and mechanisms to control opportunities, address rationalizations, reduce pressures

9. Moderately Vulnerable WHO Pharmaceutical System Vulnerability Analysis 0.0-2.0 = extremely vulnerable; 2.1-4.1 = very vulnerable 4.1-6.0 = moderately vulnerable; 6.1-8.0 = marginally vulnerable 8.1-10.0 = minimally vulnerable WHO/PSM/PAR/2006.7

11. Cases • Performance based budgeting reform in Lesotho • Water & Sanitation Agencies in South Asia • Moldova Anticorruption Activities in Health Sector

12. Performance-based budgeting in Lesotho • PBB Goals: • relate expenditures to results • link policies with resource allocation • Includes many functions: planning, budgeting, program implementation More donors channel aid through government Successful reform

13. Lesotho Reform Experience • Started 2005 • How is it working? • What factors affect progress?

14. Progress: Low

15. Barriers: Lack of alignment Proportion of total hospital budgeted activities, by purpose of activity

16. Barriers: professional boundaries • “We work the wards, they go to meetings.” (Hospital Matron) • “I can’t read the Votebook; I’m a nurse.” (District Health Management Team member) • ““These things, even though we hear about them, it is mainly something that concerns people in Accounts. The Ministry [of Health] might implement the reform, but it is really Finance who tells you what to do and what not to do. So it is not really a health initiative.” (District Medical Officer)

17. Result: Lack of Transparency The Accountant did not let you get anything. We always wondered—what is really happening? I planned and made the budget, so I know it is really there, and then you have to ask, what happened to the money? Matron Sometimes you have requested something, and the goods do not come. You try to ask questions, but the Accounts office will act like, ‘This is my job. Don’t ask questions.’ As if you’re spying on them! When really, it is just that you are asking for an explanation… Public Health Nurse

18. Future of PBB • Back to drawing board to simplify • More funding to mentor health professionals into their management roles • Link budget reform initiative to health systems strengthening initiatives

19. Expedited new connection Falsify bill Illegal service connection Water & Sanitation Services (S.Asia)1. Informal Payments Davis J. 2004. Corruption in public service delivery: Experience from South Asia’s Water & Sanitation Sector. World Development 32(1): 53-71

20. DURING tender process Contracting cartels, bribes for influence Kickbacks AFTER skimming on construction contracts, with quid pro quo of allowing sub-standard materials or over-invoicing 2. Procurement Corruption Photo credit: http://water1st.org/waterlog/wp-content/uploads/2009/04/img_8066.jpg

21. 3. Civil Service Related • Market for transfers to desirable posts • pay politicians or local leaders, not higher level staff (exerting influence) • 2.5 – 4 mo. salary, but indirect exchanges also common • may also have to pay to keep own post (if someone else is paying to get yours)

22. Analyze Drivers • Opportunities • technical problems with meters • lack of oversight • collusion among staff • Pressures/Incentives • Need to earn extra money to pay for job (pressure to accept bribes, kickbacks) • No detection or punishment (no cost to corruption)

23. Rationalizations • Everyone does it • “almost everyone uses contracts and money to get better services or special treatment” (52% of W&S staff agreed) • Everyone benefits, no one is harmed • payments “benefit the customer and employee without hurting anyone” (31% agreed) • “[It is] small potatoes...no one calls this corruption, even...” (W&S agency employee) • Culturally accepted

24. But not everyone rationalized... “We must try to improve our public image. . .[the] people must perceive us as honest. Otherwise, how can we make a case for increasing the tariff? The customer says I am having to pay an extra 100 rupees just to have my repairs made on time.’ We cannot have this kind of image and expect public support.”(Former Director, Urban Water Board)

25. How to intervene? • “Carrots and Sticks” – in short-term, no • Information technology • Transparency – publish fees • Improvements in working conditions • External scrutiny (communities, press)

26. Moldova Experience Improving Governance in Health Sector Moldova Governance Threshold Country Program (MCC) –2007 Health Sector component (Millennium IP3 Partners) decrease discretionary powers of health personnel increase accountability Civil Society Monitoring Capacity (AED) Media training, communications http://www.mip3-projects.md/projects/mgtcp/documents/index.html

27. Moldova: Health interventions Decrease discretionary powers Create competitive selection process for facility directors Physician licensing Procurement audits Create standard treatment guidelines

28. Moldova: Health interventions Increase accountability Quality Councils Clinical Audits Annual patient satisfaction surveys with “satisfaction score” and “corruption score” (informal payments)

29. Final Thoughts • Corruption is a public health problem we can diagnose and prevent • Promising approaches link information and consequences • New thinking needed • Understand pressures of cultural respect for extended family, ethnic loyalty • Expanding role models willing to “throw a small spanner in the works” to fight corruption* *John Githongo, from It’s Our Turn to Eat: the Story of a Kenyan Whistle-blower, by Michela Wrong (2009)