1. Defining Corruption: cultural aspects in health workers: ethical aspects and dimensions Global Gerecht Gesund Berlin, September 17, 2010
Sylvia Sax, RN BSN MPH
Doctoral Student
Institute Public Health, University of Heidelberg

3. Pakistan: Country Profile
Area 796,096 sq Km
Multiethnic & linguistic diversity
4 provinces & 2 territories
Population ~ 145 million
History: Rich cultural heritage
+ natural & human resources
Productive agriculture sector
Strategic trade location
Per capita income: US$
Literacy rate: 38.9%
Population doubling time: 25 years
Expenditure on health: 0.7% GNP
70-80-% of health expenditure is on
human resources
33% urban

4. Research
Case Study of North West Frontier Province, Pakistan (Khyber Pakhtoonkhwa)
Health Services Quality
Contextual factors that influence mechanisms for quality improvement
Qualitative and Quantitative methods

5. Nurses station in a district hospital
Dust at base of tap
No soap
No hand towels
No guideline for washing hands
No water
Are there issues of quality in the health services?
And there were no sinks with these commodities near this ward

9. Key Health System Issues
Critical shortage of health service providers
But not sure of the numbers (3 doctors/1 nurse)
External and internal brain drain (rural & donor)
Urban/rural discrepencies
Increasing reliance on paramedicals and ‚ward boys‘
Weak regulatory framework
Limited registration of health facilities and providers with lack of regulatory mechanisms
Professional groups weak influence on members
Corruption
Political interference in transfers and postings
Private medical schools proliferating without transparent processes
Young graduates without supervision, private medical schools proliferating without clear standards, curricula etc., 1/3 of the nursing curricula is now focused on English language

10. The darker the red – the higher the corruption perception index

11. Ease of Corruption in the Health Sector
Uncertainty about what services should be delivered and at what level of quality
Involvement of private and public actors like payers, providers, suppliers, consumers, and regulators
Asymmetric information among different actors and their individual interests
Extent to which private providers are entrusted with important public roles
Adapted from Savedoff 2006

12. Corruption
The abuse of entrusted power for private gain (Transparency International)
according to rule- corruption where payments/bribe is paid to receive preferential treatment for something that the bribe receiver is required to do by law.
Against the rule- where a bribe is paid to obtain services that the bribe receiver is prohibited from providing.
IMF and World Bank define corruption as misuse or abuse of public force (office) for private gain
Usually has to do with money
Usually involves individuals focused on profit

13. Sifarish
In our research we consistently heard about the practice of Sifarish (patronage, nepotism, favouratism)
Most interviewees identified Sifarish as a system, with specific practices which are not described or prescribed
Those who reported on Sifarish usually described harmful results of the practice

14. Culture and Corruption
Variations of levels of Corruption may be
due in part to variations in the social
norms and preferences that have been
internalized by the citizens of that
country
( Barr & Serra 2006)

15. Sifarish – a moral system?
It is a moral system which is accepted and
those participating are often not aware of the
practice
Morality can be defined as: a system of rules for guiding human conduct, and principles for evaluating those rules.
Individual acts within a cultural and social system
Even modern management recognizes that persuasion and influence are needed to get results and encourage managers to develop these skills. But Sifarish is not a skill that can be honed, learned or developed it is part of a cultural and moral system.

16. If Sifarish is not recognized as part of the
moral fabric of the cultural system and
understood as such
-then, how can we develop tools which
will maximize accountability and
transparency?

17. What can we do?
Recognize that it is a social norm, a pattern in society and not simply an individual act
Include transparent discussion of the different kinds of acts and their results
Discuss the concept of harm to society and encourage research on not only corruption but also related topics such as Sifarish
1. get rid of the shame and blame,
Recognize corruption as a practice, get away from the more abstract concepts, focus on the details
Encourage research – increase research and training health researchers to enable gathering of evidence in specific contexts on local practices that can harm society

18. Shukriya....Thank you

19. Selected References
Barr A. & Serra D Culture and Corruption. Global Poverty Research Group accessed on 21 June, 2010
Nichtar, S Corruption: the need-greed equation. News International, Islamabad, December 09.
Savedoff WD The causes of corruption in the health sector: a focus on health care systems. In: Transparency International. Global Corruption Report 2006: Special focus on corruption and health. London: Pluto Press.
Taryn Vian, 2008, Review of corruption in the health sector: theory, methods and interventions. Health Policy and Planning, Vol. 23, pp
Taryn Vian, 2002, Corruption and Health care Sector. Transparency international: Sectoral prospective of corruption, pp 1-35
Transparency International : accessed on 19th February 2010