1. Introduction Findings Conclusions Recommendations PETTY CORRUPTION IN PUBLIC HEALTH CARE Presented by Beatrice Mkani Sikika Study results from 10 districts on reported and perceived corrupt practices

2. Testimonies Concept Tools 2 INTRODUCTION

3.  “I think health workers benefit themselves, because when you get there you are told there are no drugs, but you are directed to go to a particular shop which belongs to a doctor who works in that very hospital. We, therefore, suspect that materials are taken from the hospital to go and benefit themselves.”  “We ordinary citizens don’t know where to go and complain. If we knew there is a place where one could go secretly and lodge your complaint and obtain redress many of us would go there.“  “I do not have the capacity to identify and solve problems related to delivery of services because I am not involved in anything concerning our health facility. I am called a member of the health facility governing committee just passively, I do not play any active role.” 3 TESTIMONIES

4. 4 CONCEPTUAL FRAMEWORK MonopolyDiscretionAccountability Resource Shortages Medical Equipment Health Workers Medicines Service Quality Dispensing Medicines Waiting Time Language Institutional Factors Management Supervision Transparent Entitlements Complaint Mechanisms Professional Ethics Health Seeking Behaviour Traditional Healer Private Provider Self-Medication Public Provider Governing Committees Independence Awareness Follow Up Capacity Corruption Illegal Selling of Medicines Absenteeism Bribing

5.  Institutional Factors Corrupt activities are supported by various institutional factors (the ‘rules of the game’).  Resource Shortages Supply side constraints create incentives to exchange quality services for (black) market prices that are above the regulated (standard) price scheme.  Health Seeking Behaviour Corrupt behaviour at public health facilities affects users’ preferences over health service providers.  Governing Committees Health facility governing committees effectively follow up citizens’ complaints about corrupt behaviour at the concerned health facility. 5 4 HYPOTHESES

6.  Cross-sectional design  Scope of 10 districts (4 urban and 6 rural)  Tools  Semi-structured questionnaires  Community members (N = 3886)  Out-patients (N = 1854)  In-patients (N = 485)  Health facility governing committees (N = 111)  Interviews with health facility management (N = 155)  On-site observations (N = 30)  Focus Group Discussions (N = 20) 6 SCOPE & TOOLS

7. Overt and covert bribing 7 PETTY CORRUPTION

8. 8 OVERT BRIBING N = 1854

9. Initiative of Patient Initiative of Health Worker 9 PAYMENTS WITHOUT RECEIPT N = 230

10. Supply shortages Lack of competition 10 MONOPOLY POWER

11. 11 ILLEGAL SELLING N = 3886

12. 12 HEALTH SEEKING BEHAVIOUR

13.  “It is cheaper to pay bribes at public health facilities than to seek health services at private health facilities where costs are prohibitively high.” 13 NO CHOICE

14. Monitoring of rules Enforcement of rules 14 ACCOUNTABILITY

15. 15 CORRUPTION IS THE RULE N = 3886

16. Citizens reporting corruption to HFGC Corruption featuring on HFGC meeting agenda 16 HEALTH FACILITY GOVERNING COMMITTEES (HFGC) N = 3886N = 111

17. 17 CONCLUSIONS & RECOMMENDATIONS

18.  Some medical supplies are stolen and sold in the private market  Poor service users cannot afford private health care prices  The ‘rules of the game’ are not adequately monitored  The ‘rules of the game’ are not adequately enforced 18 CONCLUSIONS

19.  Strengthen supportive supervision and independent auditing to stop the illegal selling of medical supplies, especially where public health workers own private health facilities and face conflict of interest.  Limit discretion by establishing a client service charter with service entitlements and standard rates.  Strengthen monitoring of rules by providing citizens with a mechanism to make anonymous complaints.  Strengthen enforcement of rules by ensuring that health facility governing committees have necessary independence, authority, competencies, and financial resources. 19 RECOMMENDATIONS

20. 20 Asanteni Sana

21. 21 www. sikika.or.tz Twitter: Sikika1 www.facebook/SikikaTanzania www.sikika-tz.blogspot.com www.youtube.com/sikikatanzania