1. Corruption and Health in Developing and Transition Economies Maureen Lewis Chief Economist for Human Development World Bank

2. Major Sources of Corruption in the Health Sector Contracting and procurement Petty theft Selling accreditation or positions Public funds disappearing Staff nonattendance Informal payments

3. Measuring Corruption Perceptions of leaders, providers and the public; Contracting: audit and supervision; Petty theft: difficult, track supplies; Selling accreditation: anecdotal; Public funds use: PETS; Staff attendance: surveys, records; Informal payments: surveys/studies.

4. Perceptions Out of 22 countries, 10, or almost half, consider health in the top 4 most corrupt sectors; In 60% of 22 countries canvassed, over half of interviewees perceived corruption in health, and in over 85% of the sample corruption was apparent to 60% of the public.

5. Contracting/Selling Accreditation and Positions Part of broader corruption problem; Hard to single out one sector unless it is a pilot; Tend to correlate with other forms of corruption or bad public practices; In Buenos Aires procurement data showed 15% drop in prices during corruption crackdown.

6. Misuse of Public Funds Public Expenditure Tracking Studies (PETS) trace the flow of funds from the budget to expenditure at the front line – in clinics and hospitals; Quantifies the bureaucratic capture, leakage and problems with deployment of human and other inputs.

7. Misuse of Public Funds: Education Tracing flow of funds in primary school showed that in the base year: 87 percent of funds in Uganda never reached the schools; 60 percent of funds in Zambia never reached the schools.

8. Staff Nonattendance Time and motion studies and full costing and expenditure review of hospital. In D.R. 12% of contracted physician time available at hospital. Training of interns by MDs nonexistent; Quantitative/Qualitative surveys of users and providers includes: qualitative assessment of incentives; interviews with providers; exit/follow up patient interviews (Armenia,Poland, Georgia).

9. Staff Nonattendance (cont.) Quantitative Service Delivery Surveys (QSDS) based on unannounced spot checks of clinics (Bangladesh, Honduras, India, Peru, Uganda); Apply questionnaires for: local health administration; health facility records; exit interviews (Uganda).

11. Informal Payments Household surveys Corruption surveys Reviewing patient records Qualitative studies Focus groups of providers/ patients/community Provider/administration interviews Exit surveys/follow up patients (Poland, Georgia)

18. Underlying Causes of Corruption Lack of clear standards of performance for providers Organizational and management deficiencies Lack of effective auditing and supervision Collusion in contracting Lax fiscal controls in flow of public funds Limited enforcement of rules/no sanctions Abuse is unchecked Good performance unnoticed

19. Underlying Causes of Corruption (cont.) Lack of accountability and oversight Nonattendance of staff Poor quality of care Informal payments Lack of citizen involvement and of local oversight and authority Absence of monitoring and evaluation

20. Remedies Government-wide anti-corruption stance; Culture of public service; Procurement and contracting rules, and enforcement of rules; Public standards of conduct and oversight; Effective enforcement of rules and rewards/punishment for behavior;

21. Remedies (cont.) Improvement in civil service rules, pay and review; raise quality of public management of health services; Reform of provider units (TQM) – health providers input to raise productivity and performance; Charge official fees and compensate providers accordingly for efforts; Promote private sector alternatives;

22. Remedies (cont.) Allow accountability at health service delivery unit to stem petty theft and improve management potential Improve fiscal oversight with consequences for unlawful practices Local accountability Local advertising of expected funds receipt

23. Challenges Cultural change is difficult; Physicians hard to influence; Oversight is costly and complex; Some level of corruption emerges in most health systems; Without controlling corruption health system is compromised in eyes of the public.

24. Frequency of Bribes or Informal Payments