Dying of corruption

Civil service organization as a political determinant of health: Analyzing relationships between merit-based hiring, corruption, and population health

A growing literature finds that the way governments are organized can impact the societies they serve in important ways. The same is apparent with respect to civil service organizations. Numerous studies show that the recruitment of civil servants based on their credentials rather than on nepotism or patronage reduces corruption in government. Political corruption in turn appears to harm population health. Up to this time, however, civil service organization is not a recognized determinant of health and is little discussed outside of political science disciplines. To provoke a broader conversation on this subject, the following study proposes that meritocratic recruitment of civil servants improves population health. To test this proposition, a series of regression models examines comparative data for 118 countries. Consistent with study hypotheses, meritocratic recruitment of civil servants corresponds longitudinally with both lower rates of corruption and lower rates of infant mortality. Results are similar after robustness checks. Findings with regard to life expectancy are more mixed. However, additional tests suggest meritocratic recruitment contributes to life expectancy over a longer span of time. Findings also offer more support for a direct pathway from meritocratic recruitment to population health rather than via changes in corruption levels per se, although this may depend on a country's level of economic development. Overall, this study offers first evidence that civil service organization, particularly the recruitment of civil servants based on the merits of their applications rather than on whom they happen to know in government, is a positive determinant of health. More research in this area is needed.

The role of health and health systems in promoting social capital, political participation and peace: A narrative review

High levels of violence and insecurity are highly detrimental for societies. United Nations Sustainable Development Goal 16 is advocating for peaceful, accountable and inclusive institutions as one powerful channel to foster global development. Investing in health and health policies can potentially contribute achieving these objectives. After providing a conceptual framework, this article reviews the existing literature on the evidence of the role of health and health systems in promoting social capital and trust, political engagement and participation, and peace that closely relate to the objectives of Sustainable Development Goal 16. We provide evidence of a systematically positive impact of better physical and mental health on social capital, and on political participation, both contributing to the sustainability of inclusive democratic institutions. We also document that health and health systems can help supporting peace, both via the reduction of social inequality and grievances, and by reducing the disruptive effects of epidemic shocks. Overall, the study provides evidence that health and health systems can generate co-benefits outside the health domain by promoting social capital, political participation and peace.

Does bribery increase maternal mortality? Evidence from 135 Sub-Saharan African regions

About 295,000 women died globally during and following pregnancy and childbirth in 2017. Two-thirds of these deaths occurred in Sub-Saharan Africa. By linking individual and regional data from 135 regions in 17 Sub-Saharan African countries over the period 2002-2018 this study explores how bribery affects maternal mortality in Sub-Saharan Africa. Our results show that the percentage of people who had first-hand experience in bribery is significantly and positively associated with pregnancy related deaths. We find that a 10 p.p. increase in the prevalence of bribery is associated with up to 41 [95% CI: 10-73] additional deaths for every 1,000 pregnancy-related deaths. However, the healthcare system quality appears to be an important moderator. To reduce maternal mortality, policy makers should not only increase investments in healthcare, they need also to implement measures to combat corruption.

Tripartite Evolutionary Game and Simulation Analysis of Healthcare Fraud Supervision under the Government Reward and Punishment Mechanism

This study aims to provide useful insights for the Chinese government in dealing with healthcare fraud by creating an evolutionary game model that involves hospitals, third-party entities, and the government based on the government reward and punishment mechanism. This paper analyzes the evolutionary stability of each participant's strategy choice, discusses the influence of each element on the tripartite strategy choice, and further analyzes the stability of the equilibrium point in the tripartite game system. The results show that (1) the government increasing fines on hospitals is conducive to compliant hospital operations, and the incentive mechanism has little effect on such operations; (2) the lack of an incentive mechanism for third parties results in false investigations by third parties; and (3) rewards from higher levels of government promote strict supervision by local governments, but that the high cost of supervision and rewards for hospitals inhibits the probability of strict supervision. Finally, Matlab 2020a is used for simulation analysis to provide a reference for the government to improve the supervision of healthcare fraud.

Political determinants of health: (re) examining the role of governance in reducing maternal mortality

Given change in the universal developmental agenda and the quality of governance in the last two decades, this paper re-examines the relationship between governance, health expenditure and maternal mortality using panel data for 184 countries from 1996 to 2019. By employing the 'dynamic panel data regression model', the study reveals that a one-point improvement in the governance index decreases maternal mortality by 10-21%. We also find that good governance can better translate health expenditure into improved maternal health outcomes through effective allocation and equitable distribution of available resources. These results are robust to alternative instruments, alternative dependent variables (such as infant mortality rate and life expectancy), estimation by different governance dimensions and at the sub-national level. Additional findings using 'Quantile regression' estimates show that the quality of governance matters more than the health expenditure in countries with a higher level of maternal mortality. While the 'Path regression' analysis exhibits the specific direct and indirect mechanisms through which the causal inference operates between governance and maternal mortality.

Whistleblowing as an anti-corruption strategy in health and pharmaceutical organizations in low- and middle-income countries: a scoping review

BACKGROUND

Whistleblowing can bring suspected wrongdoing to the attention of someone who is in the position to rectify the problem. Whistleblowing research can help improve effectiveness of anti-corruption efforts in the health sector.

OBJECTIVE

The objective of this scoping review is to understand the extent and type of evidence on whistleblowing as an anti-corruption strategy in health and pharmaceutical organisations in low- and middle-income countries (LMICs).

METHODS

This scoping review searched the PubMed, Scopus, and EMBASE databases from 2005 to 2020, limited to English language. We also searched websites of multilateral agencies or international non-governmental organisations for policy documents, guidance and reports. Titles and abstracts were screened to remove those where the focus was not on health, pharmaceuticals, whistleblowing, or LMIC context. Articles focused on research misconduct were excluded. Full-text articles were assessed for eligibility on these same criteria. Included sources were analysed thematically, based on five categories including definitions and models; evidence of reporting frequency; factors influencing whistleblowing; cultural context; and outcomes.

RESULTS

The review found 22 sources including reports, policies, and guidance documents (12, 55%), news articles (4, 18%), policy analyses/reviews (3, 14%), commentaries (2, 9%), and empirical studies (1, 5%). Most sources described whistleblowing policy and system components such as how whistleblowing is defined, who can report, and how confidentiality is assured. Few articles documented types and frequencies of corruption identified through whistleblowing or factors associated with whistleblowing. Several studies mentioned cultural norms as a potential limitation to whistleblowing effectiveness. About one-third of the sources described fear of retaliation and noted the need to strengthen protection for whistleblowers.

CONCLUSION

Research on whistleblowing is scarce in health and pharmaceutical organisations in LMICs. Documentation of policies, factors associated with whistleblowing, and whistleblowing outcomes is needed and could help countries to mainstream whistleblowing as a sectoral anti-corruption strategy.

Effects of Immigrants, Health, and Ageing on Economic Growth in the European Union

Population ageing and low birth rates are two problems of the EU that have an impact on employment, production, and economic growth. Against this background, immigration, health expenditure, and the health of migrants must become a key element of European policy. For this reason, this paper focused on identifying the effect of immigration, health, and ageing on economic growth in order to highlight their importance from an economic perspective. We constructed different econometric models with Eurostat data for 27 countries and 13 years (2008-2020), whose dependent variable was gross domestic product. Independent variables were the number of immigrants by gender and age, health expenditure per capita (total and by function), immigrants' perception of their health as very good, and the proportion of the population aged 65 years and over. The model selected to analyze the results was Prais-Winsten regression heteroskedastic panels corrected standard errors modeled by applying the option (ar1) to correct for autocorrelation, using Stata software (version 16). The results show that health expenditure has a significant positive effect on economic growth, higher in hospital services, followed by medical products; immigrants' perception as very good is only significant in some models. The number of immigrants has a (positive) effect, although less significant than public expenditure on health. Its effect is larger when the immigrant is aged between 15 and 64 years and smaller for male immigrants than for female immigrants. Without the ageing variable, immigration is not significant. Moreover, there are significant differences between European countries in relation to the variables analyses (immigration, immigrants' perception of their health, ageing and public expenditure on health, and public expenditure on health according to function). This may be due to the different regulations on both immigration and public health in the countries that make up the European Union.

COVID-19 and the state: Exploring a puzzling relationship in the early stages of the pandemic

During the first year of the Covid-19 pandemic, it was wealthier countries with stronger institutions that suffered the highest numbers of cases and fatalities. Many weaker countries were instead praised for more effective pandemic response. What explains this seeming puzzle? We re-consider these relationships in the cross-country data, drawing on measures of the state, Covid's health impact and pandemic response. In brief, our analysis suggests that, when appropriate additional factors are taken into account, the expected relationship between state effectiveness and pandemic health outcomes in fact is clear. We also offer insight into how different dimensions of the state influence policy and outcomes and how particular countries compare with others.

An exploration of anti-corruption and health in international organizations

Corruption is a global wicked problem that threatens the achievement of health, social and economic development goals, including Sustainable Development Goal # 3: Ensuring healthy lives and promoting well-being for all. The COVID-19 pandemic and its resulting strain on health systems has heightened risks of corruption both generally and specifically within health systems. Over the past years, international organizations, including those instrumental to the global COVID-19 response, have increased efforts to address corruption within their operations and related programs. However, as attention to anti-corruption efforts is relatively recent within international organizations, there is a lack of literature examining how these organizations address corruption and the impact of their anti-corruption efforts. This study addresses this gap by examining how accountability, transparency, and anti-corruption are taken up by international organizations within their own operations and the reported outcomes of such efforts. The following international organizations were selected as the focus of this document analysis: the World Health Organization, the Global Fund, the United Nations Development Programme, and the World Bank Group. Documents were identified through a targeted search of each organization's website. Documents were then analyzed combining elements of content analysis and thematic analysis. The findings demonstrate that accountability and transparency mechanisms have been employed by each of the four international organizations to address corruption. Further, these organizations commonly employed oversight mechanisms, including risk assessments, investigations, and audits to monitor their internal and external operations for fraud and corruption. All organizations used sanction strategies meant to reprimand identified transgressors and deter future corruption. Findings also demonstrate a marked increase in anti-corruption efforts by these international organizations in recent years. Though this is promising, there remains a distinct absence of evidence demonstrating the impact of such efforts on the prevalence and severity of corruption in international organizations.

Corruption and Population Health in the European Union Countries-An Institutionalist Perspective

Even though the European Union (EU) is considered one of the best performers in the world in fighting corruption, the situation changes when the analysis is shifted to the national dimension of its member states, with significant differences concerning the effects of corruption on population health. Using the theory of New Institutional Economics as a complementary tool that provides additional representativeness to this phenomenon, the aim of this paper is to empirically investigate the impact of corruption on population health, considering also other demographic and socio-economic determinants. Using data collected at the EU level registered between 2000-2019, we employ panel date models to validate the ongoing effect of perceived corruption on population health. Our empirical findings fully validate the institutionalist perspective, according to which countries with inclusive institutions better control the anomaly of corruption while benefitting from higher life expectancy and reducing child mortality rates. Conversely, the EU countries with rather extractive institutions suffer in terms of both longevity of population and infant mortality. Our study emphasizes that in tackling corruption pressure on population health, the most effective way is to improve the quality of governance in countries with fragile institutions.

How to detect healthcare fraud? "A systematic review"

OBJECTIVE

To identify the method used in detecting fraud cases.

METHODS

Articles searching by using topic-appropriate keywords and incorporated into search engines (data-based) journals Pubmed/Medline, Cochrane, Wiley, ScienceDirect, and secondary data-based Google scholar. Then data extraction is done based on inclusion criteria. The selected articles have the aim of investigating/detecting cases of fraud that have occurred in the health sector or other related sectors that support the study.

RESULTS

The findings of the nine reviewed articles have suggested that most of the fraud perpetrators are performed by medical personnel (doctors) and providers. Many types of fraud occur such as insurance claims or medical actions that are completely unadministered nor following the procedure and duplicating claims. The methods that appropriate to be used in detecting fraud are secondary data tracking, information, and technology specialist provision.

CONCLUSION

Secondary data tracking is the most widely used method in fraud detection. Fraud perpetrators are ones who dominated by medical circles with fictitious claim cases. Perpetrators tend not to act themselves but in organizations with network.

Effect of public corruption on the COVID-19 immunization progress

The coronavirus disease (COVID-19) outbreak has resulted in the death of over four million people since late 2019. To reduce the human and economic costs of COVID-19, different vaccines have been developed and distributed across countries. There has been significant cross-country variation in the vaccination of people against COVID-19. In this study, we focus on public corruption to explain the significant cause of cross-country variation in immunization progress. We suggest that countries with a higher degree of public corruption have been less successful in the vaccination of their population, controlling for other important determinants of immunization progress.

Legal Profession and Corruption in Health Care: Some Reflective Realities in South Africa

The article is an empirical attempt to research, analyse, and dissect the corrupt involvement of legal practitioners in illegal and fraudulent acts, and mainly their involvement in litigation associated with issues of medical negligence. This is done primarily but not exclusively through the utilisation of several qualitative research methods, including the content analysis of primary literary sources such as official state documents, existing legislation and court proceedings and personal interviews with senior public servants, as well as secondary sources. Beginning with a short exploration of South Africa's public legal terrain and the fears of sections of the statutory leadership of the legal profession, the article continues with the identification of key findings in several the country's provinces, the modus operandi of the corrupt individuals and groups, as well as the monetary, financial and social repercussions of such actions.

Country perspectives on improving technical assistance in the health sector

Background: This paper presents learnings from the Re-Imagining Technical Assistance for Maternal, Neonatal, and Child Health and Health Systems Strengthening (RTA) project implemented in the Democratic Republic of the Congo and Nigeria from April 2018 to September 2020 by JSI Research & Training Institute, Inc. and Sonder Collective and managed by the Child Health Task Force. The first of RTA's two phases involved multiple design research activities, such as human-centered design and co-creation, while the second phase focused on secondary analysis of interviews and reports from the design research. This paper explores the limitations of current technical assistance (TA) approaches and maps opportunities to improve how TA is planned and delivered in the health sector. Methods: We analyzed project reports and 68 interviews with TA funders, providers, and consumers to explore in greater detail their perspectives on TA, its characteristics and drawbacks as well as opportunities for improvement. We used qualitative content analysis techniques for this study.   Results: The issues surrounding TA included the focus on donor-driven agendas over country priorities, poor accountability between and within TA actors, inadequate skill transfer from TA providers to government TA consumers, an emphasis on quick fixes and short-term thinking, and inadequate governance mechanisms to oversee and manage TA. Consequently, health systems do not achieve the highest levels of resilience and autonomy. Conclusions: Participants in project workshops and interviews called for a transformation in TA centered on a redistribution of power enabling governments to establish their health agendas in keeping with the issues that are of greatest importance to them, followed by collaboration with donors to develop TA interventions. Recommended improvements to the TA landscape in this paper include nine critical shifts, four domains of change, and 20 new guiding principles.

Air pollution effects on adult mortality rate in developing countries

Although industrialisation is a crucial aspect of economic growth across developing nations, through the release of air contaminants, industrial activities may also create adverse environmental health consequences. Noting that continuous production and other economic activities are crucial for continued survival, this study explores this issue by including the role of governance that is deemed essential but the literature is relatively sparse particularly in the context of developing countries. This research empirically analyses the relationship between air pollution and adult mortality rates from 72 developing countries from the period of 2010 until 2017. Particulate matter (PM_2.5) and carbon dioxide (CO₂) are used as indicators of air pollution. From the generalized method of moments (GMM) estimations, the results reveal that air pollution negatively affects adult mortality rate. The result reveals that a 10% increase in the PM_2.5 level induces the adult mortality rates to increase between 0.04% and 0.06%. In addition, the government significantly moderates the negative effect of air pollution on adult mortality, whereby a one-unit enhancement in governance quality index reduces mortality among the adults in the developing countries by 0.01%. On the other hand, CO₂ emission also appears to be positive, but not statistically significant. The results suggest that governance and public health interplay in the sense of a transition towards economic development for improved living and health states can be achievable with improved governance quality.

Anti-corruption, Transparency and Accountability: Case Study of Healthcare in the Arab Countries

Background: The Arab states suffer from high levels of corruption. The UNDP’s team there developed an approach to tackle corruption and enhance transparency and accountability in healthcare as part of its broader efforts to support the Sustainable Development Goals. This work evolved into a proper tool, the Conceptual Framework for Corruption Risk Assessment at Sectoral Level (hereafter ‘Framework’), with implementation guides that enable tailoring to sector and country context.

Objectives: This article documents the development of the Framework, its methodology and observed added value.

Methods: Qualitative methods were utilized comprising desk research, field experience, stakeholder outreach, and focus group observation and documentation. It was most appropriate because the objective was to develop a methodology with specific characteristics.

Results: The new approach uses anti-corruption as an explicit entry point to governance reforms. It articulates a structured evidence-based method to apply risk management methodology – tailored to the specificities of corruption as a risk – in healthcare whereby assessment and mitigation are (a) within institutions (b) focused on decision points and (c) around transactions while bringing together health and anti-corruption communities towards designing measurable results-oriented reforms.

Conclusions: The Framework may be effective in driving concrete governance reform efforts that demonstrably reduce corruption by means of creating a common language and agenda among different stakeholders, changing the mindset towards reform, and developing targeted solutions with higher return on investment. As such, it may be capable of generating observable and sustainable progress towards healthcare reform.

Corruption and health outcomes within an economic and cultural framework

The purpose of this paper is to investigate the relationship between corruption and population health. Our cross-sectional sample covers 185 countries (54 high-income and 131 low-income countries) and the period of the analysis is 2005-2017. This research provides clear evidence that the level of corruption significantly affects physical health (expressed as life expectancy and Mortality rate) and mental health (expressed by happiness), under the moderating role of economic development and cultural framework. Moreover, we validate a powerful and positive correlation between the income level and both physical and mental health. Culture also has an important role in the corruption-health nexus, because we find evidence supporting four out of the six dimensions of culture (individualism versus collectivism, indulgence versus restraint, uncertainty avoidance and masculinity vs femininity) as having influence upon the physical and mental health of individuals. When we estimate the results on subsamples of countries (high-income and low-income countries), we validate a crisscross effect of corruption. Thus, a high level of corruption more deeply affects the physical health of population in low-income countries than in high-income countries. On the other hand, mental health is more pronouncedly affected by corruption in high-income countries than in low-income countries. This study may have important implications for national or international policy makers who need to acknowledge that anti-corruption policies play an important role in increasing population health, but they also need to adopt them according to the economic and cultural context of each nation.

Promoting anti-corruption, transparency and accountability in the recruitment and promotion of health workers to safeguard health outcomes

Background: Human Resources for Health are a core building block of a health system, playing a crucial role in improving health outcomes. While the existing literature has examined various forms of corruption that affect the health sector, few articles have examined the role and impact of corruption in the recruitment and promotion of health-workers.Objectives: This study reviews the role of corrupt practices such as nepotism, bribery and sextortion in health-worker recruitment and promotion and their implications for health systems.Methods: The study is based on an interdisciplinary non-systematic review of peer-reviewed journal articles in the public health/medicine and political science literature, complemented with the 'grey' literature such as technical reports and working papers.Results: Political and personal ties, rather than merit are often factors in the recruitment and promotion of health-workers in many countries. This results in the employment or promotion of poorly qualified or unsuitable workers, with negative implications for health outcomes.Conclusion: Corrupt practices in health-worker recruitment and promotion 'set the tone' for other forms of corruption such as absenteeism, embezzlement, theft and bid-rigging to flourish, as those recruited corruptly can collude for nefarious purposes. On the other hand, merit-based recruitment is important for curbing corruption. Corrupt recruitment practices have deleterious effects on health-worker motivation and retention, quality and competency, citizens' trust in health services and health outcomes. Whereas international law and policy such as the United Nations Convention Against Corruption and the WHO Handbook on Monitoring and Evaluation of Human Resources for Health state that recruitment of public officers and health workers respectively should be done in a transparent and accountable manner, more research is needed to inform policies on merit-based recruitment.

A critical interpretive synthesis of informal payments in maternal health care

Informal payments for healthcare are widely acknowledged as undercutting health care access, but empirical research is somewhat limited. This article is a critical interpretive synthesis that summarizes the evidence base on the drivers and impact of informal payments in maternal health care and critically interrogates the paradigms that are used to describe informal payments. Studies and conceptual articles identified both proximate and systems drivers of informal payments. These include norms of gift giving, health workforce scarcity, inadequate health systems financing, the extent of formal user fees, structural adjustment and the marketization of health care, and patient willingness to pay for better care. Similarly, there are proximal and distal impacts, including on household finances, patient satisfaction and provider morale. Informal payments have been studied and addressed from a variety of different perspectives, including anti-corruption, ethnographic and other in-depth qualitative approaches and econometric modelling. Summarizing and discussing the advantages and disadvantages of these and other paradigms illustrates the value of an inter-disciplinary approach. The same tacit, hidden attributes that make informal payments hard to measure also make them hard to discuss and address. A multidisciplinary health systems approach that leverages and integrates positivist, interpretivist and constructivist tools of social science research can lead to better insight. With this, we can challenge ‘master narratives’ and meet universalistic, equity-oriented global health objectives.

Effect of corruption on perceived difficulties in healthcare access in sub-Saharan Africa

Background

Achieving Universal Health Coverage (UHC) by improving financial protection and effective service coverage is target 3.8 of the Sustainable Development Goals. Little is known, however, about the extent to which paying bribes within healthcare acts as a financial barrier to access and, thus, UHC.

Methods

Using survey data in adults from 32 sub-Saharan African countries in 2014–2015, we constructed a multilevel model to evaluate the relationship between paying bribes and reported difficulties of obtaining medical care. We controlled for individual-, region-, and country-level variables.

Results

Having paid bribes for medical care significantly increased the odds of reporting difficulties in obtaining care by 4.11 (CI: 3.70–4.57) compared to those who never paid bribes, and more than doubled for those who paid bribes often (OR = 9.52; 95% CI: 7.77–11.67). Respondents with higher levels of education and more lived poverty also had increased odds. Those who lived in rural areas or within walking distance to a health clinic had reduced odds of reporting difficulties. Sex, age, living in a capital region, healthcare expenditures per capita, and country Corruption Perception Index were not significant predictors.

Conclusions

We found that bribery in healthcare is a significant barrier to healthcare access, negatively affecting the potential of African countries to make progress toward UHC. Future increases in health expenditures—which are needed in many countries to achieve UHC—should be accompanied by greater efforts to fight corruption in order to avoid wasting money. Measuring and tracking health sector-specific corruption is critical for progress toward UHC.

Does corruption kill? Evidence from half a century infant mortality data

We investigate the relationship between corruption and infant mortality in Turkey. Our study contributes to the literature in a couple of ways in terms of data and estimation method. First, we construct a novel index of corruption in Turkey based on the stories covered in a major newspaper between the years 1960 and 2010. Second, because we now annual data on corruption covering a period long enough, we investigate the integration properties of the data and estimate the cointegrating relationship between corruption and infant mortality using Fully Modified OLS (FMOLS) and Canonical Cointegrating Regression (CCR). We find that corruption increases infant mortality in the long-run. Our results are robust to different specifications and estimation methods.

Governance commitment to reduce maternal mortality. A political determinant beyond the wealth of the countries

Some countries reached, in 2015, the Millennium Development Goal of reducing maternal mortality to 96 or less maternal deaths per 100,000 live births. Others, however, did not. This paper analyses the strength of the association between maternal mortality and each of the six components of Governance-a political determinant scarcely explored in the literature-in 174 countries. It was found that the greater the governance, the lower maternal mortality, independently of a country's wealth. We used all six indicators of the World Bank's Worldwide Governance Indicators Project in 2015: government effectiveness, regulatory quality, rule of law, control of corruption, voice and accountability, and political stability and absence of violence. Findings were encouraging as maternal mortality in low-income countries with higher government effectiveness and regulatory quality was similar to that of medium-income countries with lower government effectiveness and regulatory quality. To achieve the post-2015 sustainable development goal on preventable maternal mortality-which persists despite economic development-all governance dimensions are essential and represent interdependent cornerstones.

Rebuilding research capacity in fragile states: the case of a Somali-Swedish global health initiative

This paper presents an initiative to revive the previous Somali–Swedish Research Cooperation, which started in 1981 and was cut short by the civil war in Somalia. A programme focusing on research capacity building in the health sector is currently underway through the work of an alliance of three partner groups: six new Somali universities, five Swedish universities, and Somali diaspora professionals. Somali ownership is key to the sustainability of the programme, as is close collaboration with Somali health ministries. The programme aims to develop a model for working collaboratively across regions and cultural barriers within fragile states, with the goal of creating hope and energy. It is based on the conviction that health research has a key role in rebuilding national health services and trusted institutions.

Corruption practices in drug prescribing in Vietnam - an analysis based on qualitative interviews

BACKGROUND

Results from a previous study showed that 40 to 60% of the price of off-patent medicines in Vietnam was typically spent to induce prescribers to use the medicines, and to persuade procurement officers within hospitals to buy them. In this article we examine how and why inducements were paid by the pharmaceutical industry to health care providers in Vietnam.

METHODS

We use a theoretically informed analysis to understand pharmaceutical companies' account of giving inducements and prescribers' account of taking them, elicited through in-depth interviews.

RESULTS

Analysis of the emergent concepts derived from our qualitative data led to viewing the constructs from the theoretical framework of opportunities; pressures; and rationalization within a hierarchy of systemic factors and individual factors. Economic survival pressures in an imperfectly competitive market reportedly encouraged pharmaceutical companies and prescribers to be linked financially. Although individual factors such as professional ethics and personal values influenced doctors' responses to corrupt practices, entrenched systemic issues, including lack of transparency, accountability, poor enforcement of legislation and prevalence of corruption emerged as important factors supporting corrupt practice or even making it very difficult for individuals to opt out of corrupt practices.

CONCLUSIONS

Our theoretically informed analysis of inducements provides an in-depth understanding of an angle of corruption in Vietnam's health sector, showing the need for multifaceted strategies in the fight against corruption in the health sector. Remedial strategies need to address both systemic and individual factors including interventions to relieve dependencies for survival of health care services on the corrupt system.

Political Economy of Infant Mortality Rate: Role of Democracy Versus Good Governance

Despite numerous studies on whether democracy reduces the infant mortality rate (IMR), the empirical results remain mixed at best. In this article, I perform several theoretical and empirical exercises that help explain why and under what conditions we should expect politics to matter most for a decrease in IMR. First, I capitalize on the epidemiological view that IMR – the most commonly used indicator of health in social sciences – is better suited to reflect public health micromanagement than overall social development. Second, I theorize that autocrats have incentives to invest in health up to a certain point, which could lead to a reduction in IMR. Third, I introduce an omitted variable – good governance – that trumps the importance of a political regime for IMR: (1) it directly affects public health micromanagement, and (2) many autocrats made inroads in achieving good governance. Finally, for the first time in such research, I use a disaggregated IMR approach to corroborate my hypotheses.

Health sector governance: should we be investing more?

Governance is central to improving health sector performance and achieving Universal Health Coverage (UHC). However, the growing body of research on governance and health has not yet led to a global consensus on the need for more investment in governance interventions to improve health. This paper aims to summarise the latest evidence on the influence of governance on health, examines how we can assess governance interventions and considers what might constitute good investments in health sector governance in resource constrained settings. The paper concludes that agendas for improving governance need to be realistic and build on promising in-country innovation and the growing evidence base of what works in different settings. For UHC to be achieved, governance will require new partnerships and opportunities for dialogue, between state and non-state actors. Countries will require stronger platforms for effective intersectoral actions and more capacity for applied policy research and evaluation. Improved governance will also come from collective action across countries in research, norms and standards, and communicable disease control.

On the role of environmental corruption in healthcare infrastructures: An empirical assessment for Italy using DEA with truncated regression approach

OBJECTIVES

This paper investigates empirically whether the institutional features of the contracting authority as well as the level of 'environmental' corruption in the area where the work is localised affect the efficient execution of public contracts for healthcare infrastructures.

METHODS

A two-stage Data Envelopment Analysis (DEA) is carried out based on a sample of Italian public contracts for healthcare infrastructures during the period 2000-2005. First, a smoothed bootstrapped DEA estimator is used to assess the relative efficiency in the implementation of each single infrastructure contract. Second, the determinants of the efficiency scores variability are considered, paying special attention to the effect exerted by 'environmental' corruption on different types of contracting authorities.

RESULTS

Our results show that the performance of the contracts for healthcare infrastructures is significantly affected by 'environmental' corruption. Furthermore, healthcare contracting authorities are, on average, less efficient and the negative effect of corruption on efficiency is greater for this type of public procurers.

CONCLUSIONS

The policy recommendation coming out of the study is to rely on 'qualified' contracting authorities since not all the public bodies have the necessary expertise to carry on public contracts for healthcare infrastructures efficiently.

Return Migrants' Experience of Access to Care in Corrupt Healthcare Systems: The Bosnian Example

Equal and universal access to healthcare services is a core priority for a just health system. A key societal determinant seen to create inequality in access to healthcare is corruption in the healthcare system. How return migrants’ access to healthcare is affected by corruption is largely unstudied, even though return migrants may be particularly vulnerable to problems related to corruption due to their period of absence from their country of origin. This article investigates how corruption in the healthcare sector affects access to healthcare for refugees who repatriated to Bosnia, a country with a high level of corruption, from Denmark, a country with a low level of corruption. The study is based on 18 semi-structured interviews with 33 refugees who returned after long-term residence in Denmark. We found that the returned refugees faced greater problems with corruption than was the case for those who had not left the country, as doctors considered them to be better endowed financially and therefore demanded larger bribes from them than they did from those who had remained in Bosnia. Moreover, during their stay abroad the returnees had lost the connections that could have helped them sidestep the corruption. Returned refugees are thus particularly vulnerable to the effects of corruption.

What Is the Association between Absolute Child Poverty, Poor Governance, and Natural Disasters? A Global Comparison of Some of the Realities of Climate Change

The paper explores the degree to which exposure to natural disasters and poor governance (quality of governance) is associated with absolute child poverty in sixty-seven middle- and low-income countries. The data is representative for about 2.8 billion of the world´s population. Institutionalist tend to argue that many of society’s ills, including poverty, derive from fragile or inefficient institutions. However, our findings show that although increasing quality of government tends to be associated with less poverty, the negative effects of natural disasters on child poverty are independent of a country´s institutional efficiency. Increasing disaster victims (killed and affected) is associated with higher rates of child poverty. A child´s estimated odds ratio to be in a state of absolute poverty increases by about a factor of 5.7 [95% CI: 1.7 to 18.7] when the average yearly toll of disasters in the child´s country increases by one on a log-10 scale. Better governance correlates with less child poverty, but it does not modify the correlation between child poverty and natural disasters. The results are based on hierarchical regression models that partition the variance into three parts: child, household, and country. The models were cross-sectional and based on observational data from the Demographic Health Survey and the Multiple Indicator Cluster Survey, which were collected at the beginning of the twenty-first millennium. The Sustainable Development Goals are a principle declaration to halt climate change, but they lack a clear plan on how the burden of this change should be shared by the global community. Based on our results, we suggest that the development agencies should take this into account and to articulate more equitable global policies to protect the most vulnerable, specifically children.

A survey of the governance capacity of national public health associations to enhance population health

BACKGROUND

National public health associations (PHAs) are key partners with governments and communities to improve, protect and promote the public's health. Governance and organizational capacity are among the key determinants of a PHA's effectiveness as an advocate for appropriate public health policies and practice.

METHODS

During 2014, the World Federation of Public Health Associations (WFPHA) conducted an on-line survey of its 82 PHA members, to identify the state of organizational governance of national public health associations, as well as the factors that influence optimal organizational governance. The survey consisted of 13 questions and focused on the main elements of organizational governance: cultivating accountability; engaging stakeholders; setting shared direction; stewarding resources; and, continuous governance enhancement. Four questions included a qualitative open-ended response for additional comments. The survey data were analyzed using Microsoft Excel. The qualitative data was analyzed using thematic content analysis

RESULTS

Responses were received from 62 PHAs, constituting a 75.6 % response rate. The two most important factors that support governance effectiveness were a high degree of integrity and ethical behavior of the PHA's leaders (77 %) and the competence of people serving on the PHA's governing body (76 %). The lack of financial resources was considered as the most important factor that negatively affected organizational governance effectiveness (73 %). The lack of mentoring for future PHA leaders; ineffective or incompetent leadership; lack of understanding about good governance practices; and lack of accurate information for strategic planning were identified as factors influencing PHA governance effectiveness. Critical elements for PHA sustainability included diversity, gender-responsiveness and inclusive governance practices, and strategies to build the future generation of public health leaders.

CONCLUSION

National PHA have a responsibility to put into place the practices and infrastructure that enhance organizational governance. This will enhance their ability to be effective advocates for policies and practices that enhance, protect and promote the public's health. The WFPHA has an important role to play in providing the technical assistance and financial resources to assist PHAs in attaining and sustaining a higher level of governance capacity.

Why health care corruption needs a new approach

While corruption has been at the center of academic studies and on the agenda of international organizations for a couple of decades, in the health care sector corruption has not generated much interest or progress. At the centre of this issue is the lack of an interdisciplinary approach, which is warranted given the complexity of the issue and the lack of cooperation between STET scientifically rigorous academics and policy-makers, leaving room for more cooperation and progress.

Democracy and self-rated health across 67 countries: A multilevel analysis

Existing research has found a positive association between countries' level of democratic governance and the health of their populations, although that research is limited by the use of data from small numbers of high-income countries or aggregate data that do not assess individual-level health outcomes. We extend prior research by using multilevel World Health Survey (2002-2004) data on 313,554 individuals in 67 countries, and find that the positive association between democratic governance and self-rated health persists after adjusting for both individual- and country-level confounders. However, the mechanisms linking democracy and self-rated health remain unclear. Individual-level measures of socioeconomic status, and country-level measures of economic inequality and investments in public health and education, do not significantly mediate the association between democratic governance and self-rated health. The persistent association between democratic governance and health suggests that the political organization of societies may be an important upstream determinant of population health.

Quality of governance, public spending on health and health status in Sub Saharan Africa: a panel data regression analysis

Background

The population in Sub Saharan Africa (SSA) suffers poor health as manifested in high mortality rates and low life expectancy. Economic growth has consistently been shown to be a major determinant of health outcomes. However, even with good economic growth rates, it is not possible to achieve desired improvements in health outcomes. Public spending on health (PSH) has long been viewed as a potential complement to economic growth in improving health. However, the relationship between PSH and health outcomes is inconclusive and this inconclusiveness may, in part, be explained by governance-related factors which mediate the impact of the former on the latter. Little empirical work has been done in this regard on SSA. This paper investigates whether or not the quality of governance (QoG) has a modifying effect on the impact of public health spending on health outcomes, measured by under-five mortality (U5M) and life expectancy at birth (LE), in SSA.

Methods

Using two staged least squares regression technique on panel data from 43 countries in SSA over the period 1996–2011, we estimated the effect of public spending on health and quality of governance U5M and LE, controlling for GDP per capita and other socio-economic factors. We also interacted PSH and QoG to find out if the latter has a modifying effect on the former’s impact on U5M and LE.

Results

Public spending on health has a statistically significant impact in improving health outcomes. Its direct elasticity with respect to under-five mortality is between −0.09 and −0.11 while its semi-elasticity with respect to life expectancy is between 0.35 and 0.60. Allowing for indirect effect of PSH spending via interaction with quality of governance, we find that an improvement in QoG enhances the overall impact of PSH. In countries with higher quality of governance, the overall elasticity of PSH with respect to under-five mortality is between −0.17 and −0.19 while in countries with lower quality of governance, it is about −0.09. The corresponding semi elasticities with respect to life expectancy are about 6 in countries with higher QoG and about 3 in countries with lower QoG.

Discussion

Public spending on health improves health outcomes. Its impact is mediated by quality of governance, having the higher impact on health outcomes in countries with higher quality of governance and lower impact in countries with lower quality of governance. This may be due to increased efficiency in the use of available resources and better allocation of the same as QoG improves.

Conclusion

Improving QoG would improve health outcomes in SSA. The same increase in PSH is twice as effective in reducing U5M and increasing LE in countries with good QoG when compared with countries with poor QoG.

Exploring corruption in the South African health sector

Recent scholarly attention has focused on weak governance and the negative effects of corruption on the provision of health services. Employing agency theory, this article discusses corruption in the South African health sector. We used a combination of research methods and triangulated data from three sources: Auditor-General of South Africa reports for each province covering a 9-year period; 13 semi-structured interviews with health sector key informants and a content analysis of print media reports covering a 3-year period. Findings from the Auditor-General reports showed a worsening trend in audit outcomes with marked variation across the nine provinces. Key-informants indicated that corruption has a negative effect on patient care and the morale of healthcare workers. The majority of the print media reports on corruption concerned the public health sector (63%) and involved provincial health departments (45%). Characteristics and complexity of the public health sector may increase its vulnerability to corruption, but the private-public binary constitutes a false dichotomy as corruption often involves agents from both sectors. Notwithstanding the lack of global validated indicators to measure corruption, our findings suggest that corruption is a problem in the South African healthcare sector. Corruption is influenced by adverse agent selection, lack of mechanisms to detect corruption and a failure to sanction those involved in corrupt activities. We conclude that appropriate legislation is a necessary, but not sufficient intervention to reduce corruption. We propose that mechanisms to reduce corruption must include the political will to run corruption-free health services, effective government to enforce laws, appropriate systems, and citizen involvement and advocacy to hold public officials accountable. Importantly, the institutionalization of a functional bureaucracy and public servants with the right skills, competencies, ethics and value systems and whose interests are aligned with health system goals are critical interventions in the fight against corruption.

Analysis of a cultural consensus model of two good-life sub-domains--health & well-being and migration & socioeconomic milieu--in three population groups in Croatia

In this study the construct of a 'good life' was explored among upper secondary school senior pupils and their parents and teachers by applying cultural consensus model analysis. A total of 469 students, 474 parents and 158 teachers from four Croatian cities participated in the study, which was conducted in 2011/2012. The information collected through interviewing and free-listing during the first phase of the study was used to create a set of structured questionnaire questions as a part of the survey in the second phase of data collection. The results are reported on two good-life sub-domains: 'health & well-being' and 'migration & socioeconomic milieu'. The results indicate heterogeneity of the sample groups, incomplete inter-generational transmission of cultural values and examples of two sub-groups that resist cultural norms and do not comply with the dominant 'competence-as-sharing' paradigm. The value of testing the cultural consensus model based on the emic approach and locally significant phenomena is demonstrated for planning and conducting holistic anthropological research.

An analysis of government immunization program expenditures in lower and lower middle income countries 2006-12

Financing is becoming increasingly important as the cost of immunizing the world's children continues to rise. By 2015, that cost will likely exceed US$60 per infant as new vaccines are introduced into national immunization programs. In 2006, 51 lower and lower middle income countries reported spending a mean US$12 per surviving infant on routine immunization. By 2012, the figure had risen to $20, a 67% increase. This study tests the hypothesis that lower and lower middle income countries will spend more on their routine immunization programs as their economies grow. A panel data regression approach is used. Expenditures reported by governments annually (2006-12) through the World Health Organization/UNICEF Joint Reporting Form are regressed on lagged annual per capita gross national income (GNI), controlling for prevailing mortality levels, immunization program performance, corruption control efforts, geographical region and correct reporting. Results show the expenditures increased with GNI. Expressed as an elasticity, the countries spent approximately $6.32 on immunization for every $100 in GNI increase from 2006 to 2012. Projecting forward and assuming continued annual GNI growth rates of 10.65%, countries could be spending $60 per infant by 2020 if national investment functions increase 4-fold. Given the political will, this result implies countries could fully finance their routine immunization programs without cutting funding for other programs.

Governance and health in the Arab world

Since late 2010, the Arab world has entered a tumultuous period of change, with populations demanding more inclusive and accountable government. The region is characterised by weak political institutions, which exclude large proportions of their populations from political representation and government services. Building on work in political science and economics, we assess the extent to which the quality of governance, or the extent of electoral democracy, relates to adult, infant, and maternal mortality, and to the perceived accessibility and improvement of health services. We compiled a dataset from the World Bank, WHO, Institute for Health Metrics and Evaluation, Arab Barometer Survey, and other sources to measure changes in demographics, health status, and governance in the Arab World from 1980 to 2010. We suggest an association between more effective government and average reductions in mortality in this period; however, there does not seem to be any relation between the extent of democracy and mortality reductions. The movements for changing governance in the region threaten access to services in the short term, forcing migration and increasing the vulnerability of some populations. In view of the patterns observed in the available data, and the published literature, we suggest that efforts to improve government effectiveness and to reduce corruption are more plausibly linked to population health improvements than are efforts to democratise. However, these patterns are based on restricted mortality data, leaving out subjective health metrics, quality of life, and disease-specific data. To better guide efforts to transform political and economic institutions, more data are needed for health-care access, health-care quality, health status, and access to services of marginalised groups.

Combating healthcare corruption and fraud with improved global health governance

Corruption is a serious threat to global health outcomes, leading to financial waste and adverse health consequences. Yet, forms of corruption impacting global health are endemic worldwide in public and private sectors, and in developed and resource-poor settings alike. Allegations of misuse of funds and fraud in global health initiatives also threaten future investment. Current domestic and sectorial-level responses are fragmented and have been criticized as ineffective. In order to address this issue, we propose a global health governance framework calling for international recognition of "global health corruption" and development of a treaty protocol to combat this crucial issue.

Evolving righteousness in a corrupt world

Punishment offers a powerful mechanism for the maintenance of cooperation in human and animal societies, but the maintenance of costly punishment itself remains problematic. Game theory has shown that corruption, where punishers can defect without being punished themselves, may sustain cooperation. However, in many human societies and some insect ones, high levels of cooperation coexist with low levels of corruption, and such societies show greater wellbeing than societies with high corruption. Here we show that small payments from cooperators to punishers can destabilize corrupt societies and lead to the spread of punishment without corruption (righteousness). Righteousness can prevail even in the face of persistent power inequalities. The resultant righteous societies are highly stable and have higher wellbeing than corrupt ones. This result may help to explain the persistence of costly punishing behavior, and indicates that corruption is a sub-optimal tool for maintaining cooperation in human societies.

No evidence of the effect of the interventions to combat health care fraud and abuse: a systematic review of literature

BACKGROUND

Despite the importance of health care fraud and the political, legislative and administrative attentions paid to it, combating fraud remains a challenge to the health systems. We aimed to identify, categorize and assess the effectiveness of the interventions to combat health care fraud and abuse.

METHODS

The interventions to combat health care fraud can be categorized as the interventions for 'prevention' and 'detection' of fraud, and 'response' to fraud. We conducted sensitive search strategies on Embase, CINAHL, and PsycINFO from 1975 to 2008, and Medline from 1975-2010, and on relevant professional and organizational websites. Articles assessing the effectiveness of any intervention to combat health care fraud were eligible for inclusion in our review. We considered including the interventional studies with or without a concurrent control group. Two authors assessed the studies for inclusion, and appraised the quality of the included studies. As a limited number of studies were found, we analyzed the data using narrative synthesis.

FINDINGS

The searches retrieved 2229 titles, of which 221 full-text studies were assessed. We found no studies using an RCT design. Only four original articles (from the US and Taiwan) were included: two studies within the detection category, one in the response category, one under the detection and response categories, and no studies under the prevention category. The findings suggest that data-mining may improve fraud detection, and legal interventions as well as investment in anti-fraud activities may reduce fraud.

DISCUSSION

Our analysis shows a lack of evidence of effect of the interventions to combat health care fraud. Further studies using robust research methodologies are required in all aspects of dealing with health care fraud and abuse, assessing the effectiveness and cost-effectiveness of methods to prevent, detect, and respond to fraud in health care.

Perceptions of the health system and public trust in government in low- and middle-income countries: evidence from the World Health Surveys

In low- and middle-income countries, health care systems are an important means by which individuals interact with their government. As such, aspects of health systems in these countries may be associated with public trust in government. Greater trust in government may in turn improve governance and government effectiveness. We identify health system and non-health system factors hypothesized to be associated with trust in government and fit several multilevel regression models to cross-national data from 51,300 respondents in thirty-eight low- and middle-income countries participating in the World Health Surveys. We find that health system performance factors are associated with trust in government while controlling for a range of non-health system covariates. Taken together, higher technical quality of health services, more responsive service delivery, fair treatment, better health outcomes, and financial risk protection accounted for a 13 percentage point increase in the probability of having trust in government. Health system performance and good governance may be more inter-related than previously thought. This finding is particularly important for low-income and fragile states, where health systems and governments tend to be weakest. Future research efforts should focus on determining the causal mechanisms that underlie the observed associations between health system performance and trust in government.