Auditing Nicaragua's anti-corruption struggle, 1998 to 2009

Corruption in the health sector: A problem in need of a systems-thinking approach

Health systems are comprised of complex interactions between multiple different actors with differential knowledge and understanding of the subject and system. It is exactly this complexity that makes it particularly vulnerable to corruption, which has a deleterious impact on the functioning of health systems and the health of populations. Consequently, reducing corruption in the health sector is imperative to strengthening health systems and advancing health equity, particularly in low- and middle-income countries (LMICs). Although health sector corruption is a global problem, there are key differences in the forms of and motivations underlying corruption in health systems in LMICs and high-income countries (HICs). Recognizing these differences and understanding the underlying system structures that enable corruption are essential to developing anti-corruption interventions. Consequently, health sector corruption is a problem in need of a systems-thinking approach. Anti-corruption strategies that are devised without this understanding of the system may have unintended consequences that waste limited resources, exacerbate corruption, and/or further weaken health systems. A systems-thinking approach is important to developing and successfully implementing corruption mitigation strategies that result in sustainable improvements in health systems and consequently, the health of populations.

Corruption: An Impediment to Delivering Pathology and Laboratory Services in Resource-Limited Settings

OBJECTIVES

Corruption is a widely acknowledged problem in the health sector of low- and middle-income countries (LMICs). Yet, little is known about the types of corruption that affect the delivery of pathology and laboratory medicine (PALM) services. This review is a first step at examining corruption risks in PALM.

METHODS

We performed a critical review of medical literature focused on health sector corruption in LMICs. To provide context, we categorized cases of laboratory-related fraud and abuse in the United States.

RESULTS

Forms of corruption in LMICs that may affect the provision of PALM services include informal payments, absenteeism, theft and diversion, kickbacks, self-referral, and fraudulent billing.

CONCLUSIONS

Corruption represents a functional reality in many LMICs and hinders the delivery of services and distribution of resources to which individuals and entities are legally entitled. Further study is needed to estimate the extent of corruption in PALM and develop appropriate anticorruption strategies.

Anti-corruption, transparency and accountability in health: concepts, frameworks, and approaches

Background: As called for by the Sustainable Development Goals, governments, development partners and civil society are working on anti-corruption, transparency and accountability approaches to control corruption and advance Universal Health Coverage.

Objectives: The objective of this review is to summarize concepts, frameworks, and approaches used to identify corruption risks and consequences of corruption on health systems and outcomes. We also inventory interventions to fight corruption and increase transparency and accountability.

Methods: We performed a critical review based on a systematic search of literature in PubMed and Web of Science and reviewed background papers and presentations from two international technical meetings on the topic of anti-corruption and health. We identified concepts, frameworks and approaches and summarized updated evidence of types and causes corruption in the health sector.

Results: Corruption, or the abuse of power for private gain, in health systems includes bribes and kickbacks, embezzlement, fraud, political influence/nepotism and informal payments, among other behaviors. Drivers of corruption include individual and systems level factors such as financial pressures, poorly managed conflicts of interest, and weak regulatory and enforcement systems. We identify six typologies and frameworks that model relationships influencing the scope and seriousness of corruption, and show how anti-corruption strategies such as transparency, accountability, and civic participation can affect corruption risk. Little research exists on the effectiveness of anti-corruption measures; however, interventions such as community monitoring and insurance fraud control programs show promise.

Conclusions: Corruption undermines the capacity of health systems to contribute to better health, economic growth and development. Interventions and resources on prevention and control of corruption are essential components of health system strengthening for Universal Health Coverage.

Mobilising communities for Aedes aegypti control: the SEPA approach

Abstract

Camino Verde (the Green Way) is an evidence-based community mobilisation tool for prevention of dengue and other mosquito-borne viral diseases. Its effectiveness was demonstrated in a cluster-randomised controlled trial conducted in 2010–2013 in Nicaragua and Mexico. The common approach that brought functional consistency to the Camino Verde intervention in both Mexico and Nicaragua is Socialisation of Evidence for Participatory Action (SEPA).

In this article, we explain the SEPA concept and its theoretical origins, giving examples of its previous application in different countries and contexts. We describe how the approach was used in the Camino Verde intervention, with details that show commonalities and differences in the application of the approach in Mexico and Nicaragua. We discuss issues of cost, replicability and sustainability, and comment on which components of the intervention were most important to its success. In complex interventions, multiple components act in synergy to produce change. Among key factors in the success of Camino Verde were the use of community volunteers called brigadistas, the house-to-house visits they conducted, the use of evidence derived from the communities themselves, and community ownership of the undertaking.

Communities received the intervention by random assignment; dengue was not necessarily their greatest concern. The very nature of the dengue threat dictated many of the actions that needed to be taken at household and neighbourhood levels to control it. But within these parameters, communities exercised a large degree of control over the intervention and displayed considerable ingenuity in the process.

Trial registration

ISRCTN27581154.

"They make money off of us": a phenomenological analysis of consumer perceptions of corruption in Kenya's HIV response system

Background

Problems with misallocation and redirection of critical resources and benefits intended for PLHIV are not uncommon in Kenya. This study explores corruption in Kenya’s HIV response system and the implications for health outcomes from the perspective of people living with HIV (PLHIV). Although they might not be directly responsible for health care fund management, PLHIV and their advocacy efforts have been central to the development of HIV system response and they have a vested interest in ensuring proper governance.

Methods

This phenomenological study was conducted in 2012 in Kiambu County in Kenya. The study was designed to capture the experiences of a select group of individuals living with HIV and AIDS and subsequent effects on intergenerational wealth transmission. Four focus groups were conducted with self-convened HIV/AIDS peer support groups. Findings related to corruption emerged unexpectedly, albeit consistently, across all four focus groups. To validate core themes within the data, including corruption, two coders independently reviewed and coded the data.

Results

Participants described incidences of resource misallocation, theft, and denial of services across three thematic levels namely at the interpersonal, provider, and institutional levels. Participants described the negative influence of corruption on their health and financial well-being, and propose: (1) strengthening legal protections for assets belonging to PLHIV, (2) direct representation of PLHIV within service agencies, (3) and addressing information asymmetries to inject transparency into the response system.

Conclusion

Our findings add to the growing literature that identifies advocacy among individuals and families impacted by HIV and AIDS to be a useful tool in drawing attention to harmful practices in the HIV response infrastructure; consistent with this movement, communities in Kenya demand greater control over programmatic interventions both at the national and local levels.

Building the community voice into planning: 25 years of methods development in social audit

Health planners and managers make decisions based on their appreciation of causality. Social audits question the assumptions behind this and try to improve quality of available evidence. The method has its origin in the follow-up of Bhopal survivors in the 1980s, where "cluster cohorts" tracked health events over time. In social audit, a representative panel of sentinel sites are the framework to follow the impact of health programmes or reforms. The epidemiological backbone of social audit tackles causality in a calculated way, balancing computational aspects with appreciation of the limits of the science.Social audits share findings with planners at policy level, health services providers, and users in the household, where final decisions about use of public services rest. Sharing survey results with sample communities and service workers generates a second order of results through structured discussions. Aggregation of these evidence-based community-led solutions across a representative sample provides a rich substrate for decisions. This socialising of evidence for participatory action (SEPA) involves a different skill set but quality control and rigour are still important.Early social audits addressed settings without accepted sample frames, the fundamentals of reproducible questionnaires, and the logistics of data turnaround. Feedback of results to stakeholders was at CIET insistence--and at CIET expense. Later social audits included strong SEPA components. Recent and current social audits are institutionalising high level research methods in planning, incorporating randomisation and experimental designs in a rigorous approach to causality.The 25 years have provided a number of lessons. Social audit reduces the arbitrariness of planning decisions, and reduces the wastage of simply allocating resources the way they were in past years. But too much evidence easily exceeds the uptake capacity of decision takers. Political will of governments often did not match those of donors with interest conditioned by political cycles. Some reforms have a longer turnaround than the political cycle; short turnaround interventions can develop momentum. Experience and specialisation made social audit seem more simple than it is. The core of social audit, its mystique, is not easily taught or transferred. Yet teams in Mexico, Nicaragua, Canada, southern Africa, and Pakistan all have more than a decade of experience in social audit, their in-service training supported by a customised Masters programme.