Transparency and Health - Boston University

Transparency and Health - Boston University

Transparency in the Health Sector USAID Technical Exchange August 19, 2009 Management Systems International Presentation by Taryn Vian Boston University School of Public Health Agenda Overview and definitions Mainstreaming strategies in health sector

Case examples Comments from panel and discussion What is corruption? Abuse of entrusted authority for private gain. (USAID Anticorruption Strategy 2005) Logo from a Moldovan NGO working on anti-corruption Corruption: a Global Issue Linking Governance to Health Systems Strengthening Informal Payments

Stealing drugs Lack of transparency No accountability for results Embezzlement of user fees Spending on pet projects Absenteeism Selling posts Over-payment of supplies (kickbacks)

Theft and diversion Mainstreaming AC & good governance strategies Government-wide strategies needed for anticorruption (rule of law, judicial reform...) Sector-specific strategies enhance effectiveness: address specific problems leadership and public opinion more supportive links to health systems strengthening Framework of corruption in the health sector monopoly discretion accountability

- social norms - moral/ethical beliefs - attitudes - personality opportunity to abuse citizen voice transparency enforcement rationalization - wages/incentives

- pressure from clients abuse of power for private gain pressures to abuse Health care system and structure Type of abuse Resources

Insurance Payer-provider split Role of private sector, etc. Hospital construction High or low incomes Procurement Donor dependence, influx Informal payments, etc. of funding (Vian T. 2008. Review of Corruption in the Health Sector, Health Policy & Planning 23:83-94) Understanding the Problem Step 1: describe and measure Step 2: examine the drivers (opportunities, rationalizations, pressures)

Step 3: consider levers and mechanisms to control opportunities, address rationalizations, reduce pressures WHO Pharmaceutical System Vulnerability Analysis Moderately Vulnerable Lao PDR Malaysia Philippines Thailand Registration

5.6 6.8 6.8 7.0 Selection 6.1 5.7 6.1

8.0 Procurement 6.9 7.1 8.5 7.1 0.0-2.0 = extremely vulnerable; 2.1-4.1 = very vulnerable 4.1-6.0 = moderately vulnerable; 6.1-8.0 = marginally vulnerable

8.1-10.0 = minimally vulnerable WHO/PSM/PAR/2006.7 Nevirapine 200mg 300 274 Number of Procurements 250 200 Median price $0.13 150

100 Price outliers range $3.43-$7.14 86 47 50 15 2 0 0.2

*Not to scale 0.4 0.6 0.8 1 1 1.8 1

1 1 1 1 1 1 3.43 3.58 4.72 5.21 5.26 6.84 7.14 Price per Tablet* (USD)

Cases Performance based budgeting reform in Lesotho Water & Sanitation Agencies in South Asia Moldova Anticorruption Activities in Health Sector Performance-based budgeting in Lesotho PBB Goals: relate expenditures to results link policies with resource allocation Includes many functions: planning, budgeting, program implementation

Successful reform More donors channel aid through government Lesotho Reform Experience Started 2005 How is it working? What factors affect progress? Progress: Low Existence of Performance-based Plan

Low to modest Existence of Performance-based budget Low Performance-monitoring Low Using data for decisions None

Barriers: Lack of alignment Proportion of total hospital budgeted activities, by purpose of activity Staff Training 22% Patient Care 26% Procurement 39% Other 13% Barriers: professional boundaries

We work the wards, they go to meetings. (Hospital Matron) I cant read the Votebook; Im a nurse. (District Health Management Team member) These things, even though we hear about them, it is mainly something that concerns people in Accounts. The Ministry [of Health] might implement the reform, but it is really Finance who tells you what to do and what not to do. So it is not really a health initiative. (District Medical Officer) Result: Lack of Transparency The Accountant did not let you get anything. We

always wonderedwhat is really happening? I planned and made the budget, so I know it is really there, and then you have to ask, what happened to the money? Matron Sometimes you have requested something, and the goods do not come. You try to ask questions, but the Accounts office will act like, This is my job. Dont ask questions. As if youre spying on them! When really, it is just that you are asking for an explanation Public Health Nurse Future of PBB Back to drawing board to simplify

More funding to mentor health professionals into their management roles Link budget reform initiative to health systems strengthening initiatives Water & Sanitation Services (S.Asia) 1. Informal Payments Expedited new connection Falsify bill Illegal service connection Davis J. 2004. Corruption in public service delivery: Experience from South Asias Water &

Sanitation Sector. World Development 32(1): 53-71 2. Procurement Corruption DURING tender process Contracting cartels, bribes for influence Kickbacks AFTER skimming on construction contracts, with quid pro quo of allowing substandard materials or over-invoicing Photo credit: http://water1st.org/waterlog/wp-content/ uploads/2009/04/img_8066.jpg 3. Civil Service Related Market for transfers to desirable posts

pay politicians or local leaders, not higher level staff (exerting influence) 2.5 4 mo. salary, but indirect exchanges also common may also have to pay to keep own post (if someone else is paying to get yours) Analyze Drivers Opportunities technical problems with meters lack of oversight collusion among staff Pressures/Incentives Need to earn extra money to pay for job (pressure to accept bribes, kickbacks)

No detection or punishment (no cost to corruption) Rationalizations Everyone does it almost everyone uses contracts and money to get better services or special treatment (52% of W&S staff agreed) Everyone benefits, no one is harmed payments benefit the customer and employee without hurting anyone (31% agreed) [It is] small potatoes...no one calls this corruption, even... (W&S agency employee) Culturally accepted

But not everyone rationalized... We must try to improve our public image. . . [the] people must perceive us as honest. Otherwise, how can we make a case for increasing the tariff? The customer says I am having to pay an extra 100 rupees just to have my repairs made on time. We cannot have this kind of image and expect public support. (Former Director, Urban Water Board) How to intervene?

Carrots and Sticks in short-term, no Information technology Transparency publish fees Improvements in working conditions External scrutiny (communities, press) Moldova Experience Improving Governance in Health Sector Moldova Governance Threshold Country Program (MCC) 2007 Health Sector component (Millennium IP3 Partners) decrease discretionary powers of health

personnel increase accountability Civil Society Monitoring Capacity (AED) Media training, communications http://www.mip3-projects.md/projects/mgtcp/documents/index.html Moldova: Health interventions Decrease discretionary powers Create competitive selection process for facility directors Physician licensing Procurement audits Create standard treatment guidelines Moldova: Health interventions

Increase accountability Quality Councils Clinical Audits Annual patient satisfaction surveys with satisfaction score and corruption score (informal payments) Final Thoughts Corruption is a public health problem we can diagnose and prevent Promising approaches link information and consequences New thinking needed Understand pressures of cultural respect for extended family, ethnic loyalty Expanding role models willing to throw a small

spanner in the works to fight corruption* *John Githongo, from Its Our Turn to Eat: the Story of a Kenyan Whistle-blower, by Michela Wrong (2009)

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