But people are fighting back against the ways bribery and fraud victimize patients.
In times of peace and stability, corruption deters foreign aid and investment. In times of national emergency, such as the Ebola outbreak in West Africa, corruption can mean the difference between life and death.
That’s what went through my mind when I read in The New York Times about the travesty of a container of $140,000 worth of medical equipment from the United States held up at the port in Freetown, Sierra Leone since August 9. The rate of spread of the disease in that country is now at five per hour. Yet the container in Freetown, which holds protective gowns, gloves, stretchers, and mattresses, remains at the port until, it seems, a “cash donation” is made to the right government official.
I’ve studied corruption in health care around the world as a law professor, and I’ve prosecuted bribery and fraud in the U.S. as an attorney for the Justice Dept. Each case of corruption in the health sector has direct or indirect effects on the patients seen by corrupt providers—and even more so on the patients whom they won’t see, because not everyone can afford a bribe.
While particularly egregious in the case of Sierra Leone, corruption in the health care industry is a global problem. Transparency International estimates that almost one in five people worldwide have paid a bribe to access medical services. While this is the most common form of petty corruption in health, drug diversion for the black market and counterfeit medicines are just as dangerous to patients, and even more lucrative.
Low wages for government employees, including staff in public health centers, is one cause of corruption. In Mombasa, Kenya, health care workers threatened to strike this year after not receiving paychecks for two months. So it’s not surprising that the need to pay bribes to hospital workers is more prevalent in the developing world, where budgets are smaller and so are civil servant salaries.
But poor countries don’t have a monopoly on the healthcare corruption: The two largest U.S. public health programs, Medicare and Medicaid, estimate that 5-to-10 per cent of their budgets are lost to fraudulent billing. (The U.S. regularly arrests people for this crime.) And a study published last year by the European Commission concludes that procurement fraud and improper marketing by providing cash or sponsoring of trips and leisure activities occur throughout the EU.
But health sector corruption in the developing world arguably has a greater impact, because it discourages foreign investment and assistance where it’s most needed. Who wants to write a check to send tuberculosis medication to Pakistan when you know half the funds will end up sending some official on vacation to the Maldives? Who wants to import medical equipment to sell or distribute to clinics when it’s going to cost another 20 percent to pay the guy at customs in Dar Es Salaam? The help that doesn’t come, or comes too late, as a result of corruption has deadly consequences.
The good news is that awareness of corruption’s effect on health is on the rise. The United Nations Convention against Corruption, an international treaty, has set the tone globally by calling on its 170 signatory countries to criminalize bribery and embezzlement and to maximize public access to information.
Perhaps the most exciting anti-corruption efforts are at the grassroots level. The Internet provides citizens with a way to demand accountability and, because of its public nature, to pressure governments to take heed. For example, Ipaidabribe.com, a website where any Internet user can report a shakedown, began in India and has since been adopted by countries in Eastern Europe.The site includes reports on bribes paid to obtain a polio vaccination certificate and other health records.
In the long term, government transparency and accountability are key to purging corruption from global health.
To start, governments and NGOs need to publish accurate health budgets and document foreign aid intended for the health sector. Health workers also need sufficient compensation. Gainful employment reduces the likelihood that they will seek to supplement their salary with bribes and embezzlement.
Finally, a free press and freedom of expression allow citizens to report and share the latest shakedown, whether at a traffic stop or in the hospital waiting room. Although it purports to aggressively prosecute corruption, the Chinese government shut down China’s I Paid A Bribe in 2011. If corruption in health care goes unreported, it won’t be addressed and our health will suffer.