Corruption in the health sector

LIVERPOOL, United Kingdom — Here at the Fifth Global Symposium on Health Systems Research, one of the panel discussions was devoted to corruption in the health sector. Organized by the Anti-Corruption Evidence research consortium, the panel speakers shared initial findings from Bangladesh, Tanzania and Nigeria, drawing mostly on qualitative research.

Interestingly — though perhaps not surprisingly — the corrupt practices from all three countries are similar, not just with each other, but to what we see in the Philippines. Moreover, as Dr. Dina Balabanova, one of the lead researchers, reminded us, we may not necessarily view them as “corruption.”

For instance, one of most widespread practices they identified is absenteeism, or doing something else during office hours. Health workers in the country will find this all too familiar: from midwives closing clinics ahead of schedule to doctors simply not showing up in government hospitals.

A related practice is “referral,” or diverting patients from the public to the private health system. This, too, is commonly done in the Philippines: Patients are not just told to go to private clinics, they are also told to go to specific drugstores, which are sometimes owned by the prescribing doctors themselves.

Then there’s “informal payments,” or “under the table” gifts to health personnel. One local example is the “extension” system in some public hospitals, which allows staff to admit their family members ahead of the regular queue. While this may be justified as an employment benefit for health workers, it becomes pernicious when some employees declare patients as their “relatives” in exchange for money.

Because health care is devolved, mayors and governors have enormous powers when it comes to acquiring medicines, and there are numerous reports of overpricing and kickbacks — another form of corruption. In 2005, a Philippine Center for Investigative Journalism report estimated that up to 70 percent of local health funds are lost to corruption; there is little reason to suppose that much has changed since.

Yet another corrupt practice identified in the panel was insurance-related fraud, and this, too, is seen in the Philippines. For several years now, health officials have been complaining about patients being coaxed to undergo certain procedures just so some clinics can boost their revenue from PhilHealth claims.

Physicians and pharmaceutical companies alike have made great progress in adhering to the “Mexico City Principles,” but as the Dengvaxia scandal reminds us, much work needs to be done ensuring that private gain — political, financial, social —

does not get in the way of making clinical and public health decisions.

Back in the symposium, the speakers were pressed for solutions. We all know that corruption is happening — and it’s adversely affecting health outcomes. What, then, can we do about it?

One overarching approach proposed by the researchers is “developmental governance,” which calls on sector-specific reforms. Instead of raging against the system or demonizing particular individuals, their proposed approach asks: What are the conditions that lead to corrupt practices? Perhaps if doctors are given more ethical guidance in medical school on real-life situations, they will be more sensitive to conflicts of interest. Perhaps if health workers are given performance-based incentives, they will be willing to strictly comply with rules on attendance.

Personally, I think it should work both ways: addressing the structures that enable corruption, but at the same time sending a clear message that there will be no impunity for offenders large and small. Given how the devolved health system has contributed to the culture of corruption, policymakers should, at the very least, strengthen the checks and balances for LGUs, and, crucially empower patient-citizens to recognize and call out corruption in all its forms.

As our country moves toward Universal Health Care (UHC), addressing corruption only becomes even more vital for the health sector. While raising the sin tax is an important step in financing UHC, only by maximizing our resources and making sure they are used as intended can we make significant progress toward achieving health for all Filipinos.

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