2020–30: the decade of anti-corruption?
Authors: None The Lancet Global Health
Journal: The Lancet Global Health (2019)

Universal health coverage (UHC) is a political choice, as WHO Director-General Tedros Adhanom Ghebreyesus is fond of reminding us. Strong leadership and good governance are prerequisites on a country's journey towards a high-quality, efficient, and equitable health system. But a largely unspoken impediment threatens to hinder the health system governance and financing necessary to make UHC a reality: corruption. It is a dirty word, but one that hardly engenders shock among those who work in health systems around the world. Transparency International has called it the “ignored pandemic”. We know it is going on, yet we largely wince when it is mentioned: it has become the epitome of the elephant in the room. Recently, however, there has been a distinct uptick in the willingness of intergovernmental agencies, policy experts, political leaders, and researchers to stare the elephant in the face. 2018's Crossing the Global Quality Chasm report by the US National Academies of Medicine included a whole chapter on corruption; in November, 2019, WHO hosted the first of a series of webinars on research priorities in anti-corruption; and last week, former Health Minister of Peru, Patricia Garcia, gave the annual Lancet–Academy of Medical Sciences lecture on the “open secret” of corruption in global health (published in Dec 7 issue of The Lancet). With Sustainable Development Goal (SDG) 16.5 being to “substantially reduce corruption and bribery in all their forms”, will the next 10 years be the decade of anti-corruption? Before we address that, perhaps we should define what we mean by corruption in health care. The dictionary definition of corruption is “dishonest or fraudulent conduct by those in power, typically involving bribery”. However, corruption within health systems is not restricted to those at the highest levels. Transparency International's definition also includes absenteeism (ie, gaining additional income from working elsewhere during paid work hours); informal payments from patients (voluntary or involuntary); theft and embezzlement (of money or medical products); kickbacks, overcharging, and unnecessary treatments; favouritism; and manipulation of data (eg, fraudulent billing). In other words, it is deeply embedded and often part of a broader process. On some levels it might be the only way for service providers to make ends meet or to make a dysfunctional system work for patients. This so-called “survival corruption” might be very convenient for governments, who could claim credit for funding a health service when in reality someone else is footing the bill. The recent growth of interest in exposing corruption has revealed the cost of such complacency. A widely cited ecological study by Hanf and colleagues showed that the degree of perceived corruption in a country correlates strongly with child mortality. The authors speculated that around 140 000 under-5 deaths per year could be attributable to corruption. The University of Portsmouth's Centre for Counter Fraud Studies looked at health-care loss analyses from seven high-income countries and estimated that fraud alone (ie, only one element of corruption as defined above) contributed to a global average loss rate of 6·19% of health-care expenditure, or US$455 billion per year. Contrast this with the additional $371 billion estimated to be needed annually to achieve the health-related SDGs by 2030. Unfortunately this new interest in reporting the breadth and depth of the problem is in no way matched by the degree of activity to counter it. A 2016 Cochrane review of interventions to reduce corruption in the health sector found no studies that met the criteria for the primary analysis. Only nine case studies provided any evidence at all, most of which was of low certainty and from high-income countries. A research agenda is desperately needed, but as Dina Balabanova put it during November's WHO webinar, we need to make sure we are asking the right questions before we start trying to invent solutions: what is driving a particular form of corruption (habit, lack of options, survival)? Who holds the power (is it inside or outside the health sector)? And who can make a difference (ie, who stands to benefit from eliminating corruption)? New policies and interventions need to be targeted rather than broad-brush, focused on what matters most for the health system, and feasible. A multidisciplinary and holistic approach is essential. While the research agenda unfolds, we should keep talking about corruption as the scandal that it is. Only by “re-problematising” what has become ingrained into many health systems will we stem the haemorrhaging of vital resources from the structures that we rely on for our health and wellbeing.