It seems that not a day goes by without some gloomy story about corruption appearing in the popular media or online. “Corruption on the rise in Africa poll as governments seen failing to stop it” says a new TI study. “In Mexico, 200 million acts of corruption a year” the Mexican Competitiveness Institute reports. Monday’s Washington Post editorial proclaims that “Mali’s corruption hindered its efforts to fight terror,” and the subtitle of a best-selling book warns that it is not only Malians who are at risk but that corruption “Threatens Global Security as Well.”
With all this bad news it was a surprise to discover a recent good news story about corruption. The news is doubly surprising as it comes out of three unexpected places: Ghana Kenya, and Uganda. Even better, rather than broad generalizations drawn from a handful of selected anecdotes, the good news in Professors Rebecca Dizon-Ross, Pascaline Dupas, and Jonathan Robinson’s July 2015 “Governance and the Effectiveness of Public Health Subsidies” paper rests on a careful, clever empirical study that employs rigorous scientific methods. The only bad news about the paper is that it is on a remote internet site beyond the ken of most web browsers. For readers whose browsers don’t travel to the National Bureau of Economic Research’s web site, a potted summary follows.
The authors set out to gauge the efficacy of providing insecticide-treated bed nets to poor, pregnant women in Ghana, Kenya, and Uganda. Research shows that furnishing bed nets, iron tablets, and other inexpensive health products to pregnant women in poor countries cuts infant mortality by more than half. The challenge comes in getting the products to those who need them but can’t pay for them. Will nurses, midwives, and other front-line health care providers actually give them to those eligible? For free? Or will they demand “informal payments” in return? Or worse, will they sell them off from the warehouse to the highest bidder? Indeed given their low pay, often poor working environment, and scant oversight, will they even show up for work regularly?
Anecdotal evidence would suggest many health care providers are corrupt, and if that is true, the risk the products will be diverted or bribes demanded or the goods simply not handed out are significant. That risk would seem all the greater in Ghana, Kenya, and Uganda where, if measures like those TI produces are to be believed, health care workers live in a sea of corruption.
But anecdotes and perceptions are one thing and hard evidence another. And what Dizon-Ross and colleagues produce is hard evidence — based on careful measurements of who got bed nets in the three countries, how many “leaked” out of the warehouses, and how hard providers worked. Their findings —
- Bribe demands are rare. Only 1.4 percent of eligible recipients were asked for one.
- Close to 80 percent of eligible recipients received a bed net.
- Less than five percent of the ineligible recipients, men paid to visit clinics to see if they could coax a net out of a provider, got one.
- Clinics were rarely closed and absence rates low.
Some readers may be shocked that the reasons the authors, all economists, advance for the unexpectedly low incidence of corruption do not involve cold calculations of dollars and cents. They argue that those who become health care providers are motivated by the opportunity to help others, realize great satisfaction from doing so, and believe their work is closely scrutinized by the community and their superiors. All are powerful reasons why the vast majority of front-line providers do their job honestly and faithfully.
Readers may also be surprised that one of those seemingly clever ways social engineers have dreamed up to reduce corruption may actually exacerbate it. Rather than a provider giving a bed net directly to a beneficiary when she visits a clinic, the provider can give her a voucher to can redeem at a local pharmacy for a bed net. The idea is that a beneficiary will be less likely to pay a bribe for a voucher than for an actual physical bed net. But the authors found somewhat greater corruption levels where voucher schemes operated. Their conjecture: voucher schemes lower providers’ morale by sending a signal they are not trusted and thus make them more likely to cheat or slack off. This thinking reflects a nascent but growing body of experimental work finding that oversight mechanisms can “crowd out” intrinsic motivations to be honest.
Like all careful researchers, and unlike popular accounts of corruption, the authors caution that their findings may not be generalizable. The study is, after all, confined to three countries and the three are all from one region. Motivations and rewards thus may differ elsewhere. Furthermore, eligible beneficiaries, pregnant woman, are easy to spot walking into a clinic, and it is easy to see whether they leave with bed net in hand. So monitoring performance is far more straightforward than, say, with the distribution of antiretrovirals to HIV patients.
The Dizon-Ross, Dupas, and Robinson paper joins a small but growing body of serious, rigorous empirical work on corruption which provide a welcome antidote to the many sloppy, poorly-reasoned papers passed off as serious work. It merits close attention from those concerned with combating corruption.