Taryn Vian, Associate Professor of Global Health at the Boston University School of Public Health, contributes the following guest post:
The recent endorsement of the Sustainable Development Goals (SDGs) has prompted greater discussion and debate about the most important aspects of, and the most effective means for achieving, sustainable development. Most of the discussion of corruption in the context of the SDGs has focused on SDG 16 (“Promote just, peaceful, and inclusive societies”), which specifically includes anticorruption and related objectives among its targets (and which has prompted some debate on this blog – see here, here, here, and here.) But the fight against corruption is also closely linked to the achievement of another one of the SDGs: SDG 3 (“Ensure healthy lives and promote well-being for all at all ages”).
On its face, SDG 3 is about health, not corruption. But the fight against corruption is in fact closely connected to SDG 3, and health professionals need to open their eyes to this connection. Corruption worsens health outcomes in many ways: siphoning off resources that are supposed to be devoted to health care (for example, through embezzlement and absenteeism), increasing the cost and decreasing the availability of medicines and medical equipment (or enabling the spread of fake medicines), creating barriers to use of health services (particularly by poor and uneducated people who are especially vulnerable to bribery) and reducing the overall availability and quality of health services. Thus the fight for increased health ought to be—perhaps must be—seen as inextricably connected to the fight against corruption.
Though measuring the impact of corruption on health is challenging, at this point we have a sufficiently large (and growing) body of evidence that corruption threatens health. Consider the following:
- Researchers found a significant association between corruption and child death rates, estimating that 1.6% of world deaths in children, or 140,000 child deaths per year, could be indirectly attributed to corruption. Moreover, public spending on child mortality had a stronger effect in reducing child mortality in countries with lower levels of corruption and higher institutional capacity.
- Other research has found that more corrupt countries have higher rates of infant, child, and maternal mortality; indeed, the prevalence of bribery is positively correlated to death rates for women giving birth, even after adjusting for per capita income and share of total spending on health in the country.
- A study of 72,524 adults from 20 African countries found that higher (perceived) national corruption was consistently associated with poor health; this association was present for in all socio-economic groups, but more prevalent among those with less education.
- One study suggested that fake anti-malarial medicines are responsible for an estimated 450,000 deaths per year
- Other research has identified corruption as the main socioeconomic factor explaining the growing problem of antibiotic resistance.
In light of this and other evidence, anticorruption should be seen as a priority for achieving public health goals, including SDG 3. Efforts to strengthen health systems should place greater emphasis on mechanisms for citizen voice, using techniques such as health boards and complaint mechanisms, which have been used to control corruption in Bolivia and Serbia. Performance indicators related to medicine stockouts should be harmonized and strengthened, with community monitoring to pressure government to halt the theft and private resale of publicly-procured medicines. Development partners need to recognize the deficiencies in capacity for financial management and audit in the health sector, and to support efforts to improve accounting and auditing capacity as health interventions.
When I first began work in public health 30 years ago, we were not yet able to see that corruption is a public health problem: a cost that rarely gets quantified in our cost-effectiveness analyses, a risk that often goes unmentioned in project appraisal reports. Yet corruption is a real barrier preventing us from achieving our goals in public health. Public health professionals need to work harder to understand why corruption happens, and to take actions to prevent it.
GAB | The Global Anticorruption Blog 
Well written piece with concrete examples and suggestions. I especially like the citizen/community involvement, many problems can be solved if only the public would take an active role. Do you have suggestions on how to encourage that to happen?
That’s a good question, Dennis! Public involvement can range from attending public meetings, to using feedback mechanisms (responding to surveys, calling a complaint number, writing to a representative), to participating more formally on a planning or advisory committee. In my international work I’ve seen several problems with trying to stimulate public participation. The first is what’s called “elite capture” or the idea that the opportunities for citizens to express themselves tend to get taken over by the more powerful people, the elites. I watched a board of directors meeting in Cameroon for a microcredit organization and saw that the woman representing the borrowers never said a word. I think she probably felt intimidated by the other board members who were wealthier and more educated. So we didn’t really get to learn from her experience as a beneficiary of the service we were trying to offer. We might have avoided this by addressing it directly when we added her to the board, making it clear that we really valued her opinions and wanted her to speak up. Or we could have found other ways to get her input rather than asking for on the fly comments in a big meeting (i.e. meet with her one-on-one, with a simple question guide). Another barrier to public participation is the fact that it takes time and effort. We all want the benefits of community participation, but few of us want to spend the time to make that happen. To overcome this barrier, we need to reduce the time costs of engagement–possible through use of information and communication technology. We can make it easy for people to write a letter online, or to sign up for updates on a topic they care about. In less developed countries, many people still have phones and can get a text message. Let me know if you have other thoughts based on your own experience!
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Dear Taryn
Social accountability mechanisms are important in the fight against corruption in the delivery of healthcare, particularly primary healthcare. Mobile phones and apps provide an opportunity for reporting cases of absenteeism, theft petty bribery anonymously, the data can then be collated and acted on. We having examples of cases where this has worked in our programme on ‘Corruption in the Healthcare and Pharmaceutical Sector’ at Transparency International. But as well as the public, the donor community has an important role to play in tackling corruption in the delivery of healthcare. Donors too often are happy to supply products and resources but do not have mechanisms for measuring and checking service delivery at the grass roots level, which would make those responsible for delivering the products and services accountable. It is important for the funders focussing on SDG 3 to also focus on strengthening health systems, increasing accountability and therefore reducing opportunities for corruption.
Dear Shalni
I’m glad that TI is supporting using mHealth to encourage reporting of corruption in the health sector. I have encouraged USAID to think more about how to involve civil society in promoting accountability for health supply chains–it is not done enough. The Medicines Transparency Alliance is helping to increase citizen voice, but I think more through a multi-stakeholder meeting platform rather than technology. I’ve also followed the experience of I-Paid-a-Bribe in India, but had not learned about health-specific interventions. I’d love to learn more. Happy to talk if you want to let me know how I can get in touch. Thanks for your comment! Taryn