Corruption negatively impacts health outcomes. As noted in a previous post, corruption is associated with higher infant, child, and maternal mortality, overall poor health, the spread of antibiotic resistance, and many other problems. When we consider the reasons why corruption undermines health, the most obvious include things like theft or diversion of healthcare resources, or how demands for extra “informal” payments to healthcare providers can deprive poor communities of adequate care. There is, however, another important mechanism through which corruption undermines public health: corruption undermines trust in government and government-run services, which in turn can hinder effective health delivery and thereby escalate the spread of infectious diseases, especially in emergency situations like the recent Ebola crisis.
Corruption creates a loss of confidence in government and public services. This loss of confidence promotes dishonest practices in people’s interactions with government, and also causes many people to turn to informal means to obtain even basic services, especially healthcare. Not surprisingly this results in people not receiving proper care, and may even lead to otherwise avoidable deaths. The corruption-induced distrust of government is even more of a problem when a crisis strikes, as vulnerability and need are both rapidly increased. The Ebola crisis demonstrated how distrust fueled by years of corruption can impact response efforts:
- Impede the Dissemination and Acceptance of Health-Related Information. In part because the government of Liberia was perceived as corrupt, many Liberians initially questioned or disbelieved health-related information, warnings, and instructions from the Ministry of Health and other health providers. Many Liberians thought that Ebola might be a hoax or a trick by the government to attract international funding. This lack of faith resulted in community members ignoring early warnings and not taking necessary precautions. Margaret Chan, the Director of the World Health Organization, commented publicly on the major problem of mistrust in government in the Ebola crisis and how it led to patients staying home rather than seeking care at treatment centers.
- Block Access to Delivering Care. In Sierra Leone, the local population fled from humanitarian workers and even chased them away. Although the government disseminated health information, the distrust in the government led citizens to believe that the government wanted to sell the blood of infected patients, inject them with the virus, among other negative scenarios. These beliefs, in other words, blocked health workers from providing adequate care or any care and led to otherwise avoidable deaths.
- Delay and Redirect International Monetary Support. Perceptions of government corruption not only affected the local populations, but also affected the international community’s response to the Ebola crisis. As reported by the Collective Commitment to Enhance Accountability and Transparency in Emergencies (CREATE) project, donors originally did not respond “very generously” to government appeals for logistical support, and this was due in part to perceptions that these governments were corrupt. This most likely slowed down early response efforts to the affected population and unintentionally allowed the virus to continue to spread. Further, as CREATE report noted, donors avoided transferring funds through national governments. While this reduced corruption risks, it added to public distrust in the government and also affected the opportunities to build management capacities.
How can the global health community can overcome the obstacle of government distrust in the next health emergency? While there is no easy answer, there are nonetheless a few actions to begin the conversation:
- Address Corruption Risks in National Health Systems as Part of Disaster Risk Reduction and Preparedness. While eliminating all corruption risks is impracticable, the global health community can work toward identifying and addressing the corruption risks specific to health delivery prior to an emergency situation. This can include incorporating fraud deterrence and prevention strategies within development project planning and implementation. Although the local population may still distrust the government, especially if corruption is rampant, decreasing corruption in national health care should at least help to restore trust in the health system. Further, reducing corruption in the health system should overall help to improve weak health systems by increasing available funds, resources, and quality care.
- Enhance Accountability to Improve Trust in Health Workers. Along with addressing corruption risks, health workers could increase transparency, awareness, and information to the population and promote participation and ownership in one’s own health during normal health delivery. Again, this may not directly address underlying distrust in government arising from corruption, but increasing accountability should build trust between health workers and patients. Ideally, this trust will overpower other forces and beliefs that may hinder the provision of health services.
While health emergencies come and go, the impact of distrust in government and public services on effective health delivery should not be forgotten. Identifying and addressing this issue now is imperative to ensuring vulnerable populations seek and receive optimal care and the number of avoidable deaths is reduced to as low as possible.
I strongly agree. However, given that the Ebola epidemic peaked four years ago and these concerns were voiced at the time, see https://www.pri.org/stories/2014-10-02/lessons-fdr-can-help-regain-public-trust-during-ebola-crisis#Global%20Post ; see also http://www.takepart.com/article/2014/10/07/corruption-creating-more-ebola-victims/, you might consider whether any lessons in governance and accountability have been learned and applied to more recent epidemics such as Zika or other global health concerns.
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