GAB welcomes back Mark Pyman, Senior Fellow at the London Institute for Statecraft, who previously served as Commissioner of the Afghanistan Joint Independent Anti-Corruption Monitoring and Evaluation Committee (MEC). He contributes this post together with Hussain Rezai, a researcher at MEC.
Despite the horror stories, interesting things are happening on tackling corruption in Afghanistan. Besides the progress (discussed in previous posts) on education and procurement, a major anticorruption initiative has been underway in the Afghanistan health system since June 2016. The initiative, which is another surprising (if qualified) anticorruption success story in a very difficult environment, offers five lessons for anticorruption practitioners and health ministers in other countries.
- First, strong and courageous political leadership is essential, but will likely provoke fierce opposition. Dr. Ferozzudin Feroz became Afghanistan’s Minister of Public Health in 2015, and immediately took a stand against corruption, despite corruption accusations against him personally, issuing several circulars on the topic and requesting an independent corruption risk assessment. When the MEC issued its hard-hitting independent report in June 2016, which was highly critical of the Ministry’s failure to address corruption in the health sector and recommended over a hundred changes, the minister publicly supported the report. However, he had to take a lot of pressure from MPs, and only narrowly survived an attempt to remove him from his post by Parliamentary impeachment. In Afghanistan, MPs are part of the problem, demanding the ministry recruit specific individuals in different sectors, including heath, and misusing their official authority by trying to influence the awarding of contracts. A strong stance by the Minister is thus both dangerous and necessary.
- Second, a comprehensive rather than piecemeal approach to fighting corruption in the health sector may be advisable. One thing that distinguished the MEC report, and the reform effort that grew out of it, was its very broad scope. The report covered corruption problems across the whole health sector, with explorations of nepotism, abuse of power, violation of human rights in health service delivery, extortion, fraud, falsification of credentials, conflict of interest, embezzlement, and misappropriation of public assets, and bribery. The Minister then formalized a comprehensive anticorruption strategy for the public sector that focuses on four major elements of fighting corruption (regulation, prevention, prosecution, and public engagement) in each of the six parts of the health system (health regulatory management, delivery of health services, product distribution and storage, marketing of health products, procurement, and financial and workforce management).
- Third, a good set of policy reforms is insufficient—it’s also important to set up robust structures and processes to implement the strategy and to report on progress. In the case of Afghanistan’s efforts to tackle corruption in the health sector, the Minister established a senior contact group consisting of health sector stakeholders and the ministry’s internal senior management personnel. He also had the active support of the President, who also ordered Ministry officials to implement the recommendations and suspended some who were resisting. Key organizational changes included the creation of a new National Medicine and Health Product Regulatory Authority (which increased audit and inspections of pharmacies, drug-importing companies, and laboratories, and blacklisted hundreds of companies without licenses) and the establishment of a functioning Complaints Handling Office within the ministry.
- Fourth, investing sufficient resources in genuine, in-depth monitoring is vital. For the Afghanistan health sector, the MEC instituted a novel form of follow-up: Instead of the traditional ticking the box of whether recommendations have been completed, the MEC set up a two-person team that spent one month in every three visiting health facilities around the country to speak with health officials, patients, and doctors about whether the necessary actions were being implemented or not. This active follow-up is quite expensive, but has been a revelation, giving first hand, independent feedback both to MEC and to the Ministry on what is really changing in the field. MEC now applies this form of follow-up to its major analyses in all ministries. (Quarterly reports are all published and publicized by MEC, and can be found here.)
- Fifth, engage with the public and community leaders, partly for transparency and feedback, and partly to manage expectations. One issue that has arisen in the context of Afghanistan’s health sector reforms is the substantial mismatch between community expectations and the ability of the ministry and NGOs to provide contracted health services. This discrepancy causes a lack of trust among community and negative perceptions of the Ministry, which in turn leads to widespread perceptions that the ministry has corrupted its own service delivery systems by failing to “force” NGOs to meet the people’s needs. This is a serious issue, and the Minister’s strategy has been to take 12-18 months to get going on corruption reforms and then to address these concerns directly by public meetings and public engagement. It is too early to tell whether this is going to be effective.