Potential corruption risks in health financing arrangements Report of a rapid review of the literature

Potential corruption risks in health financing arrangements Report of a rapid review of the literature Potential corruption risks in health financing arrangements: report of a rapid review of the literature

ISBN 978-92-4-000439-9 (electronic version) ISBN 978-92-4-000440-5 (print version)

© World Health Organization 2020

Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo).

Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition”.

Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization.

Suggested citation. Potential corruption risks in health financing arrangements: report of a rapid review of the literature. Geneva: World Health Organization; 2020. Licence: CC BY-NC-SA 3.0 IGO.

Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris.

Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing.

Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user.

General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement.

The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters.

All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use.

Printed in Switzerland Contents

Acknowledgements ...... iv Key messages ...... 1 Executive summary ...... 2 Introduction ...... 3 Background on health financing functions ...... 4 Methodology and limitations ...... 6 Review findings ...... 8 Overarching findings ...... 8 Revenue raising ...... 8 Pooling ...... 13 Purchasing ...... 17 Benefit design ...... 21 Discussion and conclusions 25 Main lessons and way forward ...... 27 References ...... 29

Contents iii Acknowledgements

In the 2018–2019 biennium, the World Health Organization Marcia McLean led the research assistance work with (WHO) is advancing a workstream on strengthening anti- support from Anna Wong and Emily Schepers. The rapid corruption, transparency and accountability in health literature review was elaborated through inputs from the systems. The workstream is a partnership between the Health Financing team at WHO headquarters. Matthew Gender, Equity and Human Rights team and the Health Jowett (Senior Heath Financing Specialist) was the Systems Governance and Financing department of WHO counterpart and provided essential technical orientations. headquarters, Geneva, Switzerland, in coordination with The publication was produced through WHO APW Contract other partners with expertise and interest in promoting 202056995 with the Gender, Equity and Human Rights transparency and accountability mechanisms in health team of WHO headquarters. systems. Theadora Swift Koller (Technical Officer, Equity; Gender, Equity and Human Rights) and David Clarke (Team The document was informed by discussions at the Technical Leader, Universal Health Coverage and Health Systems meeting on advancing a WHO approach to support Member Law; Health Systems Governance and Financing) of WHO States to strengthen transparency and accountability headquarters jointly lead the workstream. in health systems, held on 28–29 November 2017, and the WHO workshop on anti-corruption, transparency This rapid literature review contributes to the anti- and accountability in the health sector: implications for corruption, transparency and accountability workstream. health system assessments and national health planning, One objective of the workstream is to support the enhanced held on 22–23 March 2018. A draft version of the review focus on anti-corruption, transparency and accountability in provided the background for policy discussion during a WHO normative guidance on health systems strengthening. multistakeholder consultation on a proposed global network Three areas were identified for furthering this focus in on anti-corruption, transparency and accountability in 2018–2019: health financing; health systems governance; health systems (GNACTA), held on 26–28 February 2019 in and human resources for health. Geneva, Switzerland, convened by WHO, the Global Fund and the United Nations Development Programme (UNDP). With funding from UK aid, this document was commissioned to Jillian Clare Kohler, PhD, Professor at the Leslie Dan Special thanks are extended to Maureen Lewis, Bill Faculty of Pharmacy, the Dalla Lana School of Public Savedoff and Sophie Witter for their valued inputs on Health and the Munk School of Global Affairs, University a draft version of the paper. of Toronto, Toronto, Canada. The lead author was Jillian Clare Kohler and the co-author was Benoît Gomis.

iv Potential corruption risks in health financing arrangements: report of a rapid review of the literature Key messages

• Corruption in health financing arrangements is a • More research is needed on policy interventions to potential risk to the achievement of universal health reduce corruption in health financing. There is no one- coverage and other health policy goals. size-fits-all response to the range of issues found by the rapid review, and limited data exist on the effectiveness • Studies show that corruption can enter each of the of policy interventions. four main health financing functions: revenue raising; pooling (viewed within the wider context of public sector • Studies highlight potential measures to reduce the risk management); purchasing; and benefit design. of corruption in health financing, including: ensuring adequate funding to health systems; enhancing • Literature is not uniform in terms of what is considered transparency and accountability; raising awareness; as “corruption” in health financing arrangements. improving monitoring and oversight; integrating anti- corruption, transparency and accountability into health financing diagnostics and policy; and building effective accountability mechanisms.

Key messages 1 Executive summary

Introduction and purpose A rapid review is limited in that its process gives preference to research that is easily retrievable and, therefore, some Corruption in health financing poses a significant risk bias is necessarily embedded in the methodology. As this to the achievement of universal health coverage and the review is targeted to specific search terms, it is limited health-related targets of the Sustainable Development insofar as it does not address all of the core issues related to Goals. Corruption in health systems not only wastes limited corruption risks in health financing, including absenteeism, public resources and/or development funds allocated to the petty theft and other types of public sector abuse. health sector, but also limits population access to goods and services, undermines citizens’ trust in governments and causes health services to deteriorate. Poor and Findings marginalized populations typically suffer the most from the consequences of corruption in health systems. Accordingly, The studies highlight how health financing arrangements anti-corruption, transparency and accountability measures may be at risk of corruption. In the area of revenue raising, are central components of health systems strengthening embezzled funds and charging of informal payments for for universal health coverage. Such measures are also health services are identified risks. In the area of pooling, critical for upholding the right to health. the studies emphasize weak budget management and poor record keeping as issues that may allow corruption, The purpose of this rapid literature review is to identify such as the embezzlement of pooled funds. In the area of potential corruption risks in relation to health financing. It purchasing, the procurement process stands out as being also seeks to illuminate anti-corruption, transparency and particularly vulnerable to corruption; for example, fraud accountability measures that may be helpful in reducing may be found in provider billing mechanisms. Lastly, in the risk of corruption in health financing. the area of benefit design, conflicts of interest, lack of transparency in the selection of medicines for national/ institutional formularies, and overly complex benefit Methods systems can make health systems more vulnerable to corruption. A rapid literature review was conducted to provide an evidence-base on areas at risk of corruption in the core health financing functions of revenue raising, pooling Conclusions (within the broader context of public sector management), benefit design and purchasing. To reduce the risk of corruption in health financing arrangements, the literature recommends anti-corruption, Search terms were limited to the English language and transparency and accountability measures including: informed by WHO publications on health financing and ensuring adequate funding to health systems; enhancing universal health coverage. Experts in health financing transparency and accountability; raising awareness; and corruption provided inputs on the literature, structure improving monitoring and oversight; integrating anti- and content of the review. An initial pool of 185 articles corruption, transparency and accountability into health was screened for relevance, of which 112 articles were financing diagnostics and policy; and finally, building summarized and included in the literature pool. Additional effective accountability mechanisms. Such measures will articles were added following suggestions from peer reduce the likelihood of corruption in health financing reviewers, resulting in a total of 125 articles and documents arrangements and help to strengthen health systems in the final paper. towards universal health coverage.

2 Potential corruption risks in health financing arrangements: report of a rapid review of the literature Introduction

Anti-corruption, transparency and accountability measures The main objectives of this rapid literature review are to are a central component of health systems strengthening provide evidence on corruption risks in health financing for universal health coverage. Such measures are also arrangements and to identify strategies and tactics that essential for upholding the right to health and reducing can help to reduce corruption. This paper provides evidence health inequities. on potential vulnerabilities that can lead to corruption in the four core health financing functions: revenue raising; If unchecked, corruption in health systems represents pooling; purchasing; and benefit design,1,2 based on the a significant drain on national health resources and identified literature. development assistance for health. Gee & Button (2015) estimate the global average loss rate from health care The paper is organized as follows: first, the background fraud and abuse to be 6.19% of total health expenditure, describes the four main functions of health financing or US$ 455 billion, per year. Corruption in health systems (revenue raising, pooling, purchasing and benefit design). can also result in other negative consequences such as The second section presents the methodology used limiting a population’s access to goods and services, for the literature review. The findings are presented undermining citizens’ trust in governments and causing next, organized according to the main health financing health services to deteriorate, to name but a few examples. functions and within the broader context of public sector management. The paper concludes with a discussion of the findings and considers potential measures to address corruption in health financing.

1 Kutzin, J (2001). A descriptive framework for country-level analysis of health care financing arrangements. Health Policy. 56(3):171–204.

2 Schieber G (1997). Innovations in health care financing: proceedings of a World Bank conference, March 10-11, 1997. World Bank discussion paper no. 365. Washington (DC): World Bank.

Introduction 3 Background on health financing functions

WHO’s 2010 world health report provides a definition The universal health coverage goals can be achieved of health financing for universal health coverage: through fulfilling intermediate objectives, namely: equity in resource distribution; efficiency; and transparency and Financing systems need to be specifically designed to: provide accountability (see Fig. 1) (Kutzin et al. 2017), which are all people with access to needed health services (including themselves related to the four main functions of health prevention, promotion, treatment and rehabilitation) of financing arrangements, as defined and described below.3 sufficient quality to be effective; [and to] ensure that the use of these services does not expose the user to financial hardship (WHO, 2010, p. 6).

Fig. 1. Universal health coverage goals and intermediate objectives influenced by health financing policy

Health financing within UHC intermediate Final coverage the overall health system objectives goals

Creating resources

Equity in resource Utilization relative distribution to need Revenue raising

Financial protection & Pooling Efficiency equity in finance Benefits

Purchasing

Transparency & Quality accountability Stewardship / Governance / Oversight / Governance Stewardship

Service delivery

Source: Kutzin et al. (2017).

3 Definitions in italics from WHO: Health financing, topics A–Z [website]. Geneva: World Health Organization (https://www.who.int/health_financing/topics/en/, accessed 25 April 2019).

4 Potential corruption risks in health financing arrangements: report of a rapid review of the literature Revenue raising is “the way money is raised to pay health Purchasing is “the arrangements in place, and mechanisms systems costs” (WHO, 2010, p. 4). It may involve improving used, to allocate pooled funds to health service providers. tax administration, introducing new health taxes and/or Providers use these funds to deliver defined benefits to using revenue from health taxes more effectively, as well the population”. Strategic purchasing is also relevant, and as raising external funding from donors and development is defined as “the active, evidence-based engagement in banks. Public funds need to be available, along with the defining the service-mix and volume and selecting the stable and predictable flow of the funds to health facilities, provider-mix in order to maximize societal objectives”. It to ensure the effective delivery of health services to those involves “linking the transfer of funds to providers, at least who need them. Reliable cash flow is also important for in part, to information on aspects of their performance or good service delivery performance. the health needs of the population they serve”.4

Pooling is “the accumulation and management of financial Benefit design refers to “decisions concern[ing] which resources to ensure that the financial risk of having to health services to include, as well as related rules such pay for health care is borne by all members of the pool as a requirement to use a referral system, making co- and not by the individuals who fall ill” (WHO, 2010, p. 4). payments, or being subject to waiting lists”. The purchaser Pooling aims to provide equity in resource allocation, or insurer will make decisions about what services and allowing funds to be spent according to the (covered) products to include (and exclude) in a benefits package. health services needed by the population, thus bolstering financial protection.

4 Mathauer I, Dale E, Meessen B (2017). Strategic purchasing for universal health coverage: key policy issues and questions. A summary from expert and practitioners’ discussions. Geneva: World Health Organization.

Background on health financing functions 5 Methodology and limitations

Rapid literature reviews provide evidence-based answers to on health financing policy for universal health coverage policy questions. More specifically, according to Khangura (https://www.who.int/health_financing/training/e-learning- et al. (2012), rapid reviews are a “form of knowledge course-on-health-financing-policy-for-uhc/en/).Experts synthesis in which components of the systematic review in health financing and corruption provided inputs on the process are simplified or omitted to produce information literature, structure and content of the rapid review. The in a timely manner”.5 limitations of this review process include giving preference to research that is easily retrievable and, therefore, The diagram below shows the methodology applied to some bias is necessarily embedded in the methodology.6 identify relevant literature for this rapid review. Search The search was also limited to documents available in terms were informed by WHO publications on universal the English language. health coverage, as well as WHO’s e-learning course

5 Khangura S, Konnyu K, Cushman R, Grimshaw J, Moher D (2012). Evidence summaries: the evolution of a rapid review approach. Syst Rev. 1:10.

6 Stated differently, a rapid review does not seek to provide an overview of the universe of literature, which is the approach more typically adopted for a systematic review.

6 Potential corruption risks in health financing arrangements: report of a rapid review of the literature Literature search The following databases were searched: Ovid MEDLINE, PubMed, EMBASE, Scopus, Web of Science, Economic Literature Index, PAIS International, Google and Google Scholar. Two main search strategies were utilized, with a combination of keywords: • “health financing” AND “corrupt*” • “health” and (“purchasing” OR “revenue raising” OR “revenue generation” OR “pooling” OR “benefit design”) AND “corrupt*”. More specific search terms were used on EMBASE, PubMed and Ovid MEDLINE to see if additional articles would be found. This strategy used the terms: • health insurance OR revenue pooling OR DRG* OR diagnostic related group* OR fee-for-service OR ffs OR fee for service OR capitation OR performance-based financing OR pay for performance OR value-based purchasing OR P4P OR line-item budgeting OR risk-adjusted formula OR risk-adjusted OR premium* OR informal payment* AND (corrupt* OR bribe* OR leakage OR embezzlement*).

IDENTIFICATION Searches were conducted in September/October 2018.

Document identification by subject matter experts Experts in health financing corruption were asked to recommend key documents.

Targeted searches World Health Organization, World Bank, U4 Anti-Corruption Resource Centre, USAID websites

Searches were restricted to articles published in English. No restrictions were placed on timeframe (aside from database-specific limitations), settings, population, or any specific definition of corruption. All articles types were considered in the white and grey literature, including commentaries, original qualitative and quantitative research papers, literature reviews, academic reports, documents from international organizations, and book chapters. Articles were included if they related to corruption in

ELIGIBILITY health financing and/or corruption in any of the four main functions of health financing: revenue raising, pooling, purchasing or benefit package design.

Titles were screened and duplicates were removed, leaving 185 articles for more detailed review SCREENING

Documents determined to be out of scope, from review of abstract or full text, were removed, leaving 139 articles to be summarized.

INCLUDED 112 articles were selected for inclusion. Following peer review, further articles were added to the pool to give a total of 125 articles and documents.

Methodology and limitations 7 Review findings

Overarching findings Institutional corruption was also shown to be an overarching issue. Light, Lexchin & Darrow (2013) describes institutional The articles reviewed show, some in more detail than corruption as “… a normative concept … that embodies others, specific corruption risks in health financing the systemic dependencies and informal practices that arrangements. Examples from the literature mainly focused distort an institution’s societal mission” (p. 2). Lessig on African and Eastern European countries; however, it (2013) argues that institutional corruption is “manifest is recognized that many issues are not limited to these when there is a systemic and strategic influence which regions, but are global in scope. Although examples are is legal, or even currently ethical, that undermines the clustered in specific regions, the lessons learned are institution’s effectiveness by diverting it from its purpose largely generalizable. or weakening its ability to achieve its purpose, including to the extent relevant to its purpose, weakening either In the area of revenue raising, embezzled funds and the public’s trust in that institution or the institution’s charging of informal payments for health services are inherent trustworthiness” (p. 2). clearly identified risks. In the area of pooling (in the context of public sector management), the literature emphasizes weak budget management and poor record Revenue raising keeping as two examples that may allow for corruption, such as the embezzlement of pooled funds. In the area of This section of the review targeted literature that focused purchasing, the procurement process stands out as being on low- and middle-income countries, with particular particularly vulnerable to corruption; for example, fraud emphasis on economies in transition. The vast majority may be found in provider billing mechanisms. Lastly, in of articles on corruption in revenue raising were found the area of benefit design, conflicts of interest, lack of to concern informal payments, which are therefore the transparency in the selection of medicines for national/ focus of the section. First, articles relevant to revenue institutional formularies and overly complex benefit raising and corruption in general are discussed, followed systems can present corruption risks. by aspects of informal payments and the recommended policy interventions. As cross-cutting themes, some studies show that countries with political leaders willing to tackle corruption, well- established institutions, well-paid, qualified and trained General corruption risks in revenue raising personnel, formal and timely pooling processes (including accurate record keeping), built-in flexibility for delivery Juwita (2018) underscores that corruption may limit of services in emergency situations, and effective the ability of countries to implement universal health transparency, oversight, evaluation and accountability coverage, and notes that revenue raising is particularly mechanisms, are more likely to effectively mitigate susceptible to corruption given the significant value of vulnerabilities to corruption. Dorotinsky & Pradhan (2007) funds. Corruption in tax administration was identified as a and Uzochukwu et al. (2018) emphasize how political will central issue in the area of revenue raising, and is briefly and institutional capacity underpin any reforms to address discussed here – although corruption in the tax system corruption. In addition to financial resources to increase is beyond the purview of health ministries. Examples the number of staff and their wages, supportive mentoring, of corruption in tax administration include: deliberate training and education are identified ways to strengthen failure to collect taxes from an individual or firm; diverting institutional responses (Nocera, 2010; Njog & Ngantcha, tax revenue to an individual or firm, including through 2013; Uzochukwu et al., 2018). the falsification of receipts or abuse of refund accounts

8 Potential corruption risks in health financing arrangements: report of a rapid review of the literature in the case of hospitals (Vian et al., 2010); and individuals Stepurko et al. (2010) highlight the importance of timing. or firms colluding with tax collectors to lower the collected Payments made before or during treatment may be sums, seek tax exemptions or tax breaks, and/or undervalue considered as coerced, while those made after treatment goods for tariffs (Rose-Ackerman, 1999). These issues can be classified as voluntary. However, the latter may can jeopardize basic primary care delivery and reduce still be non-optional, particularly if a patient is in a repeat quality of care and equity in access, thus hampering overall relationship with a provider. progress towards universal health coverage (Kohler & Ovtcharenko, 2013; Michaud, Kates & Oum, 2015; United Nations, 2015). Key factors

In Kenya, Okungu et al. (2018) found that perceptions Studies highlight a number of key factors that may be of corruption influence informal workers’ preferences conducive to informal payments, including: for types of revenue raising proposed for health service coverage. Study participants expressed concerns about • low salaries and poor working conditions of medical embezzlement and 47% preferred a non-contributory staff, including little opportunity for career advancement financing mechanism. Funds controlled by the government (Balabanova & McKee, 2002; Bloom, Han & Li, 2001; Chiu through the collection of taxes were, in contrast, thought to et al., 2007; Hotchkiss et al., 2005; Mokhtari & Ashtari, be more prone to corruption. Most participants expressed 2012; Shahriari et al., 2001; Stringhini et al., 2009); a preference for out-of-pocket payments for medical expenses as a safety valve against the risk of embezzlement • imbalances in health systems between mandated health of funds by public officials. care and available resources (Shahriari et al., 2001);

• lack of an incentive system for health providers to stop Informal payments the practice of informal payments (Balabanova & McKee, 2002; Bloom, Han & Li, 2001; Shahriari et al., 2001); Informal payments are defined in the literature in similar ways. Lewis (2007) defines informal payments as “payments • shortages of medical supplies (Shahriari et al., 2001); to individual and institutional providers, in kind or in cash, that are made outside official payment channels or are • lack of transparency in health facility operations purchases meant to be covered by the health care system” (Shahriari et al., 2001); (p. 985). Gaal et al. (2006) define informal payments as “direct contribution, which is made in addition to any • asymmetric information between physicians and patients contribution determined by the terms of entitlement, allowing providers to take advantage of asymmetries in cash or in-kind, by patients or others acting on their to seek informal payments (Lewis 2000), including in behalf, to health care providers for the services that the the case of specialized care (Buch Mejsner & Karlsson, patients are entitled to” (p . 276). Gaal et al. emphasize 2017; Mokhtari & Ashtari, 2012); that this approach implies it is not relevant whether a type of informal payment is legal, and write: “What shifts • perception that informal payments may positively a direct payment from the category of informal payments impact the quality of care received from health providers to the category of other direct payments, or vice versa, (Balabanova & McKee, 2002; Hotchkiss et al., 2005; is any change in the legally defined entitlements for Liaropoulos et al., 2008; Praspaliauskiene, 2016); health service” (p .276). Balabanova & McKee (2002) and

Review findings 9 • weak governance and corruption (Lewis, 2000, describes A cultural explanation of informal payments views them as corruption using Klitgaard’s formula of “monopoly plus a form of gratitude payment (Bloom, Han & Li, 2001; Cohen, discretion minus accountability”7); 2012; Liaropoulos et al., 2008; Vian et al., 2015; Zasimova, 2016). As such, informal payments may not be corruption • market failure (Lewis, 2000); per se, but instead a culturally acceptable practice often related to the poor salaries received by health professionals • cultural factors (Shahriari et al., 2001; Chiu et al., 2007; (Baji et al., 2013; Cohen, 2012; Praspaliauskiene, 2016; Praspaliauskiene, 2016; Balabanova & McKee, 2002). Thompson & Witter, 2000). However, it is important to note For example, a study of unofficial payments in the health that even where staff receive higher salaries, informal sectors of Baltic States found that nearly 50% of patients payments may still exist. surveyed did not consider unofficial payments to health workers as corruption. Interestingly, in some cases, Nearly all the studies note that a central motivation for although cash payments were perceived as corruption, health care providers in accepting or encouraging informal gift giving was not (Cockcroft et al., 2008). payments is to supplement revenue in the context of underresourced facilities and/or low personal income. More specifically, the literature discusses what may lead After the collapse of the Former Soviet Union, many patients to make informal payments for health services countries in weak economic situations were unable to and products, and indicates the motivations of health care provide universal health coverage so that other revenue providers. With regards to patients, the most commonly sources, such as informal payments from patients, became cited reason is “fee for access”. In such cases, if a patient essential (Sari, Langenbrunner & Lewis, 2000). Thompson does not pay a fee, she/he will not receive a service or & Witter (2000) further highlight that informal payments product (Kotoh, Aryeetey & Van der Geest, 2018; Zasimova, likely represent a significant portion of total health care 2016). Many studies note that this is particularly true for spending in countries undergoing economic transition. access to specialist care, such as surgery (Buch Mejsner & Karlsson, 2017). Overall, studies show that informal payments exacerbate inequity (Cohen, 2012; Hotchkiss et al., 2005; Shahriari Patients may offer informal payments in order to receive et al., 2001; Szende & Culyer, 2006; Tatar et al., 2007). faster and/or better quality services (Lewis, 2007; Moldovan In Bangladesh, poor rural women bear a “tremendous & Van de Walle, 2013; Praspaliauskiene, 2016; Thompson cost” for caesarean section and other surgeries, as & Witter, 2000; Vian et al., 2015; Witter et al., 2011; well as for medicines, laboratory investigations, blood Zasimova, 2016). A study in Viet Nam found that patients transfusions, food, travel and other expenses, in part made informal payments largely out of concern about because of widespread corruption in the form of demands the quality of care they would receive if they did not pay: for informal payments (Afsana, 2004). Hotchkiss et al. “Official fees are regulated and low, so patients know (2005) suggest that providers may be more likely to demand that they need to offer top-up payments to get a good payments from the poor given they are less likely to give quality service. Even those with health insurance make gifts. Hunter & Murray (2017) examined the efficacy of direct payments to staff” (Witter et al., 2011, p.6). In other different demand-side financing interventions, including words, informal payments have become “normalized” cash transfers and vouchers, for maternity care services. or arguably embedded in the culture.

7 “... one will tend to find corruption when an organization or person has monopoly power over a good or service, has the discretion to decide who will receive it and how much that person will get, and is not accountable”. Klitgaard R (1998). International cooperation against corruption. Finance & Development, 35.

10 Potential corruption risks in health financing arrangements: report of a rapid review of the literature The analysis found that community-based workers who district health managers often relied on informal mechanisms are reimbursed for facilitating demand-side financing to ensure continuity of services, including buying supplies programmes may be asked for informal payments by facility on credit, borrowing cash internally, purchasing materials staff and/or may be used as go-betweens to request money in advance, or conserving funds for future use. While such from families. Hunter & Murray conclude that informal practices are crucial in enabling the continued functioning payments, as well as out-of-pocket payments, may prevent of health services, they also are vulnerable to corruption women from accessing maternal care. due to: a lack of paper trails; favouritism shown to suppliers willing to work on credit; a dependent relationship with suppliers; the potential for over-invoicing; and, pre- Examples of informal payment practices8 purchasing leading to wasteful spending.

A survey conducted by Mæstad & Mwisongo (2011) in the United Republic of Tanzania reveals that providers may: Impact of informal payments offer to reduce waiting times in exchange for informal payments; charge for services that are meant to be free; Rose (2006) highlights that the imposition of a “corruption falsely claim there is a shortage of drugs and supplies; tax” on free services clearly has an overall negative impact on operate a private practice or pharmacy within a public health gains. In the United Republic of Tanzania, Stringhini health clinic; and reduce baseline quality so as to encourage et al. (2009) found that informal payments contribute to payment for better quality services and products. The an environment that in fact demotivates and demoralizes study also highlights that health workers at all levels are health workers themselves. In terms of how informal identified as being involved in “rent-seeking” behaviour.9 payments impact the population, particularly the poor, Ensor & Savelyeva (1998) suggest that informal payments A study in the Democratic Republic of the Congo found that may facilitate a quasi-redistribution of resources from the many nurses were reluctant to charge informal fees when rich to the poor, with physicians “price discriminat[ing] patients were already struggling to pay user fees for health so that the rich are charged more than the poor” – in services and/or were well-informed about a facility’s official other words, playing the role of “Robin Hood” (Szende & user-fee structure (Maini, Hotchkiss & Borghi, 2017). In Culyer, 2006). However, a number of subsequent studies Hungary, Szende & Culyer (2006) found that strategies used emphasize how informal payments are in fact mostly by obstetric care providers to demand informal payments regressive, with the poor paying disproportionately more include the refusal of treatments as well as justifying such for health services than the rich (Baschieri & Falkingham, payments as “extra” services. A study in India found that 2006; Cohen, 2012; Kankeu & Ventelou, 2016; Lewis, 2000; physicians in the private health care sector commonly ask Shahriari et al., 2001; Sundell, 2014; Szende & Culyer, for payments in exchange for referrals (Gadre, 2015). 2006). Notably, informal payments may cause poor people to delay using the health system, or to not use the health Asante, Zwi & Ho (2006) analysed the implications of the system at all (Kankeu & Ventelou, 2016; Miller & Vian, unpredictable release of quarterly funds to decentralized 2010; Thompson & Witter, 2000). health systems in Ghana. In this uncertain environment,

8 The examples provided are not exhaustive, but were selected from the reviewed literature and are useful in terms of illustrating the findings.

9 Rent-seeking is defined as “a concept in economics that states that an individual or an entity seeks to increase their own wealth without creating any benefits or wealth to the society. Rent-seeking activities aim to obtain financial gains and benefits through the manipulation of the distribution of economic resources”. Corporate Finance Institute (CFI) (https://corporatefinanceinstitute.com/ resources/knowledge/economics/rent-seeking/, accessed 30 July 2019).

Review findings 11 The literature illuminates how informal payments impact • Enhance transparency (Stepurko et al., 2017; Vian & different population groups in different ways. In a survey on Burak, 2006; Vian et al., 2015). the quality of health care in Moldova, Mokhtari & Ashtari (2012) found that patients with long-term health conditions • Establish an effective means for patients to voice made informal payments less often than average, while complaints (Shahriari et al., 2001). pregnant women made informal payments more often than most. The study also noted that patients that are • Enforce accountability among management and providers, better informed about their entitlements under health and encourage communities to hold providers accountable insurance schemes made informal payments less often, (Lewis, 2002; Lewis, 2007). but were more likely to leave informal payments as gifts. • Strengthen patient education on the right to access health services (Ensor, 2004; Hotchkiss et al., 2005; Policy interventions Killingsworth et al., 1999; Shahriari et al., 2001).

Policy recommendations advanced in the literature to • Allow for private health service alternatives into the address corruption in revenue raising include the following market (Lewis, 2000; Lewis, 2002; Thompson and interventions. Witter, 2000);

• Public leaders must state that informal payments between • Implement revised and improved individual payments public sector employees and citizens are unacceptable (Lewis, 2007; Thompson and Witter, 2000; Zasimova, 2016) and do not correlate to quality care (Baji et al., 2013; including performance-based payment for providers Habibi et al., 2017; Lewis, 2000; Vian et al., 2015). (Hotchkiss et al., 2005; Thompson and Witter, 2000; Vian et al., 2015). • Implement household expenditure surveys that document out-of-pocket payments, including informal payments, • Impose meaningful legal penalties on providers that to reveal problems and create demands for solutions breach the rights of insured patients (Habibi et al., 2017; (Vian, 2008). Hotchkiss et al., 2005; Thompson and Witter, 2000; Vian et al., 2015). • Regularize informal payments (Barber, Bonnet & Bekedam, 2004; Baschieri & Falkingham, 2006; Ensor, Gaitonde et al. (2016) reviewed promising reforms to the 2004; Killingsworth et al., 1999; Lewis, 2007; Thompson health system in Kyrgyzstan, which were initiated in 1997 & Witter, 2000). and occurred in several stages. Aiming to decrease the prevalence of informal payments, the reforms notably • Increase funding/resources to health systems (Ensor, introduced a more transparent co-payment system as 2004; Shahriari et al., 2001; Thompson & Witter, 2000). well as changes in the payment structure for health care providers. The percentage of patients who paid for consultations went down from 55% in 1994 to 20% in 2007.

12 Potential corruption risks in health financing arrangements: report of a rapid review of the literature Pooling • in Uganda, 70% of drugs and supplies were leaked (Reinikka & Svensson, 2003); This section of the review seeks to clarify corruption risks in pooling revenues. First, the main risks (as identified • in Kenya, the Ministry of Finance estimated that 38% in the literature) are discussed, including: leakage of of funds received at health centres in 2004 were leaked funds; ad hoc responses in uncertain environments, (Gauthier, 2010); where disbursement of funds can be delayed or smaller than expected; vulnerabilities along the main phases of • in Zambia, one fifth of health facilities did not receive the budget management process; and implications of their full funding allocation (Picazo & Zhao, 2009); various structural forms of governance (centralized versus decentralized systems, or public versus private entities). • in Chad, the government spent on average US$ 1.17 per Next, the merits of performance-based financing and PETS person, but each person effectively received US$ 0.02 as tools to measure and address the risks are discussed, due to major leaks at all levels of government (Gauthier followed by structural issues in implementation, namely & Wane, 2008; formal processes, data management, transparency and accountability. • in Cameroon, 18.8% of funds intended for decentralized health services did not reach the intended target, while health facilities received an even smaller portion of their Leakage of funds official budget (Njog & Ngantcha, 2013) .

In many countries, investments in health services have Much of the identified literature on leakage of funds not led to a significant improvement in health outcomes, focused on African countries. However, Savedoff (2008a) thereby raising questions about how the money is being studied examples from other regions, including Latin distributed. A number of public expenditure tracking America (Peru) and Asia (Cambodia). Savedoff concludes surveys (PETS) have found substantial leakage of health that PETS can have variation in terms of how well leakages care funds. Some leaks occur when inadequately allocated are measured; nevertheless, PETS are often useful in funds need to be diverted to cover legitimate, urgent needs. terms of solid expenditure analysis and provide useful Although these diversions do not constitute corruption as data on budget and finance processes. It is important such, Marouf (2010) notes that leakage is “often a good to acknowledge that some leaks occur because funds indicator of corruption”. are inadequate overall, or are diverted to cover other priority areas in the health system. However, leakages are Country examples of leakage of funds include: problematic, even when not due to private gain.

• in Ghana, 80% of non-wage health expenditures and about 20% of salary expenditures were leaked (Ye & Canagarajah, 2002);

Review findings 13 Budget management Forms of governance

In an analysis of corruption in public financial management, Structural characteristics of governance can have an impact Dorotinsky & Pradhan (2007) highlight vulnerabilities to on levels of corruption in pooling. Gomez (2017) compares corruption in each of the four phases of the budget cycle. the development of bureaucratic institutions to monitor First, budget formulation may involve grand corruption: financial protection in personal health expenditures in the form of corruption perpetrated at the highest levels China and Indonesia, countries with divergent political of government, which involves substantial sums of money processes. In Indonesia, federal institutions and laws or political corruption. Campos & Bhargava (2007) refer to were created to monitor hospital performance, including grand corruption as favours exchanged for financial and preventing corrupt practices such as charging extra fees and non-financial support towards strengthening or maintaining prescribing unnecessary medications. The transparency and the political power of particular individuals or groups. accountability mechanisms introduced in this centralized As noted by Martinez-Vazques et al. (2004), government system resulted in lower out-of-pocket and catastrophic officials may have the power to favour certain individuals expenses, predominantly among the poor. In contrast, and/or groups. Inaccurate or vague revenue planning or Gomez (2017) suggests that China’s decentralized process expenditure estimates hamper a government’s ability to for health care delivery and regulation has offered entry audit public spending. Examples of corrupt practices include points for corrupt practices to bridge funding gaps, such as tax benefits for preferred groups, allocation of resources the sale of medicines for profit, prescription of unnecessary based on political affiliation, or diversion of funds for private medications and tests, and acceptance of bribes for special gain. Delay, Devas & Hubbard (1998) note that corruption treatment. The lack of a centralized, federal oversight is a major problem in revenue administration. Second, structure resulted in a lack of financial protection, with the budget execution phase is particularly vulnerable 35% of participants in the rural cooperative medical to corruption given that funds change hands. Examples scheme facing catastrophic expenses. Liu & Chen (2018) include receipt skimming, favouritism in the payment of also highlight that China’s social health insurance funds invoices, ordering goods that were not on the approved are managed by over 7000 local agencies. In this context budget, and kickbacks (Isaksen, 2005). Such issues notably of a decentralized process without sufficient oversight, the occur when transactions are cash-based, and audit trails basic health insurance programme (the country’s largest are thus lacking. Third, budget accounting and reporting social health insurance) had accumulated a surplus of US$ can involve risks of corruption, particularly when budgets 60 billion by 2009. Liu & Chen (2018) note that “(w)ithout are inaccurate, delayed and opaque, or when accounting independent supervision, these huge surpluses open up procedures are weak or lack capacity, and systems are opportunities for fund fraud and misuse. Wan-Xiang Qu, fragmented. Fourth, external audit and oversight can be the vice director of the Bureau of Anti-corruption in China, performed by legislative committees, audit agencies, commented that a huge amount of these surpluses might civil society and the media. Corruption can occur at this be misappropriated” (p. 276). However, it is not necessarily stage if political influences result in an underreporting the case that surpluses carry the risk of corruption. Indeed, of irregularities or subpar investigations (Dorotinsky & any budget item that is potentially exploitable needs to Pradhan, 2007). be addressed by policy-makers.

14 Potential corruption risks in health financing arrangements: report of a rapid review of the literature Kivumbi, Nangendo & Ndyabahika (2004) note that Uzochukwu et al. (2018) caution that our understanding centralized bureaucratic processes – notwithstanding of the impacts of performance-based financing remains their potential to mitigate corruption – can also prove very limited and, therefore, similar schemes may not counterproductive in delivering health services. The necessarily have the same effects in different countries. study showed that, in Uganda, strict guidelines, risk of Nocera (2010) found that performance-based hospital imprisonment, accumulation of bureaucratic steps and funding, although believed to enhance performance, can lack of built-in flexibility to respond to outbreaks prevented result in fraudulent practices to attain funding. Nocera’s the provision of malaria control in a timely manner. In case-study analysis in the Australian states of Victoria short, anti-corruption, transparency and accountability and New South Wales revealed fraudulent reporting of measures may have costs that need to be balanced against data, including “ghost wards” and “phantom admissions”. the scale and nature of the given corruption. PETS In addition to the degree of centralization of political processes, the role of private actors has been researched. Numerous studies highlight that leakage of funds may be In a study of the Italian health system, Lagravinese & shown by PETS, or other similar methods. PETS examine Paradiso (2014) estimate that corruption has an impact on the flow of funds from central government to central all components of health expenditure, but is statistically providers, while quantitative service delivery surveys focus significant only for pharmaceutical expenditure and on the efficiency of service delivery and the dissipation of private hospital expenditure. Lagravinese & Paradiso’s resources (Gauthier, 2010). Marouf (2010) points out that research suggests a relationship between corruption and PETS can be an important tool to monitor budget execution, the regional governance of the Italian health system. This and other case-studies (see examples in previous section confirms findings by Gupta, Davoodi & Tiongson (2000) that on Leakage of funds) illustrate the usefulness of PETS in privatizing health services does not reduce corruption in identifying vulnerabilities to corruption and areas for policy the health sector when public systems of regulation and interventions. Nonetheless, as Marouf (2010) notes and control of private care and treatment are weak or lacking. objects to, there has been some pushback from the World Bank, which warns that the PETS method presents cost and time constraints, making it difficult to apply universally. Policy interventions Gauthier (2010) cautions that methods to account for funding flow (notably through PETS) in one country can Performance-based financing significantly differ from analyses in other countries, given the complexities and discrepancies between public One method identified in the literature as a potential way to administration structures. Lindelöw, Kushnarova & Kaiser measure and mitigate corruption in pooling is performance- (2006) further warn that, even once an estimate of leakage based financing, also referred to as results-based financing has been established, difficulties exist in determining or pay-for-performance. Performance-based financing is the role of corruption as opposed to legitimate diversion a system in which disbursements are conditional, based of resources or difficulties in executing a budget due to on the results of previous disbursements and using excessive bureaucracy. PETS are further hampered by the performance indicators. Rigorous impact evaluation of a fact that governments often neither possess nor share performance-based financing scheme in Rwanda shows that data. Ultimately, how well PETS may work depends on a it can have a strong positive impact (Basinga et al, 2011). number of structural factors, some of which are addressed in the following subsections.

Review findings 15 Structural factors impacting implementation Transparency

Formal processes In a transparent environment, corrupt activities are less likely to occur (Lewis & Pettersson, 2009). Njog & Ngantcha Uzochukwu et al. (2018) found that government officials (2013) propose to publicize disbursements to districts and politicians in Nigeria have a tendency to pursue their in Cameroon. A qualitative study in Nigeria notes that own personal interests in an environment characterized survey respondents were in favour of publicizing budget by pervasive corruption. Establishing formal processes releases and evaluation results carried out as part of can help to reduce the prevalence of corruption and performance-based financing schemes, including through leakage in pooling. Formal processes include: allocation of different media sources (Uzochukwu et al., 2018). Gauthier resources on schedule; official mechanisms for obtaining (2010) finds that wage expenditures are less open to supplies, including a supplier-approval process (Asante, leakage than other public expenditures precisely because Zwi & Ho, 2006); and an independent, rigorous oversight of the transparency involved. Health workers know how system to limit the discretion of politicians/public officials much money they should be paid, so any missing funds over allocation of funds and to restrict overall political are more likely to be detected; because wages are paid interference in the funding process (Gauthier, 2010; directly to staff bank accounts, there are no intermediary Uzochukwu et al., 2018). levels to deviate them. According to Vian (2008), public dissemination of budget information can help prevent Data management diversion of funds. Hospital report cards, which measure important statistics on patient care and access, can reveal The literature highlights the role of data management problems and create demand for solutions. in addressing corruption risks in pooling. Research by Lindelöw, Kushnarova & Kaiser (2006) shows the importance Accountability of sound financial records, which are often found to be lacking due to either unqualified staff or an intentional Almost all of the studies emphasized the importance of attempt to mask corrupt practices. In Mozambique, for enhancing accountability mechanisms. Uzochukwu et al. example, accounts could be provided for only 40% of (2018) usefully describe three categories of accountability. districts for which provincial health authorities were responsible (Lindelöw & Ward, 2003). In Cameroon, • Financial accountability, which focuses on tracking and Njog & Ngantcha (2013) found that inadequate financial reporting on allocation, disbursement and utilization of records at the peripheral level made it difficult to match financial resources through auditing tools (which need intended budget targets with actual spending. The authors to be frequent and independent: Dorotinsky & Pradhan, suggest incentivizing compliance in good record keeping 2007; Nocera, 2010), budgeting and accounting; financial through improving health workers wages. Uzochukwu et accountability seeks to control the misuse and abuse al. (2018) also cite improved data management, which can of public resources and/or authority. be facilitated by the use of electronic and bank payments instead of cash, as a key strategy to address corruption • Performance accountability, which supports improved service risks in this area. delivery and management through feedback and learning, and focuses primarily on services, outputs and results.

• Political/democratic accountability, which relates to the institutions, procedures and mechanisms that aim to ensure that governments deliver on electoral promises.

16 Potential corruption risks in health financing arrangements: report of a rapid review of the literature Uzochukwu et al. (2018) make a distinction between internal More generally, Ware et al. (2007) explain how bribes accountability mechanisms, including the institutional or kickbacks are common forms of corruption in public oversights, checks and balances internal to the public procurement. A “reward” may be given to a government sector, and external accountability mechanisms used official for a public contract. Red flags include: a by non-state actors to hold public sector power-holders supplier being awarded multiple bids; officials accepting accountable. The authors note that “non-state actors, inappropriate gifts such as expensive meals; officials particularly communities, must be empowered and engaged displaying excessive wealth in relation to their salaries; as instruments for ensuring external accountability at information from the community about who takes bribes; lower levels of implementation”. Lewis & Pettersson and the existence of personal relationships between (2009) stress the importance of citizen participation to suppliers and officials. The authors also explain how the encourage accountability. In a case-study of Romania, bidding process may be rigged: a public tender may be where 41 high-ranking health officials faced corruption manipulated to ensure that a particular supplier is awarded charges between 2015 and 2017, Ungureanu, Gheorghe the contract, or insider information may be shared so that & Voinea (2017) point to large popular protests against a preferred supplier wins. Bidding processes may also the government’s attempts to soften anti-corruption be rigged through the pre-selection of tenders based on allegations as a sign of external accountability. kickbacks, cartels and so on. The authors highlight that there are a variety of risks that can occur throughout the procurement cycle, including: political corruption resulting Purchasing in particular projects being supported by a politician; pre-qualification clearly favouring a particular supplier; This section discusses three main types of corruption or unclear evaluation criteria leaving ample room for risk identified in the literature, namely in procurement, discretion. After a bid is awarded, substandard goods or no pharmaceuticals purchasing and provider payments. deliveries of goods will also constitute clear health risks. Each of these risks are broken down and summarized into existing challenges and policy interventions. The Savedoff (2008b) provides country-level examples in an section concludes with general policy interventions on examination of hospital procurement in Argentina and purchasing suggested by existing literature. Bolivia. The study found that spending on public hospitals could be wasted due to kickbacks and the receipt of substandard and expired products. In Argentina, price Corruption risks in procurement information was collected for medical supplies and then disseminated to purchasing managers, allowing for Corruption in public procurement can have a negative impact each hospital to compare prices. Price variation dropped on the quality of health care services and infrastructure, substantially one month before the price information was and lead to inflated costs for governments, resulting in circulated; five months later, however, price variation rose less money being available for service provision. Savedoff again. A major factor behind this variation was the lack of & Grépin (2012) present a number of corrupt activities in sanctions placed on managers, who inflated medical supply procurement processes including: bribes for inspectors; prices. Mann (2013) illuminates cases of purchasing fraud improper bidding procedures for purchasing; diversion of identified by the Association of Certified Fraud Examiners, the public drug supply to private practice; kickbacks for including kickback schemes whereby something of value referrals; and pharmacies or drug shops selling illegal is given in exchange for influence over a business decision. items. For example, in Ethiopia a black market exists for generics and drugs that are unavailable in the country; illicit products are mostly imported from Kenya.

Review findings 17 Policy interventions The authors caution that the use of the technology must be open-sourced to preclude private companies from Interventions to reduce corruption in procurement include: interfering with the data. ensuring clarity about the roles of both purchasers and providers (Fryatt, Bennett & Soucat, 2017); effective oversight/ Hussmann (2011) suggests that systems for delivering monitoring; implementation of e-procurement procedures; donor aid should be examined to ensure they do not provide inspections; audits; enforcement and punishment of opportunities for corruption. For instance, the release of corrupt practices; whistleblower programmes; external funds at the end of the year may be associated with officials monitoring and freedom of information; competitive tendering circumventing the usual procurement protocols. Although procedures; ensuring personnel are trained in financial this phenomenon (which also occurs with public funds) management and procurement; and regulation of public and could be related to inefficiency more than corruption, private roles (Savedoff & Grépin, 2012; Ware et al., 2007). it certainly calls for further study. Furthermore, the issue of corruption in donor funding may not necessarily be Vian (2006) notes that procurement systems should be a country problem per se, but rather a donor issue. accountable and transparent, be based on rules, promote fairness, encourage competition, and lead to the efficient use of effective and judicious government resources. Vian Corruption risks in pharmaceuticals notes a supply chain management system was funded by purchasing the President’s Emergency Plan for AIDS Relief (PEPFAR) with the goal of providing countries with procurement The pharmaceutical procurement process stands out as assistance, including predicting supply requirements, being particularly vulnerable to corruption (for example, publishing drug cost data and developing distribution Kohler & Ovtcharenko, 2013; Ware et al., 2007). There are chains that adhere to best practices. As the study was numerous examples of corruption within the pharmaceutical published a few months after PEPFAR was set up, Vian procurement process, whether operating at the national, state/ was not able to address the results of the project. Savedoff provincial or local levels. These include: “different” bidders (2008b) points to transparency in pricing and sanctions as having the same contact information; forged documents; potential solutions to corruption in purchasing. The author deliberately missing documents; clustering of bids; colluding notes the effectiveness of citizen oversight in reducing companies; pricing irregularities; and bribes and kickbacks procurement corruption in Bolivia, observing that when an to government officials. Direct purchasing from a supplier is active committee with citizen representation supervised also vulnerable to corruption as it is highly fragmented and can hospital purchases, the hospitals paid less for purchases. be challenging to audit if there is no clear information path.

Till et al. (2017) examined the potential positive impact of Lewis & Pettersson (2009) note the logistic process for blockchain technology on global health equity, including medicines procurement is complicated by difficulties in through improving procurement processes. Blockchain quality assessment, while procurement and regulatory technology allows records of every transaction to be processes themselves are further complicated by the need recorded and unaltered, increasing transparency and for coordination. The authors give examples of corrupt the ease with which a health system could be monitored practices, including: bid rigging; bypassing regulatory to prevent corruption and minimize fraud. Contracts controls; delivery of smaller quantities than paid for; based on blockchain technology could link funding to the and leakages in the distribution chain. Lewis & Musgrove purchase of goods and ensure that goods go to the intended (2008) note that corrupt activities include: theft of supplies; recipient. In this way, data could be also analysed more absenteeism; and private use of public facilities/equipment. expediently allowing fraudulent activity to be identified.

18 Potential corruption risks in health financing arrangements: report of a rapid review of the literature Vian (2008) warns that bribes to circumvent government the authors emphasize the critical importance of transparency regulation of drugs and medicines clearly have adverse in the procurement process to help governments to ensure effects on health, citing the dilution of vaccines in Uganda competitive prices and delivery of medicines to the population and the growing problem of falsified medicines globally. in a timely manner. Lewis also notes that, in Ethiopia, theft of public sector medicines for resale on the more lucrative Unregulated medicines of subtherapeutic value can private market is common practice. In Uganda, an average contribute to the development of drug-resistant organisms of 73% of drugs across 10 public facilities were stolen, and increase the threat of pandemic disease and anti- resulting in high-demand drugs (such as antimalarials) microbial resistance (Nwokike, Clark & Nguyen, 2018; being less available to patients. Lewis also emphasizes Transparency International, 2006). In addition to the presence that theft of public funds commonly takes place during the of counterfeit drugs on the market, corruption can lead to tendering and payment process for medicines. shortages of available drugs in government facilities due to theft and diversion to private pharmacies. This in turn Vian (2006 & 2008) explains how international efforts to leads to reduced utilization of public facilities, further rapidly expand access to medicines (as in the case of HIV/ damaging the well-being of populations. AIDS treatment) can generate pressure for governments to spend funds quickly, thus creating opportunities for In a study of over 100 regions in Europe, Ronnerstrand & corruption. Weak supply systems can be made even weaker Lapuente (2017) demonstrate how corruption seemed to when faced with a sudden increase in volume, also creating account for higher use of antibiotics. Bribery by pharmaceutical opportunities for drug diversion from the public sector. companies and the influence of pharmaceutical companies on provider prescribing practices were likely responsible A study in Pakistan highlights how pharmaceutical companies for the high variation in antibiotics consumption across bypass licensing and accreditation processes, and may Europe. Numerous studies demonstrate the influence of bribe or influence regulators. There is notably widespread the pharmaceutical industry globally, and particularly in overpayment for supplies in public hospitals and huge the United States of America. Companies such as Purdue variation in cost across institutions. Medicines and supplies Pharm have faced fines amounting to billions of dollars to are stolen from hospitals and diverted to the private system settle charges of inappropriate promotion and failure to for personal gain (Transparency Fund, NWFP Health Reform report safety issues of products (Lexchin & Kohler, 2011). Unit & Heartfile, 2007). The pharmaceutical industry often aims to directly influence the prescribing practices of doctors through bribery, by Policy interventions providing lavish conferences, seminars in holiday locations and other perks (European Commission, 2017). Vian (2006) describes how publishing medicines price information can provide a measurement standard, allowing Lewis (2007) highlights how public sector purchases oversight committees to monitor for inflated drug prices. of medicines can be wasted if corruption enters the The author notes that increased security of distribution pharmaceutical system. Lewis cites the work of Cohen, systems can help reduce drug diversion due to theft. Vian Mrazek & Hawkins (2007) which illuminated weaknesses also recommends monitoring for possible diversion from in procurement processes in the pharmaceutical system the public to the private market: batch numbers could be in Costa Rica, with noted deficits in quality monitoring, designated for use in each particular market, or each set inventory management and information systems (Cohen, of benefits could be labelled with the intended market. Mrazek & Hawkins, 2007). Using the example of Costa Rica,

Review findings 19 In a 2008 study, Vian points out that publishing price lists for Johnson & Nagarur (2016) discuss examples of duplicate services can help patients understand the difference between billing (billing twice for the same procedure), unbundling official and unofficial services. Lewis & Pettersson (2009) (billing for separate services, although an inclusive also advance transparent pricing practices as a potential code is available) and billing for procedures that are not solution, and promote the idea of social pharmacies (i.e. medically necessary. McGee et al. (2018) discuss one of the not-for-profit or government run) or nongovernmental largest Medicare frauds ever detected, in 2016, when 301 organizations dispensing medicines as an alternative to individuals were involved in fraudulent billing amounting corporations primarily driven by commercial interests. to US$ 900 million. The authors note corruption risks including kickbacks from pharmaceutical companies to patients and physicians, prescribing for a family member Corruption risks in provider payments who is below coverage maximum, or altering diagnoses to fit coverage criteria. McGee et al. also highlight that Payments to health care providers can provide opportunities organized crime organizations can enter the system and for fraud. Bauder, Khoshgoftaar & Seliya (2016) highlight seek to steal patient information for profit. the occurrence of “upcoding”, a practice whereby providers bill for more expensive services than those actually Lubao (2008) examined how providers in Florida submitted performed. Dietz et al. (2013) highlight that current data claims of US$ 2.5 billion for HIV/AIDS-related care, far systems are more capable of uncovering fraud than systems exceeding the US$ 1 billion in legitimate claims required in the past, such as billing for services not performed for all of the United States. Lastly, Kesselheim & Brennan or services that are performed but unnecessary, and (2005) discuss health care fraud by insurance companies. the occurrence of kickbacks. As noted in the section on Physicians in the United States brought a class-action pooling, results-based or performance-based financing lawsuit against insurers, upheld by a federal court of appeal (where health providers are partly funded on the basis in 2004, alleging corrupt activities including: rejection of of their performance to meet targets or take specific valid claims; delaying claim adjudication; incentivizing actions) and audit mechanisms can also be helpful tools claim reviewers to deny payments; and using market to aid compliance to contractual obligations. power to pressure physicians to accept billing practices.

However, important complexities remain. Witter et al. Policy interventions (2012) note that performance-based funding consists of a number of different approaches and its impact depends Dietz et al. (2013) and Sparrow (2000) suggest the proactive on various factors, including the design of an intervention, identification of outliers and a reporting system for billing the incentive structures, targets and their measurement, activities to help to detect fraud. Identifying outliers and the amount of additional funding, and other factors such analysing data in billing activities will find a certain class as organizational context. Sparrow (2000) emphasizes that of corruption (for example, a claim for a pregnant man), automatic methods to identify corruption, such as those but not other kinds (for example, “roboclaims” designed found in data systems, may not necessarily be effective: to look entirely consistent with the system rules). Joudaki an intelligence-gathering unit that is proactive towards the et al. (2015) recognize that standard auditing procedures identification of corruption is required. Although technology are expensive and time-consuming which, in turn, affects has greatly evolved since 2000, Sparrow’s emphasis on the ability of low- and middle-income countries to detect the importance of human inspection in fraud detection fraud. The authors propose a data mining procedure to remains relevant today. identify suspect groups and allow targeted investigations.

20 Potential corruption risks in health financing arrangements: report of a rapid review of the literature Specifically, indicators employed in the data mining process Other studies point out that processes and procedures (for example, the number of patients that visited more to reduce the risk of fraud in purchasing include: annual than once a month, and the average cost of prescribed fraud risk assessment; employee codes of conduct/codes medications) were useful in identifying physicians suspected of ethics, with consequences outlined for violations; codes of abusing the billing system. McGee et al. (2018) advocate of conduct for all vendors; a gift policy; a purchasing more generally for computer programmes that are able policy with segregation of duties; processes to report any to detect deviations from normal billing practices. possible breaches; and internal audits (Mann, 2013). Bauder, Khoshgoftaar & Seliya (2017) recommend the need for In a study on financial pressure and upcoding behaviour fraud analysis and detection research to minimize financial in French hospitals, Georgescu & Hartmann (2013) losses due to upcoding. The current availability of large recommend identifying the source of pressure – the data sources opens up possibilities for the integration of hospital’s administration or the professional peer group data and detection. Lewis & Pettersson (2009) point out – to understand physicians’ likelihood of engaging in data the importance of ensuring that the payroll process is manipulation and the specific kinds of upcoding involved. up-to-date with accurate lists of employees and budgets. It was noted that organizational recognition of existing The combination of policies and procedures that will administrative and peer pressures may help to prevent work best is clearly context-specific. Interventions that such behaviour. If upcoding seems to be associated with have proved effective in one country may not necessarily financial pressure on health care decision-making, better be directly replicable in another if important contextual understanding of the implications of financial targets nuances are not taken into account. would help to improve the situation. Lastly, Taitsmann (2011) advocates for better education of physicians in order to prevent fraud, waste and abuse. Benefit design

This section of the paper aims to review academic research General policy interventions on purchasing on the main vulnerabilities to corruption in benefit package design. It highlights the role of interference The literature reviewed also identifies overall policy by pharmaceutical companies in the decisions made by interventions to address corruption risks in purchasing. purchasers or insurers in what products and services to Lewis & Musgrove (2008) note that the financing stage include (and exclude) in a benefits package. After presenting presents challenges for governance, as the high number the main issues discussed in the literature, and the key of people involved and high number of possible choices structural factors behind them, recommendations to among inputs, people, diseases and services greatly improve the current status quo are suggested. increases opportunities for corruption, incompetence and fraud. Whereas poorly controlled funding and pooling may lead to theft of funds, the purchase of services or Corruption risks in benefit design the payment of suppliers/providers allows for theft of supplies, especially drugs, as well as loss of time and A case-study of Ghana’s national health insurance use of public equipment and facilities for private gain. To scheme shows that overly complex benefit systems counter the risk of corruption, Lewis & Musgrove suggest may introduce vulnerabilities to fraud and corruption. that accountability be designed at the individual level, In an environment marked by ambiguous and noting that oversight is meaningless without a system of confusing information, users may be charged for reward and punishment. services that are in fact covered by health insurance.

Review findings 21 For example, in Ghana, HIV/AIDS treatments are not have managed to shape both pharmaceutical policies and covered by the insurance scheme, but AIDS-related the information used to evaluate them, as well as subsidize infection treatments are; orthopaedic treatments are not political allies and influence congressional voting. Brown covered, unless resulting from a road traffic accident; (2013) analyses how clinical trials and the overall regulatory and it is unclear which hospital services are covered for approval process are vulnerable to corruption. For instance, newborns (Barimah & Mensah, 2013). Key informants the regulatory approval process allowing a drug to enter interviewed by Barimah & Mensah (2013) identified the market is based on the results of two trials, selected at fraud as a basic problem, notably agents collecting and the discretion of the applicant. Therefore, many trials may embezzling premiums, pharmacists making fraudulent have to be completed in order to produce two trials with the claims for payment of products covered by the scheme, or desired results. Academics may be paid large consulting fees members of the public attempting to procure free health to write up clinical trials or disseminate information on the services they are not qualified to receive. purported advantages medicines may provide (i.e. off-label uses). Ebrahim, Sohani & Montoya (2014) found that only Mostert et al. (2015) studied corruption in health care a small number of studies have re-analysed randomized systems in Africa and the effect on cancer care, finding clinical trials, that even fewer were conducted by authors that patients unable to pay their medical bills may be entirely independent of the pharmaceutical industry, and detained by the hospital. Medical bills then rise with each that over one third of published re-analyses led to changes day of detention, and families become increasingly unable in findings and conclusions. to pay as a result. Patients may be abandoned, or a spiral begins whereby families sell vital assets to pay medical Light, Lexchin & Darrow (2013) focus on the negative bills and bribes resulting in further impoverishment, consequences for patients of pharmaceutical companies’ lower likelihood of being able to pay bills and worse established practices, namely: hiding, ignoring and massaging health outcomes. evidence; distorting medical literature; and misrepresenting products to physicians. In the United States, three levels of Overall, the bulk of the literature on corruption risks in institutional corruption are at play when pharmaceutical benefit design focuses on the pharmaceutical industry companies carry out large-scale lobbying and campaign and its relations with politicians, government officials and contribution efforts to: (1) undermine and compromise the academics. Jorgensen (2013) introduces the dependence mission of the Food and Drug Administration (FDA); (2) lead corruption framework, which “posits that a political system to underfunding of the FDA’s enforcement capacities and over-reliant on the pharmaceutical industry will cater to ability to protect the public from adverse drug reactions; the needs of the industry while disregarding the public’s and (3) commercialize the role of physicians and undermine needs and values” (p. 565). Jorgensen points out: “When their independence (Light, Lexchin & Darrow, 2013). a less-than-legitimate influence becomes more important than others, it can cause an institution to deviate from its Although much of the literature focuses on the United intended purpose” (p. 565). States, corruption in benefit design has also been found to exist in other countries. In Hungary, for example, Szebik The United States of America is used as an example in a (2003) demonstrates that the funding of clinical trials by number of studies, which is understandable given the history, multinational companies can result in situations where size and political influence of the pharmaceutical industry physicians make choices that are not in patients’ best interest, in the country, as well as the potential global ramifications but instead designed to maximize financial compensation, of its activities and the policy responses. Jorgensen (2013) with important consequences for the inclusion and exclusion shows how pharmaceutical companies in the United States of certain products in benefit packages.

22 Potential corruption risks in health financing arrangements: report of a rapid review of the literature Structural factors Policy interventions

The literature identifies a number of structural factors The literature suggests a number of recommendations behind the challenges to benefit design. Szebik (2003) to tackle vulnerabilities to corruption in benefit design discusses how low public funding for research, high costs and, in particular, to address the influence of the of clinical trials and pressure on research physicians to pharmaceutical industry. publish may lie behind corruption issues in Hungary. Brown (2013) goes further by highlighting three main areas that Jorgensen (2013) argues that more independent research discourage the fair evaluation of evidence in clinical trials is needed to uncover the undue political influence of the and other academic research. pharmaceutical industry in influencing how governments determine what is included in benefit design, notably by • Career concerns – for example: a pharmaceutical investigating lobbying practices and resulting links between company employee worried about losing her/his job; an political donations by pharmaceutical companies and public academic concerned about future prospects of obtaining policy. In terms of clinical trials and relevant academic research funding from the pharmaceutical industry; or, research, Brown (2013) notes that other advocates of an academic journal hesitant about publishing research reform have argued in favour of banning pharmaceutical criticizing a pharmaceutical company, given the revenue industry funding of research; for example, Light, Lexchin they generate through advertising. & Darrow (2013) recommend to “separat[e] the funding of clinical trials from their conduct, analysis, and publication” • Reputation concerns – pharmaceutical companies have (p. 590). Brown (2013) proposes three steps to improve distorted proxies for academics’ reputations through the quality of relevant information in clinical trials and their ability to increase an academic’s productivity, the other scientific research which inform decision-making. number of citations by others in the field and the status of the journals where she/he publishes, all key criteria • Incentivizing individuals aware of a pharmaceutical for career advancement in academia. company hiding information about safety and efficacy of a drug to report that company. Certain tools to prevent • Legal liability – fines for wrongdoing are simply too accounting fraud could help in this regard, including the limited to warrant any change in behaviour. Shi et al. Dodd-Frank Act whistleblower programme; in addition, (2018) also note that reforms to the Chinese health more public education is needed to inform people in a system in the 1990s included anti-corruption measures, position to report research fraud – including academics such as fines and criminal penalties, which were not – of financial incentives to do so. sufficient to deter corrupt activity. • Changing the journal acceptance process, including Overall, the large financial pressures associated with FDA making a decision on publication before clinical trials approvals in the United States of America, and similar are carried out, and holding researchers accountable processes in other countries, mean there are strong for any deviations from an agreed-upon protocol. personal incentives to skew data in order to maximize chances of drug approval (Brown, 2013). • Subsidizing insurance against failed clinical trials undertaken with the purpose of obtaining FDA approval, as failed trials are expensive. If governments were to accept the financial risk, on condition of transparency and data quality on the pharmaceutical companies’ part, then companies may be less likely to skew their findings.

Review findings 23 At a regulatory level, Light, Lexchin & Darrow (2010) Regarding hospital detention, a further cited vulnerability support nomination of FDA leadership (independent of the in benefit design, Mostert at al. (2015) highlight the fact pharmaceutical industry), full funding for all FDA activities that such detentions violate the Universal Declaration including enforcement, and creation of a national drug of Human Rights, which has been signed by African safety board. At the practitioner level, Shi et al. (2018) governments. There is a need for further investigation of suggest improving financial incentives for hospitals, how to eliminate the practice of hospital detention and to physicians and insurers in order to counter the risks of advise stakeholders on appropriate actions. corruption in China. Ultimately, Jorgensen (2013) warns that “(u)nless citizens mobilize to confront the political power of pharmaceutical firms, objectionable industry practices and public policy will not change” (p. 561).

24 Potential corruption risks in health financing arrangements: report of a rapid review of the literature Discussion and conclusions

Relevance of findings for health Relevance of findings for further financing diagnostics and policy research

Although the rapid literature review was not exhaustive, Gaitonde et al. (2016) point out that there is “a paucity of it clarifies – with a good body of evidence – that health evidence regarding how best to reduce corruption” (p. 27) financing goals can be undercut by corruption. Mostert et in the health sector overall. With regards to corruption al. (2015) note that corruption can result in undertreatment, in health financing, the literature suggests a number overtreatment (see also Jain, Nundy & Abbasi, 2014), of general policy interventions to address the issue (in patients being deprived of generic drugs (given the lower addition to the specific interventions pertaining to each financial incentives such drugs present for pharmaceutical core function, as explored in previous sections). companies, physicians and pharmacists), and patients being pushed towards alternative, lower quality treatments. These overarching policy interventions – enhancing transparency and accountability, raising awareness, monitoring The rapid review clearly shows that corruption in health and oversight, and integrating anti-corruption, transparency financing wastes already limited public resources allocated and accountability into health financing diagnostics and policy to the health system. It also decreases access to services, – should be studied further to examine their effectiveness in undermines equity and fairness, and jeopardizes progress different health systems and contexts. Crucially, based on towards universal health coverage – harming poor and the recommendation of Gaitonde et al. (2016), there is a need vulnerable populations the most. Thus, the value of to advance research to “monitor and evaluate the impacts integrating anti-corruption, transparency and accountability of all interventions to reduce corruption, including their measures into health financing diagnostics and policy potential adverse effects” (p. 2). The issue of accountability discussions is clear. WHO’s 2019 publication Integrating a is particularly in need of research as, to date, there has focus on anti-corruption, transparency and accountability been little empirical work on accountability and it has been in health systems assessments provides an excellent weighed down by too many definitions. There is a need to foundation to help to advance work in this area.10 investigate how governments can implement accountability measures, and what works best, and why.

In short, there is ample space for further research to build up the evidence base for anti-corruption, transparency and accountability measures. There is a need to evaluate their effectiveness in reducing corruption and in helping to promote universal health coverage and other health goals, and to assess whether such strategies and tactics prove to be sustainable in the long-term.

10 Integrating a focus on anti-corruption, transparency and accountability in health systems assessments. Geneva: World Health Organization; 2018 (https://www.who.int/gender-equity-rights/knowledge/focus-on-anticorruption-transparency-accountability-health- syste/en/).

Discussion and conclusions 25 Relevance of findings for capacity- This requires the development of training modules to explain building in the health system corruption risks in health financing arrangements, how to identify them and what to do in order to reduce corruption. The findings of the rapid literature review suggest that, in Capacity-building could take place through the integration order to make progress towards universal health coverage and or “mainstreaming” of anti-corruption, transparency and other health goals, there is a need to ensure the integration accountability into existing health financing knowledge of anti-corruption, transparency and accountability into products. This would help to advance knowledge so that health financing policy discussions as well as diagnostics. practitioners are mindful of corruption risks, understand To facilitate this, it is necessary to bridge the divide that the lessons learned and can take appropriate action to may exist between health financing and corruption experts. address the risks.

26 Potential corruption risks in health financing arrangements: report of a rapid review of the literature Main lessons and way forward

Increased investments in health care may not necessarily Accountability, as part of good governance. As case- translate into improvements in health outcomes (Lindelöw studies illustrate, there have to be consequences for et al., 2006; McIsaac et al., 2018; Njog & Ngantcha, 2013; corrupt practices (Lewis & Pettersson, 2009; Nocera, Nocera, 2010). As has been shown, the extent to which 2010) such as investigation, disciplinary procedures and public spending on health impacts health outcomes is criminal prosecution (Hussmann, 2011). Accountability indeed undermined by corruption and mismanagement mechanisms can be either internal (including institutional throughout the process (Gauthier & Wane, 2008). While oversights, checks and balances) or external (non-state corruption in health financing takes many different forms, actors holding public sector power-holders to account) the reviewed literature agrees on the importance of the (Uzochukwu et al., 2018). For maximum impact, several following measures. studies stress the need for citizen mobilization at all levels (Lewis & Pettersson, 2009) to ensure accountability Sufficient good governance mechanisms. If sufficient and of public officials (Gatti, Gray-Molina & Klugman, 2002; widely implemented good governance mechanisms are in Rispel, de Jager & Fonn, 2015; Uzochukwu et al., 2018). place – in addition to good working conditions, appropriate income for health professionals, and promotions based Awareness raising. Raising awareness of corruption risks on merit – corruption may be reduced (Jain, Nundy & in health financing, and their consequences, is important Abbasi, 2014). This may partly be due to the fact that good in enforcing accountability. Hussmann (2011) highlights governance encourages good behaviour and sufficiently the need for awareness raising on corruption to change well paid human resources. attitudes and normalized behaviour, notably through training programmes, education on patient rights and programmes Transparency, as part of good governance. Vian (2008) through professional associations. A number of studies notes that enhancing transparency in health financing highlight the central role of public education in raising provides citizens with much needed information on which awareness about corruption risks (Ensor, 2004; Hotchkiss they can act or demand answers, thus increasing their et al., 2005; Killingsworth et al., 1999; Njog & Ngantcha, ability to participate in governance. The author adds that 2013; Nocera, 2010; Shahriari et al., 2001; Uzochukwu et freedom of information acts, which have been adopted in al., 2018). In addition, strong whistleblower programmes many countries to help citizens to access information (see can help to shed light on corrupt practices and lead to also Hussmann, 2011), are important, as is investigative public demand for reforms (Brown, 2013; Mostert et al., journalism which can expose corruption. A number of areas 2015; Jain, Nundy & Abbasi, 2014; Juwita, 2018; Ware within the health system may particularly benefit from et al., 2007). However, increasing transparency may not greater transparency, including: budgets; performance; be effective in reducing corruption in and of itself, as decision-making processes (Mostert et al., 2015); payments Gaitonde et al. (2016) caution; hence the need for further (Segato et al., 2013); drug benefit packages; pharmaceutical interventions, including those discussed below. procurement; and pharmaceutical distribution and supply (Kohler & Ovtcharenko, 2013; Prabhakaran et al., 2017).

Main lessons and way forward 27 Monitoring and oversight. Monitoring and oversight To increase efficiency, Gaitonde et al. (2016) found that mechanisms are essential for enhancing accountability. coordinated interventions undertaken by the Department The reviewed literature points to the importance of strong of Health and Human Services, the Department of Justice monitoring frameworks and oversight mechanisms to and other agencies in the United States helped to recover identify and potentially deter corrupt practices in health billions of dollars and resulted in hundreds of new cases financing (Lewis, 2007; Savedoff & Grépin, 2012; Vian, 2006; and convictions each year. The package of interventions Ware et al., 2007). Mostert et al. (2015) specify installing included: increasing computer analytic capacity to review monitoring systems to ensure integrity in health budgets, payment trends and identify improper billing; stricter address health workforce issues (absenteeism and dual health care fraud and abuse control laws; prepayment practice), secure medicines supplies and eliminate informal claim checking; manual reviews; educating providers; payments, while Hussmann (2011) suggests expanding and, provider enrolment screening. monitoring to include the assets and lifestyles of senior health officials. Monitoring and oversight can be carried out Integration of anti-corruption, transparency and by community oversight boards (Vian, 2008), independent accountability in health financing diagnostics and policy. agencies or anti-fraud teams (Juwita, 2018). Vian & Collins Anti-corruption, transparency and accountability should (2006) note monitoring of financial performance is necessary be built into health financing diagnostics and policy, and to curb corruption and inefficiency, requiring service not viewed as standalone measures. Prior to designing statistics and financial information to be integrated. The strategies, there also needs to be a thorough understanding authors use the example of South Africa, where a reporting of the country-specific nature of corruption, local values system was introduced to allow for comparison of statistics, and international standards – including anti-corruption indicators and budgets across facilities. Flow of funds, and human rights obligations (Juwita, 2018). Governments, information systems, and budget and data management are providers and civil society should jointly identify corrupt also important areas to track (Lewis & Pettersson, 2009). practices, and strategies to mitigate these practices Although performance-based financing can incentivize should be designed and combined with awareness raising better services, it may prove counterproductive if the (Hussmann, 2011). Such comprehensive strategies are process is not effectively monitored and wrongdoers are likely to be most effective when there is strong political not held accountable. For example, in some hospitals in commitment to tackle the issue of corruption in health Australia, performance data was manipulated in order to financing (Fryatt, Bennett & Soucat, 2017). Governance meet criteria for further funding (Nocera, 2010). reforms outside of the health sector are equally important; for example, ensuring strong governance in the financial sector, strengthening the civil service, decentralizing of processes, and increasing local accountability.

28 Potential corruption risks in health financing arrangements: report of a rapid review of the literature References

1. Afsana K (2004). The tremendous cost of seeking hospital obstetric care in Bangladesh. Reprod Health Matters. 12(24):171–80.

2. Asante AD, Zwi AB, Ho MT (2006). Getting by on credit: how district health managers in Ghana cope with the untimely release of funds. BMC Health Serv Res. 6.

3. Baji P, Pavlova M, Gulácsi L, Groot W (2013). Exploring consumers’ attitudes towards informal patient payments using the combined method of cluster and multinomial regression analysis – the case of Hungary. BMC Health Serv Res. 13.

4. Balabanova D, McKee M (2002). Understanding informal payments for health care: the example of Bulgaria. Health Policy. 62(3):243–73.

5. Barber S, Bonnet F, Bekedam H (2004). Formalizing under the-table-payments to control out-of-pocket hospital expenditures in Cambodia. Health Policy Plan. 19(4):199–208.

6. Barimah KB, Mensah J (2013). Ghana’s National Health Insurance Scheme: insights from members, administrators and health care providers. J Health Care Poor Underserved. 24(3):1378–90.

7. Baschieri A, Falkingham J (2006). Formalizing informal payments: the progress of health reform in Kyrgyzstan. Central Asian Survey. 25(4)441–60.

8. Basinga P, Gertler PJ, Binagwaho A, Soucat AL, Sturdy J, Vermeersch CM (2011). Effect on maternal and child health services in Rwanda of payment to primary health-care providers for performance: an impact evaluation. Lancet. 377(9775):1421–8.

9. Bauder R, Khoshgoftaar TM, Seliya N (2017). A survey on the state of health care upcoding fraud analysis and detection. Health Serv Outcomes Res Methodol. 17(1):31–55.

10. Bloom G, Han L, Li X (2001). How health workers earn a living in China. Human Resources for Health Development Journal. 5(1):25–38.

11. Brown A (2013). Understanding pharmaceutical research manipulation in the context of accounting manipulation. J Law Med Ethics. 41(3):611–9.

12. Buch Mejsner S, Eklund Karlsson L (2017). Informal patient payments and bought and brought goods in the Western Balkans – a scoping review. Int J Health Policy Manag. 6(11):621–37.

13. Campos JE, Bhargava V (2007). Introduction: tackling a social pandemic. In: Campos JE, Pradhan S. The many faces of corruption: tracking vulnerabilities at the sector level. Washington (DC): World Bank.

14. Chiu YC, Smith KC, Morlock L, Wissow L (2007). Gifts, bribes and solicitations: print media and the social construct of informal payments to doctors in Taiwan. Soc Sci Med. 64(3):521–30.

15. Cockcroft A, Andersson N, Paredes-Solis S, Caldwell D, Mitchell S, Milne D, et al. (2008). An intercountry comparison of unofficial payments: results of a health sector social audit in the Baltic States. BMC Health Serv Res. 8:15.

16. Cohen J, Mrazek M, Hawkins L (2007). Corruption and pharmaceuticals: strengthening good governance to improve access. In: Campos JE, Pradhan S, editors. The many faces of corruption: tracking vulnerabilities at the sector level. Washington (DC): World Bank.

References 29 17. Cohen N (2012). Informal payments for health care – the phenomenon and its context. Health Econ Policy Law. 7:285–308.

18. Delay S, Devas N, Hubbard M (1998). The reform of revenue administration: a study for the Department for International Development. Birmingham: Development Administration Group, School of Public Policy, University of Birmingham.

19. Dietz J, Gamble WB, Marchlowska J, Wheeler BT (2013). Fighting health care fraud in bold and innovative ways. Mil Med. 178:1041–3.

20. Dorotinsky W, Pradhan S (2007). Exploring corruption in public financial management. In: Campos JE, Pradhan S, editors. The many faces of corruption: tracking vulnerabilities at the sector level. Washington (DC): World Bank.

21. Ebrahim S, Sohani ZN, Montoya L (2014). Reanalyses of randomized clinical trial data. JAMA. 312(10):1024–32.

22. Ensor T (2004). Informal payments for health care in transition economies. Soc Sci Med. 58(2):237–46.

23. Ensor T, Savelyeva L (1998). Informal payments for health care in the Former Soviet Union: some evidence from Kazakstan. Health Policy Plan. 13(1):41–9.

24. European Commission (2017). Updated study on corruption in the healthcare sector. Luxembourg: Publications Office of the European Union.

25. Fryatt R, Bennett S, Soucat A (2017). Health sector governance: should we be investing more? BMJ Glob Health. 2(2):e000343.

26. Gaal P, Belli PC, McKee M, Szócska M (2006). Informal payments for health care: definitions, distinctions, and dilemmas. J Health Polit Policy Law. 31(2):251–93.

27. Gadre A (2015). India’s private health care sector treats patients as revenue generators. BMJ. 350:h826.

28. Gaitonde R, Oxman AD, Okebukola PO, Rada G (2016). Interventions to reduce corruption in the health sector. Cochrane Database Syst Rev. 8:CD008856.

29. Gatti R, Gray-Molina G, Klugman J (2002). Determinants of corruption in local health care provision: evidence from 108 municipalities in Bolivia. Societa italiana di econima pubblica.

30. Gauthier B (2010). PETS-QSDS in sub-Saharan Africa: a stocktaking study. Washington (DC): World Bank.

31. Gauthier B, Wane W (2008). Leakage of public resources in the health sector: an empirical investigation of Chad. J Afr Econ. 18(1):52–83.

32. Gee J, Button B (2015). The financial cost of health care fraud 2015: what data from around the world shows. London: PKF Littlejohn LLP.

33. Georgescu I, Hartmann FG (2013). Sources of financial pressure and up coding behavior in French public hospitals. Health Policy. 110(2-3):156–63.

34. Gomez EJ (2017). Democratic transitions, health institutions, and financial protection in the emerging economies: insights from Asia. Health Econ Policy Law. 12(3):309–23.

30 Potential corruption risks in health financing arrangements: report of a rapid review of the literature 35. Gupta S, Davoodi H, Tiongson E (2000). Corruption and the provision of health care and education services. IMF working paper 00/116. Washington, DC: International Monetary Fund.

36. Habibi NF, Jafari PI, Harirchi I, Arab M (2017). Reduction and elimination solutions of informal payment in Iran’s health system. Med J Islam Repub Iran. 31:139.

37. Hotchkiss DR, Hutchinson PL, Malaj A, Berruti AA (2005). Out-of-pocket payments and utilization of health care services in Albania: evidence from three districts. Health Policy. 75(1):18–39.

38. Hunter B, Murray SF (2017). Demand-side financing for maternal and newborn health: what do we know about factors that affect implementation of cash transfers and vouchers programmes? BMC Pregnancy Childbirth. 17:262.

39. Hussmann K (2011). Addressing corruption in the health sector: securing equitable access to health care for everyone. U4 issue no 1. Bergen: Anti-Corruption Resource Centre, Chr. Michelsen Institute.

40. Isaken J (2005). The budget process and corruption. U4 issue no 3. Bergen: U4 Anti-Corruption Resource Centre, Chr. Michelsen Institute.

41. Jain A, Nundy S, Abbasi K (2014). Corruption: medicine’s dirty open secret. BMJ. 348:g4184.

42. Johnson ME, Nagarur N (2016). Multistage methodology to detect health insurance claim fraud. Health Care Manag Sci. 19(3):249–60.

43. Jorgensen PD (2013). Pharmaceuticals, political money, and public policy: a theoretical and empirical agenda. J Law Med Ethics. 41(3):561–70.

44. Joudaki H, Rashidian A, Minaei-Bidgoli B, Mahmoodi M, Geraili B, Nasiri M et al. (2015). Improving fraud and abuse detection in general physician claims: a data mining study. Int J Health Policy Manag. 5(3):165–72.

45. Juwita R (2018). Good governance and anti-corruption: responsibility to protect universal health care in Indonesia. Hasanuddin Law Rev. 4(2):162–80.

46. Kankeu HT, Ventelou B (2016). Socioeconomic inequalities in informal payments for health care: an assessment of the “Robin Hood” hypothesis in 33 African countries. Soc Sci Med. 151:173–86.

47. Kesselheim AS, Brennan TA (2005). Overbilling vs. Downcoding — the battle between physicians and insurers. New Engl J Med. 352(9):855–7.

48. Killingsworth J, Hossain N, Hedrick-Wong Y, Thomas SD, Rahman A, Begum T (1999). Unofficial fees in Bangladesh: price, equity and institutional issues. Health Policy Plan. 14(2):152–63.

49. Kivumbi GW, Nangendo F, Ndyabahika BR (2004). Financial management systems under decentralization and their effect on malaria control in Uganda. Int J Health Plan Manage. 19(Suppl 1):S117–31.

50. Kohler JC, Ovtcharenko N (2013). Good governance for medicines initiatives: exploring lessons learned. U4 issue no 3. Bergen: Chr. Michelsen Institute.

51. Kotoh AM, Aryeetey GC, Van der Geest S (2018). Factors that influence enrolment and retention in Ghana’ National Health Insurance Scheme. Int J Health Policy Manage. 7(5):443 –54.

References 31 52. Kutzin J, Witter S, Jowett M, Bayarsaikhan D (2017). Developing a national health financing strategy: a reference guide. (Health Financing Guidance Series No 3). Geneva: World Health Organization.

53. Lagravinese R, Paradiso M (2014). Corruption and health expenditure in Italian regions. Economics Bulletin. 34(3):1498–511.

54. Lessig L (2013). “Institutional corruption” defined. JLME. 41(3):553–5. doi: 10,1111/jlme.12063.

55. Lewis MA (2000). Who is paying for health in Eastern Europe and Central Asia? Washington (DC): World Bank.

56. Lewis MA (2002). Informal health payments in central and eastern Europe and the Former Soviet Union: issues, trends and policy implications. In: Mossialos E, Dixon A, Figueras J, Kutzin J, editors. Funding health care: options for Europe, Buckingham: Open University Press.

57. Lewis M (2007). Informal payments and the financing of health care in developing and transition countries. Health Aff (Millwood). 26(4):984–97.

58. Lewis MA, Musgrove P (2008). Governance issues in health financing. Health Affairs. Bethesda: Elsevier Inc.

59. Lewis MA, Pettersson G (2009). Governance in health care delivery: raising performance. Policy research working paper 5074. New York: World Bank.

60. Lexchin J, Kohler JC (2011). The danger of imperfect regulation: OxyContin use in the United States and Canada. Int J Risk Saf Med. 23(4):233–40.

61. Liaropoulos L, Siskou O, Kaitelidou D, Theodorou M, Katostaras T (2008). Informal payments in public hospitals in Greece. Health Policy. 87(1):72–81.

62. Light DW, Lexchin J, Darrow JJ (2013). Institutional corruption of pharmaceuticals and the myth of safe and effective drugs. J Law Med Ethics. 41(3):590–600.

63. Lindelöw N, Ward P, et al. (2003). Primary health care in Mozambique: service delivery in a complex hierarchy. World Bank Africa Region Human Development Working Paper Series No. 69.

64. Lindelöw M, Kushnarova I, Kaiser K (2006). Measuring corruption in the health sector: what we can learn from public expenditure tracking and service delivery surveys in developing countries. In: Kotalik J, Rodrigues D, editors. Global corruption report 2006. Berlin: Transparency International.

65. Liu J, Chen T (2018). Sleeping money: investigating the huge surpluses of social health insurance in China. Int J Health Care Finance Econ. 13(3-4):319 –31.

66. Lubao M (2008). Claiming responsibility. With new revenue integrity technologies, health plans and payers are more effectively controlling costs and identifying fraud. Health Manag Technol. 29(6):16.

67. Mæstad O, Mwisongo A (2011). Informal payments and the quality of health care: mechanisms revealed by Tanzanian health workers. Health Policy. 99(2):107–15.

68. Maini R, Hotchkiss DR, Borghi J (2017). A cross-sectional study of the income sources of primary care health workers in the Democratic Republic of Congo. Hum Resource Health. 15(1):17.

69. Mann L (2013). How to reduce the risk of purchasing fraud. Health Financ Manage. 67(7):78–82.

32 Potential corruption risks in health financing arrangements: report of a rapid review of the literature 70. Marouf FE (2010). Holding the World Bank accountable for leakage of funds from Africa’s health sector. Health Hum Rights. 12(1):95–108.

71. Martinez-Vazquez J, Arze FJ, Boex J (2004). Corruption, fiscal policy, and fiscal management. Working Paper fr1003. Washington (DC): United States Agency for International Development.

72. McGee J, Sandridge L, Treadway C, Vance K, Coustasse A (2018). Strategies for fighting Medicare fraud. Health Care Manage (Frederick). 37(2):147–54.

73. McIsaac M, Kutzin J, Dale E, Soucat A (2018). Results-based financing in health: from evidence to implementation. Bull World Health Organ. 96:730–730A.

74. Michaud J, Kates J, Oum S (2015). Corruption and global health: summary of a policy roundtable. Menlo Park: Kaiser Family Foundation.

75. Miller K, Vian T (2010). Strategies for reducing informal payments. In: Vian T, Savedoff WD, Mathisen H, editors. Anticorruption in the health sector: strategies for transparency and accountability. Sterling (VA): Kumarian Press.

76. Mokhtari M, Ashtari M (2012). Reducing informal payments in the health care system: evidence from a large patient satisfaction survey. J Asian Econ. 23(2):189–200.

77. Moldovan A, Van de Walle S (2013). Gifts or bribes? Attitudes on informal payments in Romanian health care. Public Integrity. 15(4):385–402.

78. Mostert S, Njuguna F, Olbara G, Sindano S, Sitaresmi MN, Supriyadi et al. (2015). Corruption in health-care systems and its effect on cancer care in Africa. Lancet Oncol. 16(8):e394404.

79. Njog AM, Ngantcha JT (2013). Institutions and leakage of public funds in the Cameroonian health care delivery chain. Journal of African Development. 15(1):19–43.

80. Nocera A (2010). Performance-based hospital funding: a reform tool or an incentive for fraud? Med J Aust. 192(4):222–4.

81. Nwokike J, Clark A, Nguyen PP (2018). Medicines quality assurance to fight antimicrobial resistance. Bull World Health Organ. 96:135–7.

82. Okungu V, Chuma J, Mulupi S, McIntyre D (2018). Extending coverage to informal sector populations in Kenya: design preferences and implications for financing policy. BMC Health Serv Res. 18(1):13.

83. Picazo OF, Zhao F (2009). Zambia health sector public expenditure review: accounting for resources to improve effective service coverage. A World Bank country study, no. 47110. Washington (DC): World Bank.

84. Prabhakaran S, Dutta A, Saxena A, Stromberg K, Clarke D, Sharma S (2017). Do better laws and regulations promote universal health coverage? A review of the evidence. Washington DC: Health Policy Plus/USAID.

85. Praspaliauskiene R (2016). Enveloped lives: practicing health and care in Lithuania. Med Anthropol Q. 30(4):582–98.

86. Reinikka R, Svensson J (2003). Working for God? Evaluating service delivery of religious not-for-profit health care providers in Uganda. Policy research working paper 3058. Washington (DC): World Bank, Development Research Group.

References 33 87. Rispel LC, de Jager P, Fonn S (2015). Exploring corruption in the South African health sector. Health Policy Plan. 31(2):239–49.

88. Ronnerstrand B, Lapuente V (2017). Corruption and use of antibiotics in regions of Europe. Health Policy. 121(3):250–6.

89. Rose R (2006). Corruption is bad for your health: findings from Central and Eastern Europe. In: Kotalik J, Rodrigues D, editors. Global corruption report 2006. Berlin: Transparency International.

90. Rose-Ackerman S (1999). Corruption and government: causes, consequences, and reform. Cambridge: Cambridge University Press.

91. Sari N, Langenbrunner JC, Lewis MA (2000). Affording out-of-pocket payments for health services: evidence from Kazakhstan. EuroHealth 2000. 16(2):37–9.

92. Savedoff WD (2008a). Public expenditure tracking surveys: planning, implementation and uses. Portland, MA: Social Insight.

93. Savedoff WD (2008b). The impact of information and accountability on hospital procurement corruption in Argentina and Bolivia. U4 brief no. 7. Bergen: Anti-Corruption Resource Centre, Chr. Michelsen Institute.Savedoff WD, Grépin K (2012). Health sector corruption in Ethiopia. In: Plummer J, editor. Diagnosing corruption in Ethiopia: perceptions, realities, and the way forward for key sectors. Washington (DC): World Bank.

94. Segato L, Pinna A, Ceron M, Del Monte D, Sardella F, Mennini FS et al. (2013). Corruption and waste in the health system. Milan: Transparency International Italia.

95. Shahriari H, Belli P, Lewis MA (2001). Institutional issues in informal health payments in Poland: report on the qualitative part of the study. HNP thematic group discussion paper 28862. Washington (DC): World Bank.

96. Shi J, Lui R, Jiang H, Wang C, Xiao Y, Liu N et al. (2018). Moving towards a better path? A mixed-method examination of China’s reforms to remedy medical corruption from pharmaceutical firms. BMJ Open. 8(2):e018513.

97. Sparrow MK (2000). License to steal: how fraud bleeds America’s health system. Boulder (CO): Westview Press.

98. Stepurko T, Pavlova M, Gryga I, Groot W (2010). Empirical studies on informal patient payments for health care services: a systematic and critical review of research methods and instruments. BMC Health Serv Res. 10:237.

99. Stepurko T, Pavlova M, Gryga I, Gaal P, Groot W (2017). Patterns of informal patient payments in Bulgaria, Hungary and Ukraine: a comparison across countries, years, and type of services. Health Policy Plan. 32(4):453–66.

100. Stringhini S, Thomas S, Bidwell P, Mtui T, Mwisongo A (2009). Understanding informal payments in health care: motivation of health workers in Tanzania. Hum Resource Health. 7:53.

101. Sundell A (2014). Understanding informal payments in the public sector: theory and evidence from nineteenth- century Sweden. Scand Political Stud. 37(2):95–122.

102. Szebik I (2003). Masked ball: ethics, laws and financial contradictions in Hungarian health care. Sci Eng Ethics. 9(1):109–24.

103. Szende A, Culyer AJ (2006). The inequity of informal payments for health care: the case of Hungary. Health Policy. 75(3):262–71.

34 Potential corruption risks in health financing arrangements: report of a rapid review of the literature 104. Taitsmann JK. (2011). Educating physicians to prevent fraud, waste, and abuse. New Engl J Med. 364(2):102–3.

105. Tatar M, Narci HO, Sahin B, Belli P, Burman P (2007). Informal payments in the health sector: a case study from Turkey. Health Aff (Millwood). 26(4):1029–39.

106. Thompson R, Witter S (2000). Informal payments in transitional economies: implications for health sector reform. Int J Health Plan Manage. 15(3):169–87.

107. Till BM, Peters AW, Afshar S, Meara JG (2017). From blockchain technology to global health equity: can cryptocurrencies finance universal health coverage? BMJ Glob Health. 2(4):e000570.

108. Transparency Fund, NWFP Health Reform Unit and Heartfile (2007). Pakistan’s health sector: does corruption lurk? Islamabad: NWFP Health Reform Unit and Heartfile.

109. Transparency International (2006). Global corruption report 2006: special focus: corruption and health. London: Pluto Press.

110. United Nations (2015). 69/313. Addis Ababa Action Agenda of the Third International Conference on Financing for Development (Addis Ababa Action Agenda). Resolution adopted by the General Assembly on 27 July 2015 (A/RES/69/313). New York: United Nations.

111. Ungureanu M-I, Gheorghe A, Voinea SA (2017). Patients are denied care because of corruption in Romania. Lancet. 390(10108):2139.

112. Uzochukwu B, Onwujekwe E, Mbachu C, Okeke C, Molyneux S, Gilson L (2018). Accountability mechanisms for implementing a health financing option: the case of the basic health care provision fund (BHCPF) in Nigeria. Int J Equity Health. 17(1):100.

113. Vian T (2006). Anti-corruption in the health sector: preventing drug diversion through supply chain management. U4 brief no. 4. Bergen: Anti-Corruption Resource Centre, Chr. Michelsen Institute.

114. Vian T (2008). Corruption and the consequences for public health. In: International Encyclopedia of Public Health, p. 26–33.

115. Vian T, Burak LJ (2006). Beliefs about informal payments in Albania. Health Policy Plan. 21(5):392–401.

116. Vian T, Collins D (2006). Using financial performance indicators to promote transparency and accountability in health systems. U4 brief no. 1. Bergen: Anti-Corruption Resource Centre, Chr. Michelson Institute.

117. Vian T, Savedoff WD, Mathisen H, editors. (2010). Anticorruption in the health sector: strategies for transparency and accountability. Sterling (VA): Kumarian Press.

118. Vian T, Feeley F, Domente S, Negruta A, Matei A, Habicht J (2015). Barriers to universal health coverage in Republic of Moldova: a policy analysis of formal and informal out-of-pocket payments. BMC Health Serv Res. 15:319.

119. Ware JT, Moss S, Campos JE, Noone GP (2007). Corruption in public procurement: a perennial challenge. In: Campos JE, Pradhan S, editors. The many faces of corruption: tracking vulnerabilities at the sector level. Washington (DC): World Bank.

120. WHO (2010). The world health report: health systems financing: the path to universal coverage. Geneva: World Health Organization.

References 35 121. Witter S, Thi Thu Ha B, Shengalia B, Bijicic M (2011). Understanding the ‘four directions of travel’: qualitative research into the factors affecting recruitment and retention of doctors in rural Vietnam. Hum Resource Health. 9:20.

122. Witter S, Fretheim A, Kessy FL, Lindahl AK (2012). Paying for performance to improve the delivery of health interventions in low- and middle-income countries. Cochrane Database Syst Rev. Issue 2:C007899.

123. Ye X, Canagarajah S (2002). Efficiency of public expenditure distribution and beyond: a report on Ghana’s 2000 public expenditure tracking survey in the sectors of primary health and education. Africa Region Working Paper Series, No. 31. Washington (DC): World Bank.

124. Zasimova L (2016). The use of medical care and out-of-pocket payments in Russia. Scand J Public Health. 44(5):440–5.

36 Potential corruption risks in health financing arrangements: report of a rapid review of the literature

ISBN 978-92-4-000439-9