GC2006 00 Part1 2 3
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The prescription drug beneft, known as Medicare Part D, comes into full effect in January
2006 under the Medicare Prescription Drug Improvement and Modernization Act of 2003.
8ox 1.Z 6orrupIIon In 6ambodIas haaIIh saoIor
1
Cambodias health record is amongst the worst in Asia. The maternal mortality rate is the
highest in the region, with 437 deaths per 100,000 live births. Skilled personnel attend
less than a third of all births.
2
Almost one in every ten babies does not live to his/her frst
birthday and more than 60,000 babies die every year of malnutrition or diseases that
4
GC2006 01 part1 22 8/11/05 17:54:52
Tha oausas oI oorrupIIon In Iha haaIIh saoIor Z8
can be prevented or cured.
3
Malaria remains a serious problem, and known cases of
tuberculosis have increased from approximately 61,000 in 1999 to 108,000 in 2004.
4
Such a poor state of health exists despite money pouring into Cambodias health sector
over the past decade to reconstruct a health system that was systematically decimated
under the Khmer Rouge regime (197578) and underfunded in subsequent years.
Overseas development aid (ODA) funded a lot of the reconstruction and continues to be
an important source of fnance for the government. In 2002 the US $490 million ODA
Cambodia received accounted for just over 12 per cent of the GDP, some 20 per cent of
which was spent on health.
However, government and ODA spending on health are dwarfed by the sums spent
privately. Of the 177 countries assessed in the Human Development Report, Cambodia
has the highest private health expenditure as a percentage of the GDP. Out-of-pocket
spending on health care in Cambodias private clinics or as informal payments for public
health services accounts for 10 per cent of the countrys GDP.
5
Corruption is one reason why public investment in health, coupled with high rates
of private spending, has not translated into good health outcomes. Anecdotal evidence
suggests that corruption takes place at every level of the health system in Cambodia,
but there has typically been a reluctance to speak about it. Researchers, health workers
and administrators interviewed in July 2005 said it was widely assumed that between
5 and 10 per cent of the health budget disappears before it is paid out by the Ministry
of Finance to the Ministry of Health.
6
More money is then siphoned off as funds are
channelled down from the national government to the provincial governors and to the
directors of operational districts, and then to directors or managers of local hospitals
and clinics.
Reports commissioned by the World Bank and USAID indicate that corruption is common
in public procurement and contracting processes, public fund management activities at
central and district government levels and in health service delivery schemes. It is common
for companies to pay bribes for public contracts.
7
Several experts interviewed alleged that
health ministry offcials and hospital administrators infate the cost of medical equipment
in collusion with private suppliers and share the non-reported difference, which can be
as much as fve times the true cost.
Another source of concern is that public health services are underutilised due to their
poor quality and inaccessibility. With the increase in land prices in Phnom Penh and Siem
Reap, this problem threatens to escalate under the governments reported plans to remove
hospitals from city centres to outskirts where land is cheaper, but where the hospitals will
be less accessible. In Siem Reap, for example, a hospital is in danger of being destroyed
to free up prime real estate close to a popular tourist attraction. The government claims
that the land is valued at US $4 million. Health programme managers from the private
and public health system claim the land is worth many times more than the cost of
rebuilding the hospital.
The potential for proft-making through schemes such as this can be the very motivation
for entering the health sector. In Cambodia it is considered common practice to pay
large sums of money to secure positions as public offcials in government: the higher the
position, the higher the price.
8
Health workers interviewed reported a going rate of up
to US $100,000 for a post as director at the provincial or national offces of the health
ministry. A job as a low-level public servant in the health sector may go for US $3,000.
These sums represent a large investment considering that government employee salaries
are generally very low: on average US $40 per month.
4
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6orrupIIon and haaIIh Z4
Corruption also takes place at the point of health service delivery, where underpaid
health workers request informal payments above the normal cost service, or siphon off
public funds from available cash budgets. Informal payments to doctors or nurses in
order to receive better and more expedient treatment are common, and the low salary
paid to health workers is an important area to reform. In 2001, Mdecins Sans Frontires
worked with the Ministry of Health and UNICEF on a project in Sotnikum district, Siem
Reap province, that topped up salaries for health workers based on performance and
commitment to ethical practice.
It also tried to initiate an Equity Fund to assist the poor
in paying for medical costs and services. These two strategies have been successful and
continue in many donor-funded health care projects in Cambodia, though coverage is
patchy.
Other important reforms include increasing transparency in procurement, improving
links between health policies and budgets, and conducting research to help understand
the mechanisms of corruption in the sector. A planned public expenditure tracking survey,
initiated by the World Bank for the health sector to identify bottlenecks and leaks in public
fnances at national and local levels, is an important step towards plugging the information
gap surrounding Cambodias health sector.
Urgent attention also needs to be paid to law enforcement. An extremely weak judiciary,
coupled with inadequate laws that are very slowly being reformed, mean that impunity
is the norm for cases of corruption. There are 100 prosecutors, 250 private attorneys and
100 judges operating in the country most of the latter self-selected, having bought their
positions.
9
Some progress has been made in training judges and a number of NGOs are
developing basic legal services for the weak and poor, but to all intents and purposes
there is no redress for those who have suffered from the effects of corruption at the hand
of health authorities or staff.
Lisa Prevenslik-Takeda
10
Notes
1. The article is based on feldwork and author interviews conducted from May to July 2005.
2. Royal Government of Cambodia, Cambodia Millennium Development Goals Report 2003.
3. UNDP, Human Development Report 2003 (Geneva: UNDP, 2003); UNICEF, Childhood Under Threat:
The State of the Worlds Children 2005 (New York: UNICEF, 2005).
4. WHO Report, Global Tuberculosis Control (Geneva: WHO, 2005). The actual fgures are probably
much higher since normal tuberculosis testing in medical centres throughout the country is
done by sputum tests which detect only 75 per cent of pulmonary tuberculosis infections.
5. Although the constitution enshrines the right to free medical care to all Cambodian citizens, a
recent government policy requires all Cambodians to pay 2,0003,000 riel (US $0.75) to access
health care in public health facilities. This entitles the patient to be examined by a doctor, though
additional costs for medicine and other medical supplies must be borne by the patient.
6. Author interviews, Phnom Penh, Cambodia, July 2005.
7. Michael Calavan, Sergio Diaz Briqvets and Jerald OBrien, Cambodian Corruption Assessment,
report prepared for the World Bank, USA/Cambodia, August 2004; Jean-Franois Bayart,
Thermidor au Cambodge, Alternatives Economiques, March 2005; Peter Leuprecht, Special
Representative of the UN Secretary-General for Human Rights in Cambodia, Rethinking Poverty
Reduction to Protect and Promote the Rights of Indigenous Minorities in Cambodia, NGO Forum
on Cambodia, April 2005.
8. See, for example, Calavan et al., Cambodian Corruption Assessment.
9. Ibid.
10. Lisa Prevenslik-Takeda is a project coordinator in Transparency Internationals Asia-Pacifc
department.
GC2006 01 part1 24 8/11/05 17:54:52
Tha soaIa oI Iha probIam Z6
Z Tha soaIa oI Iha probIam
Women lie in bed at the Sisters Missionary of Charity Hospital in Port-au-Prince, Haiti, 22
March 2005. (Shaul Schwarz/Getty Images)
While it is impossible to determine the overall costs of corruption in the health sector
worldwide, it is evident that it amounts to tens of billions of dollars. Indeed one US
estimate of annual earnings from the sale of counterfeit drugs alone puts the annual
cost at more than US $30 billion, which is just the tip of the iceberg of health care
corruption.
In this chapter, the World Banks efforts to track expenditure in health give an
indication of costs by tracking how much money dispersed by higher levels of
government fails to reach its intended recipients. New data from Central and Eastern
Europe fnds a strong correlation between perceptions of corruption and an individuals
health. A study in the Philippines highlights how local-level corruption undermines
health service delivery. The case study on Costa Rica looks higher up in the chain of
responsibility for health budgets, and follows the money trail in one of the countrys
GC2006 01 part1 25 8/11/05 17:54:53
6orrupIIon and haaIIh Z6
biggest ever corruption scandals. An example from Mexico shows that corruption can
affect not only the volume of resources for health care, but also health policy. The UKs
National Health Service claims high returns on its investment in anti-corruption and
counter-fraud mechanisms.
The real costs, however, cannot be measured in dollar terms alone. The impact of
corruption must also be measured in terms of those people who suffer because they cannot
afford brown envelope payments to health care workers (see Chapter 4) and those who
are forced to pay far more than they should for hospital services and pharmaceuticals
due to rampant corruption (see Chapters 3 and 5). Corruption has a direct negative
impact on access and quality of patient care and is one reason why, so often, increased
spending on health does not correlate with improved health outcomes.
6asa sIudy. rand oorrupIIon In 6osIa Ioa
Emilia Gonzlez (TI Costa Rica)
Costa Rica has one of the best funded health systems in Latin America. Established in
1941, the Caja Costarricense de Seguro Social (CCSS) has been responsible for providing
universal health care coverage since 1961. The health care network comprises fve health
regions, each with hospitals, clinics, health centres and mobile health units. Costa Ricas
health indicators are comparable to those of developed countries and better than any
Latin American country with the exception of Cuba. Workers pay 5.5 per cent of their
salary in health insurance and employers contribute a further 9.25 per cent.
Given the high cost and the high regard in which the CCSS is held, its fall from
grace was therefore steep when reports of maladministration and corruption started
to seep into the public domain in 2001. Two congressional party commissions were
tasked with looking into the matter. Allegations involved corruption at many different
levels, most commonly in the purchase of medical services, often at infated prices; the
procurement of medicines and equipment; the provision of private training courses
and medical research; the construction of hospitals; and the management of the CCSS
pensions system.
The climax of the scandals came in October 2004 when the public prosecutor accused
CCSS head Eliseo Vargas, members of the board of directors, several CCSS managers
and former president Rafael Angel Caldern of corruption in the running of the agency.
They had allegedly skimmed millions off a US $39 million Finnish government loan
(see Finland country report, page 156).
The loan to modernise hospitals was conditional on Costa Rica using at least half of it
to buy Finnish products. The contract was won by Finnish consortium Instrumentarium
Corporation Medko Medical and a commission of US $8.8 million (20 per cent of
the value of the loan) was paid to Corporacin Fischel, the consortiums Costa Rican
representative. It was this commission that found its way into the bank accounts of
CCSS directors and senior government offcials. The CCSS spent the loan plus an extra
US $7.5 million of its own funds on equipment that was not needed.
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Tha soaIa oI Iha probIam Z7
The money trail was uncovered in October 2003 by journalists who found that the
head of CCSS, Eliseo Vargas, was living in a house worth US $750,000, which had been
paid for by Corporacin Fischel (see Global Corruption Report 2005).
1
Suspecting that
the house was payment for a favour, the reporters looked for a possible motive. They
found that two years earlier, as head of the ruling party faction in congress, Vargas had
pushed through approval of the tied loan from Finland. Vargas now argues that he was
assisted and encouraged to do so by then president Caldern. The journalists later
uncovered a series of bank accounts in Panama, Costa Rica, the United States and the
Bahamas through which commissions had been paid to politicians and CCSS offcials.
Vargas and the fnancial director of Fischel resigned when the news hit the headlines
in April 2004.
The Finnish loan was not the frst to be called into question. In 1997, a US $40
million loan by the Spanish government and Banco Bilbao Vizcaya, also to modernise
hospitals, was spent on equipment, much of which has never been used. A group
of notable experts named by the government to look into the functioning of CCSS
requested that the authorities responsible for executing the loan be investigated for
paying above-market rates for the equipment and for failing to prepare the hospitals
for the equipment to be installed.
Incidents of opaque procurement processes at CCSS are unfortunately not restricted
to the use of the two loans. Complaints of systematic corruption have been made in a
series of reports and statements by a special legislative commission, the ombudsman,
a group of notable experts and users of the health system. CCSS internal audit reports
also point to irregularities.
A majority party congressional investigation report published in April 2001 provided
evidence of disorganised purchasing the results of a decentralisation strategy that
was supposed to make procurement processes more effcient.
2
The result was a chaotic
network of channels through which millions of colones fowed, swelling the accounts of
private pharmaceutical companies at the cost of the CCSS, and ultimately the taxpayer.
In addition to the monetary costs involved, there were also the associated health costs
resulting from delays in getting medicine to the sick and the use of poorer-quality
medicines
The various reports into the CCSS note that a common practice at some hospitals
was to purchase excessive quantities of medicines not included on the offcial list of
medicines (defned by the WHO as those necessary to counter the principal causes of
morbidity). These were purchased under a budget line reserved for medicines needed
for uncommon illnesses or exceptional cases, which are not subject to the usual CCSS
controls. Another concern is the readiness with which some CCSS doctors accepted
trips paid for by pharmaceutical companies. This was the subject of a Supreme Court
ruling in January 2004 stating that acceptance of gifts from providers could lead to
a loss of confdence in the doctor and therefore could be cited as grounds for lawful
dismissal.
3
Many examples of overpayment for medical services contracted out to private service
providers emerged from the investigations. It is diffcult, however, to distinguish between
poor management and corruption, where doctors often with one foot in the public
GC2006 01 part1 27 8/11/05 17:54:54
6orrupIIon and haaIIh ZB
system and the other in private practice might have unnecessarily contracted out
expensive treatments. For example, the CCSS paid a private foundation close to US $1
million in 2000 for 9,600 minor surgical procedures, 37,000 eye and nose consultations
and 322 vitrectomies at a cost per intervention of between 40 per cent and 140 per
cent above the cost of CCSS providing the treatment at one of its own clinics. A special
congressional commission published a report in May 2001 into the procurement of
private medical services and the misuse of CCSS resources through offering excessively
cheap teaching facilities to private university students.
4
The CCSS response to these multiple accusations of maladministration and corruption
has been to hire consultants and researchers to come up with new strategic plans and
new mission and values statements. Complaints mechanisms have been introduced,
and the client has been placed at the forefront of the institutions plans.
But the correctives do not go to the root of the problem. With the exception of the
investigation into misuse of the Finnish loan, senior CCSS staff have not been asked
to take responsibility for wrongdoing. Few are named in the numerous reports and
documents written on the cases, and no administrative, criminal or civil action has
been taken to sanction those responsible.
Close ties between the board and directors of the CCSS many party members hold
board-level positions at the CCSS may have stood in the way of judicial and audit
bodies, contributing to a situation where the CCSS functions with virtual impunity,
unaccountable to users. There are indications that the close relationship between
political parties and the CCSS may have led to conficts of interest that infuenced
decision-making. The 1999 budget shows, for example, that more than US $160 million
of CCSS funds was invested in state bonds at a time of dire need for investment to
improve health care facilities.
Scandals have erupted before without responsibility being assigned to the offcials
involved, while civil society watched on impassively. This time, public pressure and
media attention is not abating. There is hope that high- and middle-ranking CCSS
staff will be held to account and deep reforms will be made to the management,
organisation and structure of CCSS, including the introduction of greater accountability
and transparency mechanisms to reduce future opportunities for corruption.
hoIas
1. The team of investigative journalists from La Nacin (Costa Rica) were awarded Transparency
Internationals Journalism for Transparency prize in 2005.
2. Costa Rican Legislative Assembly, Informe de Mayora: Comisin Especial que proceda a
analizar la calidad de los servicios, compra de servicios privados, utilizacin de los recursos de
la CCSS para la enseanza universitaria privada, medicamentos y pensiones (Majority Report:
Special Commission to proceed to analyse the services, purchase of private services, use of
CCSS resources for private university teaching, medicines and pensions), File number 13-980,
San Jos, Costa Rica, 26 April 2001.
3. Ruling by the second tribunal of the Supreme Court, Exp: 95-000493-02-LA Res: 2004-
00212.
4. A second congressional report co-sponsored by current president Abel Pacheco, a congressman
at the time, presented a contrasting view of the CCSS, concluding that: There is no legal,
GC2006 01 part1 28 8/11/05 17:54:54
Tha soaIa oI Iha probIam Z9
technical, scientifc nor strategic reason whatsoever for us to have reservations about the
contracting modalities used by CCSS since the end of the 1990s. See Costa Rican Legislative
Assembly, Informe de Mayora: Comisin Especial que proceda a analizar la calidad de los
servicios, compra de servicios privados, utilizacin de los recursos de la CCSS para la enseanza
universitaria privada, medicamentos y pensiones.
MaasurIng oorrupIIon In Iha haaIIh saoIor. WhaI Wa oan Iaarn
Irom pubIIo axpandIIura IraokIng and sarvIoa daIIvary survays
In davaIopIng oounIrIas
Magnus Lindelow, Inna Kushnarova and Kai Kaiser
1
Most government offcials and development practitioners acknowledge that high
levels of health spending do not necessarily translate into improved health status. This
observation is also borne out by empirical evidence studies have found that once other
factors are controlled for, increased government spending on health is not associated
with a reduction in child mortality in cross-country data, at least not in contexts with
weak governance.
2
In part, the challenge in transforming resources into improved
health outcomes is technical in nature; it concerns the allocation of resources across
interventions and programmes, as well as the technical skills of providers responsible for
delivering the interventions. The focus of this chapter, however, is on how corruption
defned here as the abuse of public offce for private gain can drive a wedge
between what is put into the health system, on the one hand, and what it delivers,
on the other.
Some of the evidence on the nature and consequences of corruption in the sector
comes from perception-based surveys.
3
While these surveys have generated useful
insights, the data suffer from many of the same weaknesses that plague perception-
based measures of corruption in general. An alternative approach is to try to develop
more direct measures of fscal leakages, including corruption. This has been the aim of a
number of recent Public Expenditure Tracking Surveys (PETS), which aim to answer the
question: Does public money spent on health and education actually reach frontline
health facilities and schools? They seek to achieve this by tracking the fow of public
resources through various layers of the administrative hierarchy to individual service
providers, and by developing quantitative estimates of fscal leakage that is, the failure
of resources intended for frontline service provider (clinics and hospitals) facilities to
reach their intended destination.
The World Bank and other organisations have conducted PETS, almost exclusively
in the social sectors, in over two dozen countries, beginning with Ugandas education
sector in 1995 where it was found that 77 per cent of non-wage funds failed to reach
schools. This chapter reviews what has been learnt from tracking surveys in the
health sector so far. It shows that while many PETS have generated valuable insights,
practical and methodological challenges have often made it diffcult to develop frm
and comprehensive estimates of leakage.
GC2006 01 part1 29 8/11/05 17:54:54
6orrupIIon and haaIIh 80
Moreover, once an estimate of leakage has been arrived at, there are challenges
interpreting the data, specifcally in how to establish the relationship between leakage
and corruption. There are two main reasons for this diffculty. First, it is possible that
resources were legitimately diverted from their intended purpose towards other ends.
All budget systems allow for some fexibility in the resource allocation process: budgets
can be changed, allocation rules can be modifed or ignored, and so on. This provides
government with the fexibility to adjust plans in response to unexpected events and
needs, and means that discrepancies between expenditure outcomes and original
allocations (leakage) may be both legitimate and desirable.
Second, facilities or lower levels of government may receive less than intended due
to problems in the budget execution or resource distribution process. For example,
capacity weaknesses and red tape can result in low levels of budget execution, and
a broken down vehicle can disrupt the distribution of drugs. A discrepancy between
expenditure allocation and outturn may hence be the consequence of delays in the
disbursement or distribution of funds rather than evidence of corrupt acts.
With these caveats in mind, what have tracking surveys revealed about leakage in the
health sector? As can be seen from the summary in Table 2.1, the focus of the surveys
has varied across countries. Some surveys such as those in Ghana, Tanzania and Rwanda
have generated leakage estimates for overall expenditures. For example, the Ghana
PETS found that 80 per cent of non-salary funds did not reach health facilities, with
most of the leakage arising between central government and the district. Considering
that approximately 65 per cent of total health spending (total spending estimated to be
about US $2.24 per capita in 1998) is non-salary recurrent, and assuming that the total
of the 35 per cent salary expenditures reached the health facilities, approximately half
of the overall amount allocated to clinics and hospitals did not actually reach them.
Similar problems were found in Tanzania and Rwanda.
Tracking overall expenditures is often diffcult, however. Health facilities typically
do not receive a single monthly budget allocation that they proceed to spend and
account for. Rather, they receive resources through multiple channels and sources.
4
The upshot of these institutional arrangements is a myriad of complex resource fows,
each governed by separate administrative and recording procedures. In each case,
there are risks of leakage. Expenditures on drugs and other supplies can leak through
the procurement process, or through supplies being stolen, lost or disposed of (such
as expired drugs or vaccines) as part of the distribution process. Administrative and
logistical procedures tend to be different for other non-salary expenditures, but similar
issues arise. Salary budgets can be siphoned off at different levels of government either
by simply withholding salary payments, by creating fctitious health workers (ghosts)
and collecting the salaries on their behalf, or by paid staff simply not showing up
for work.
Given this complexity, tracking surveys have often been forced to be selective about
what resources to track. For example, the survey in Honduras collected individual-level
data on 14,454 health professionals, and found that 9.3 per cent did not actually work
in the location where they were offcially assigned. About a quarter of these individuals
GC2006 01 part1 30 8/11/05 17:54:54
Tha soaIa oI Iha probIam 81
Table 2.1: Overview of fndings from Public Expenditure Tracking Surveys in the health
sector
Country Year Sample Leakage Other fndings
Ghana
a
2000 200 facilities;
40 districts
Leakage of non-salary
recurrent expenditures
is estimated at 80%.
Found greater leakage between
centre and district than
between district and facility.
Service users bear much
higher cost than intended
primarily due to the non-salary
expenditure leakage.
Honduras
b
2000 805 staff;
35 facilities
2.4% of all workers on
the payroll at health
facilities considered
ghosts.
Absenteeism estimated at
27%. In addition, study found
that 5.2% of workers were not
actually in the assigned post but
had moved to other locations.
Mozambique
c
2002 90 facilities;
167 staff;
679 users
Some evidence of
leakage of drugs in
transfer from provinces
to districts, within the
primary health care
system, but no frm
estimate.
Documented delays and
bottlenecks in budget execution
and supply management;
inequalities in allocation of
resources across districts and
facilities; incomplete registering
of user-fee revenues by facilities
(reported revenue as per cent
of expected revenue was 67.6%
for consultations and 79.6%
for medicines); absenteeism
estimated at 19%.
Nigeria
d
2002 252 facilities;
30 loc. gov.;
700 staff
No frm estimate of
leakage (focus was
on governance issues
in health sector, in
particular on fow of
resources, provider
behaviour and
incentives, and the role
of local governments
and community
participation).
42% of staff experience salary
delays despite suffcient
budget; detailed description of
governance and service delivery
arrangements, including facility
characteristics; evidence of
delays in salary payments.
Papua New
Guinea
e
2002 117 facilities No frm estimate of
leakage (main focus on
the education sector,
but some data on
health facilities were
collected).
Evidence of poor access to
care and limited availability of
drugs; absenteeism estimated
at 19%.
GC2006 01 part1 31 8/11/05 17:54:54
6orrupIIon and haaIIh 8Z
Country Year Sample Leakage Other fndings
Peru
f
2001 120 munici-
palities
Leakage in Glass of
Milk food supplemen-
tation programme esti-
mated at 71% (includes
leakage of benefts at
household level).
Quantifed leakage at different
levels of government (greater at
the higher levels); evidence that
poorer municipalities affected
the most; diversion of funds to
cover operational costs.
Rwanda
g
2000 351 facilities;
40 districts
Some evidence of
leakage between
regions and districts,
but no frm estimate.
Evidence of delays in budget ex-
ecution and low execution rates
(80% of non-wage funds released
at year end); user-fee revenues
and drug sales shown to be prin-
cipal sources of funding.
Senegal
h
2002 100 facilities;
10 districts;
37 loc. gov.
Some evidence of
leakage at regional and
communal level in
allocation of non-salary
resources from the
central level to service
providers through the
decentralisation fund
but no frm estimate.
Delays in the decentralisation
fund transfers; evidence on
extent of discretion by local
governments in allocation of
resources.
Tanzania
i
1999 36 facilities;
3 districts
Leakage of non-salary
funds estimated at 41%
(budget and accounting
mechanisms were
studied for health and
education at district
and facility level).
Donor contributions shown
to favour better-off districts;
leakage attributed to poor
record-keeping and lack of
audits.
Tanzania
j
2001 20 facilities;
5 districts
No frm estimate of
leakage in primary
education and health
facilities studied.
Substantial delays at all levels,
especially non-wage
expenditures; lack of supplies in
facilities; some evidence of
underreporting of facility
revenues.
Uganda
k
1996 100 facilities;
19 districts
No frm evidence of
leakage in fow of
resources to primary
health care providers
but heavy reliance
on in-kind fows and
poor record-keeping
hampered data
collection. Qualitative
evidence suggests that
leakage is limited.
Qualitative evidence suggested
that main leakage takes place
at facility level, rather than in
transfer of resources to facilities.
Table 2.1: continued
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Tha soaIa oI Iha probIam 88
were ghost employees, while the remainder were retired or had been transferred
without records being updated. The survey also found evidence of dual job-holdings,
absenteeism and other human resource management problems.
While most health PETS have managed to generate leakage estimates for overall or
specifc resource fows to health care providers, the reliability of fndings has often
been undermined by the quality of administrative records (budgets, expenditure
accounts, receipts, drug records, payrolls, and so on). These records are often poorly
kept, refecting a lack of capacity, weak procedures and possibly efforts by staff to play
the system. As a result, survey enumerators have to contend with records that are both
incomplete and riddled with errors. In Mozambique, provincial health departments
Uganda
l
2000 155 facilities Leakage of specifc
drugs and supplies
estimated at 70% in
government, private
non-proft facilities
studies.
Detailed descriptive data on
facility characteristics and
performance; overview of
accountability arrangements;
comparison of government and
non-government providers.
hoIas
a Xiao Ye and Sudharshan Canagarajah, Effciency of Public Expenditure Distribution and Beyond:
A Report on Ghanas 2000 PETS in the Sectors of Primary Health and Education, World Bank
Africa Region Working Paper Series No. 31, 2002.
b World Bank, Honduras: Public Expenditure Management for Poverty Reduction and Fiscal
Sustainability, Report No. 22070, World Bank Poverty Reduction and Economic Sector Management
Unit, Latin America and the Caribbean Region, 2001.
c Magnus Lindelow, Patrick Ward et al., Primary Health Care in Mozambique: Service Delivery in
a Complex Hierarchy, World Bank Africa Region Human Development Working Paper Series No.
69, 2003.
d Monica Das Gupta, Varun Gauri et al., Decentralized Delivery of Primary Health Services in
Nigeria: Survey Evidence from the States of Lagos and Kogi, World Bank Africa Region Human
Development Working Paper 70, 2004.
e World Bank, Papua New Guinea: Public Expenditure and Service Delivery, unpublished manuscript,
2004.
f World Bank and Inter-American Development Bank, Peru: Restoring Fiscal Discipline for Poverty
Reduction: Public Expenditure Review, Report No. 24286-PE, 2002.
g Hippolyte Fofack, Robert Ngong et al., Public Expenditure Performance in Rwanda: Evidence from
a Public Expenditure Tracking Study in the Health and Education Sectors, Africa Region Working
Paper Series No. 45, 2003.
h World Bank, Expenditure Tracking Survey in Senegal: The Health Sector, unpublished manuscript,
2003.
i PricewaterhouseCoopers, Tanzania Public Expenditure Review: Health and Educational Financial
Tracking Study, Final Report, vols III (Dar es Salaam, 1999).
j Research on Poverty Alleviation and Economic and Social Research Foundation, Pro-poor
Expenditure Tracking, unpublished manuscript, 2001.
k Emmanuel Ablo and Ritva Reinikka, Do Budgets Really Matter? Evidence from Public Spending
on Education and Health in Uganda, Policy Research Working Paper 1926, World Bank, 1998.
l Magnus Lindelow, Ritva Reinikka et al., Health Care on the Frontline: Survey Evidence on Public
and Private Providers in Uganda, World Bank Africa Region Human Development Working Paper
38, 2003.
GC2006 01 part1 33 8/11/05 17:54:55
6orrupIIon and haaIIh 84
could provide complete district-level data for only 40 per cent of their districts. Similarly,
complete records were found in less than half of the district health offces surveyed in
Ghana, and although the data collected in Rwanda were consistent with high levels of
leakage there were substantial discrepancies between funds recorded as dispersed by
higher levels of government and the funds recorded as received by lower levels these
discrepancies may in part be due to poor book-keeping, and no frm leakage estimate
could be developed.
8ayond Iaakaga. InsIghIs InIo pubIIo axpandIIura managamanI
Where, due to the paucity of administrative records or the absence of clear allocation
rules, it has not been possible to reach frm conclusions concerning leakage, valuable
insights may still be gleaned from PETS. An important contribution has been to provide
hard evidence on the extent and source of delays and bottlenecks in budget execution
and supply management systems. For example, the Nigeria study found that although
funds had been released to local government, 42 per cent of the facility workers had
not received their salaries for more than six months in the year prior to the survey.
Similarly, in the Mozambique survey, 30 per cent of staff said that salaries are always
or almost always late, and 15 per cent of staff reported that salaries are sometimes not
paid in full. Whatever the source of the problem, delays in payments are likely to have
adverse consequences for staff morale, and may contribute to problems of absenteeism,
informal charging and other problems.
Problems of the same nature have been documented in the case of non-salary budgets,
and in the distribution of drugs and other essential supplies. The Senegal PETS found
that it takes an average of 10 months for the resources from the Decentralisation Fund
the main source of government fnancing for health facilities to actually reach the
providers. In Mozambique, nearly 30 per cent of district health offces received their frst
budget transfer of the year more than three and a half months late. Delays in budget
transfers often conspire with other factors to result in low levels of budget execution.
For example, in Mozambique, districts executed an average of only 80 per cent of their
budgets, and in some districts execution rates were as low as 35 per cent.
More generally, tracking surveys have contributed to a better understanding of the
public expenditure management process, allocation rules, fnancial management and
accounting practices, and accountability arrangements; in particular, at lower levels
of government where routine monitoring and reporting systems tend to be weak. For
example, the Ghana, Mozambique and Rwanda PETS found evidence that existing
user fee rules and regulations are not followed: patients are charged more than they
should be, exemptions are not granted, revenues are not used as intended, and so on.
In part, these problems probably refect the problems in the budget and supply systems,
that is, user fees become a lifeline for facilities that do not receive adequate funds and
resources from government but opportunistic overcharging by health workers may
also be a factor.
GC2006 01 part1 34 8/11/05 17:54:55
Tha soaIa oI Iha probIam 86
Tha oonsaquanoas oI Iaakaga and oIhar pubIIo axpandIIura managamanI
probIams
Do problems of leakage, delays and reallocation of resources matter? Many surveys
have focused on primary health care services, which often account for a relatively small
share of health spending. However, even though dollar values may be small, leakage
of resources or delays in budget transfers or drug supplies may seriously undermine
the capacity of facilities to deliver services. The costs in terms of poor health, suffering
and loss of life may be considerable.
In Ghana, most clinics received fewer resources than intended some received no
cash at all and had to rely on internally generated funds for their operations. As
a result, users were forced to bear higher costs than intended, in part through high
charges for drugs. The Nigeria survey found that most facilities were missing essential
equipment, medications, vaccines and supplies: 95 per cent did not have microscopes,
59 per cent did not have sterile gloves, 98 per cent did not have a malaria smear, and 95
per cent did not have urine test strips. In Mozambique, over 60 per cent of facilities had
been out of stock of one or more essential medicines during the six months preceding
the survey, with an average stock-out time of six weeks. The Uganda survey (2000)
also found evidence of stock-outs of vaccines and drugs, combined with overuse of
antibiotics and other drugs. These problems may have multiple causes, but are clearly
a cause for concern.
Tracking surveys thus can help diagnose leakages, delays and other budget execution
problems that can seriously undermine service delivery and contribute to an improved
understanding of how resources are allocated and used at lower levels of government
issues that often fall outside the purview of routine reporting systems. But PETS also
have important limitations. For one thing, most tracking surveys have mainly been
implemented in integrated health systems, where public resources are channelled to
public providers, and have proven most effective in contexts with clearly identifable
service providers and explicit resource allocation rules. Tracking surveys may be less
useful in other contexts, such as where third-party payers (insurers) play an important
role, or where private provision and contracting is more widespread. Even within public
integrated systems, different tools are needed to diagnose some forms of corruption. This
raises questions about how PETS relate to other integrity and accountability tools.
5
It
is clear that effective efforts to diagnose and combat corruption will depend on a wide
range of internal mechanisms (such as clear rules and procedures, effective accounting
and record keeping, internal and external audits) and external ones (transparency,
mechanisms for client voice, and so on). PETS may have an important role to play,
but this role needs to be determined with an eye on their cost, and with a view to
complement rather than replace other parts of the public fnancial management
system.
Ultimately, however, successfully channelling resources to providers is only half
the battle. Once there, resources must be used effciently and as intended in order to
have an impact. Tracking surveys have increasingly sought to provide evidence on
facility performance, but detailed studies including facility surveys, case studies and
GC2006 01 part1 35 8/11/05 17:54:55
6orrupIIon and haaIIh 86
qualitative work of absenteeism, informal charging and pilfering of drugs and other
supplies also have an important role to play.
For example, a recent multi-country study based on multiple, unannounced facility
visits reports absenteeism rates ranging from 23 per cent to 40 per cent in the health
sector, and fnds absenteeism to be related to both the location and the characteristic
of the health facility.
6
Evidence from provider and household surveys have shown
that informal or unoffcial charges add an unintended fnancial burden on patients
in many countries.
7
Finally, there have been attempts to collect facility-level data on
theft of drugs and other supplies by health workers through small-scale surveys or
case studies.
8
Such studies have revealed serious service delivery problems in many
countries, and highlighted the importance not only of getting resources to facilities,
but also of ensuring that health workers are provided with incentives and opportunities
to perform. But the studies have also helped counter the image of health workers and
government administrators as inherently corrupt agents an unfortunate by-product
of single-minded efforts to diagnose corruption in service delivery. Detailed case studies
and qualitative work has shown that the majority of health workers are dedicated
professionals trying to cope in diffcult and frustrating environments with low pay,
poor management and support systems, and weak accountability mechanisms.
9
This
is an important perspective to keep in mind in any efforts to strengthen the tools for
diagnosing corruption in the health sector.
hoIas
1. Magnus Lindelow is an economist at the World Bank in East Asia Pacifc Human Development,
Inna Kushnarova is a consultant with the World Bank, and Kai Kaiser is an economist with
the World Banks Public Sector Group in Poverty Reduction and Economic Management.
2. Deon Filmer and Lant Pritchett, Child Mortality and Public Spending on Health: How Much
Does Money Matter?, Policy Research Working Papers, World Bank, 1997; Vinaya Swaroop
and Andrew Sunil Rajkumar Swaroop, Public Spending and Outcomes: Does Governance
Matter?, World Bank, Policy Research Working Paper Series, 2002. For a general discussion of
the weak links in the chain between public expenditure and outcomes in health and other
public services, see World Development Report 2004: Making Service Work for Poor People (Oxford:
Oxford University Press and World Bank, 2003).
3. See, for example, Anne Cockcroft, Lorenzo Monasta et al., Bangladesh Baseline Service Delivery
Survey: Final Report, CIET International, 1999, and Filipino Report Card on Pro-Poor Services,
World Bank Environment and Social Development Sector Unit East Asia and Pacifc Region,
May 2001. Evidence of corruption from perception-based service delivery surveys has been
linked to child and infant mortality by Sanjeev Gupta, Hamid R. Davoodi and Erwin R.
Tiongson, Corruption and the Provision of Health Care and Education Services in George
T. Abed and Sanjeev Gupta, Governance, Corruption, and Economic Performance (Washington,
DC: IMF, 2002).
4. For example, facilities in Ghana, Rwanda and Mozambique receive practically no cash through
the budget process. Salaries are paid directly to staff and other resources are procured at higher
level and distributed in kind.
5. Increasingly, both bilateral and multilateral development agencies are channelling aid as
general budget or sector support. Shifts in aid modalities, combined with debt reduction
initiatives, have led to a growing concern with the transparency and integrity of public
fnancial management in developing countries. In this context, PETS have emerged as an
important diagnostic tool. Recently, PETS have also been proposed as a tool for promoting
GC2006 01 part1 36 8/11/05 17:54:55
Tha soaIa oI Iha probIam 87
accountability in public spending. For a discussion of PETS as a tool for tracking poverty-
reducing public spending under the Enhanced HIPC Initiative, see Tracking of Poverty-Reducing
Public Spending in Heavily Indebted Poor Countries (Washington, DC: IMF, 2001). A general
discussion is provided in the World Banks Public Financial Management: Performance Measurement
Framework (Washington, DC: World Bank, 2005). The jury is still out on whether PETS are a
useful and cost-effective tool for preventing corruption.
6. Nazmul Chaudhury, Jeffrey Hammer et al., Provider Absence in Schools and Health Centers,
Journal of Economic Perspectives, (forthcoming).
7. James Killingsworth, Najmul Hossain et al., Unoffcial Fees in Bangladesh: Price, Equity and
Institutional Issues, Health Policy Plan 14(2): 15263, 1999; Maureen Lewis, Who is Paying
for Health Care in Eastern Europe and Central Asia? (Washington, DC: World Bank, 2000); Tim
Ensor and Sophie Witter, Health Economics in Low Income Countries: Adapting to the Reality
of the Unoffcial Economy, Health Policy 57(1): 113, 2001; Paolo Belli, George Gotsadze,
and Helen Shahriari, Out-of-Pocket and Informal Payments in Health Sector: Evidence from
Georgia, Health Policy 70(1): 10923, 2004; Tim Ensor, Informal Payments for Health Care
in Transition Economies, Social Science and Medicine 58(2): 23746, 2004.
8. Barbara McPake, Delius Asiimwe et al., Informal Economic Activities of Public Health Workers
in Uganda: Implications for Quality and Accessibility of Care, Social Science and Medicine 49(4):
84965, 1999; Rafael Di Tella and William D. Savedoff, Diagnosis Corruption: Fraud in Latin
Americas Public Hospitals (Washington, DC: Inter-American Development Bank, 2001).
9. Paulo Ferrinho, Wim Van Lerberghe and Aurlio da Cruz Gomes Ferrinho, Public and Private
Practice: A Balancing Act for Health Staff, Bulletin of the World Health Organization 77(3): 209,
1999; Wim Van Lerberghe, Claudia Conceio, Wim Van Damme and Paulo Ferrinho, When
Staff is Underpaid: Dealing with the Individual Coping Strategies of Health Personnel, Bulletin
of the World Health Organization 80(7): 5814, 2002.
LooaIIavaI oorrupIIon hIIs haaIIh sarvIoa daIIvary In Iha
FhIIIppInas
Omar Azfar and Tugrul Gurgur
1
In the past two decades there has been a widespread devolution of authority to local
governments around the world. As local governments increase their share of authority
and responsibility vis--vis central government, their effectiveness in terms of quality,
quantity and the accessibility of public services has become critical. Consequently, the
effect of local-level corruption on service delivery has critical relevance for development
economists and policy-makers.
The Philippines is an ideal place to study the impact of corruption on service delivery.
Five years after the democratic revolution in the Philippines, the Local Governments
Act of 1991 devolved both political authority and administrative control of many
health and education services to the provincial and municipal level. According to
some public survey results and anecdotal evidence, much of the corruption in the
Philippines does appear to be at the local level. The large number of municipalities, the
signifcant devolution of authority, and the high and varying levels of corruption make
the Philippines an ideal place to study the impact of corruption on service delivery.
Data collected in 2000 from 80 municipalities in the Philippines was used to assess
the impact of corruption in local governments on health and education outcomes. The
results showed clearly that corruption undermines the delivery of health services. We
GC2006 01 part1 37 8/11/05 17:54:56
6orrupIIon and haaIIh 8B
found a signifcant partial correlation between 13 dependent variables that measure
various aspects of health and education services and corruption perceptions, after
controlling for capacity (based on measures of human and physical capital), adult
education levels, urban residence, living standards (as proxied by assets), inequality,
existence of private sector competition, voting and media exposure, accountability
measures and local autonomy.
Corruption levels were measured using corruption perceptions of households and
public offcials (administrators, health and education services, school principals and
health workers). The respondents were asked questions about specifc acts of corruption
(such as bribery, the sale of jobs and theft of supplies) as well as their general perceptions
about the corruption level at each municipal government, public school and public
health clinic. Most kinds of corruption were found to be more prevalent in the municipal
administrators offce than in other offces, perhaps due to the administrators offce
exerting more authority and thus having more opportunity to extract rents. A total of
19 per cent of municipal administrators said there were cases of bribery in their offces
in the year preceding the survey (1999), while 32 per cent said there were instances of
theft of funds. By contrast, the fgures for municipal health offcers were 2.5 per cent
and 16.5 per cent, respectively.
To measure the quality, quantity, and accessibility of health services, we used seven
variables: six of them from a household survey (immunisation of children, delay
in vaccination of children, patient waiting times, accessibility of health clinics for
treatment, choosing public health clinics for immunisation, and satisfaction with public
health clinics) and one from the Ministry of Health (municipal average of immunisation
rate of children).
The results showed clearly that corruption undermines the delivery of health services
in the Philippines. In each case regression results indicated a signifcant and negative
effect of corruption on the quality of health services. For example, a standard deviation
(about 10 per cent) increase in corruption reduces the immunisation rate by around
1020 per cent, increases waiting time in public health clinics as much as 30 per
cent, decreases user satisfaction by 30 per cent, and reduces the odds of completing
vaccination by four times and choosing public health facilities by a factor of three.
The results also suggest that corruption does not affect the rural areas the same way
it affects the urban areas. In the urban areas demand for public health care is more
corruption-elastic (that is, households use of public health facilities declines more
rapidly in response to higher corruption incidence). Households in rural areas, on the
other hand, suffer with more waiting at public health clinics, late immunisation of
infants, and less satisfaction with public health services as compared to households
in urban areas facing the same level of corruption. The presence of alternative health
facilities in urban areas, either in the form of private health care providers or other
public health facilities, may be the reason for such differences.
We also ran regressions to understand the effect of corruption in rich, middle-income
and poor municipalities. Even after controlling for other factors we found that when
corruption is endemic, poor and middle-income municipalities report more waiting at
public clinics and a higher frequency of being denied vaccines than rich municipalities.
GC2006 01 part1 38 8/11/05 17:54:56
Tha soaIa oI Iha probIam 89
Corruption in public clinics is also more likely to deter households living in poor
municipalities and forces them to opt for self-medication.
Robustness checks that control for outliers, sample selection problems and reverse
causality concerns (for instance, that some common variable is affecting both corruption
and service delivery, or that poor service delivery is causing corruption) confrmed our
fndings.
Taken together our results suggest that corruption undermines the delivery of services
in the Philippines. This complements cross-country fndings on the subject, and adds
to the expanding list of ways corruption undermines welfare.
hoIa
1. Omar Azfar ([email protected]) is a research associate at the IRIS Center of the University
of Maryland College Park, and Tugrul Gurgur ([email protected]) is a graduate student at the
Economics department of the University of Maryland College Park. The article summarises
research conducted by the IRIS Center of the University of Maryland on behalf of the World
Bank and the Netherlands Trust Fund. The full report was published as: Omar Azfar and Tugrul
Gurgur, Does Corruption Affect Health and Education Outcomes in the Philippines?, Working
Paper (College Park: IRIS Center, University of Maryland College Park, 2004), available at www.
iris.umd.edu. The authors thank Satu Kahkonen, Anthony Lanyi, Patrick Meagher and Diana
Rutherford for their contributions to this report.
6orrupIIon Is bad Ior your haaIIh. IIndIngs Irom 6anIraI and
LasIarn Luropa
Richard Rose
1
Modern medicine offers many treatments that can alleviate pain or restore people to
good health. Moreover, in prosperous OECD countries there is the assurance that, if
you do get ill, you will be treated by a state-funded health service or through a private
health insurance programme. But health care costs money, and in many developing
countries the most the state can fnance are the rudiments of public health facilities,
such as clean water and sewers. In the developing world, individuals needing health
care must sometimes turn to traditional remedies or borrow money to pay for private
health care. Where corruption is rife, people have the worst of both worlds: paying
twice for treatment, once through taxes and once in a brown envelope.
Communist governments in Central and Eastern Europe once promised health care to
everyone in need. However, the result was favouritism and corruption in the allocation
of medical and hospital treatment. Those who were in the party nomenklatura had access
to good treatment; those who could pull strings through informal networks (blat) also
benefted; and people who could offer payments on the side were more likely to get
good treatment than those who could not. The corruption that was an integral part
of the shadow economies of communist countries has left a legacy of corruption
throughout the region, particularly in the health sector.
GC2006 01 part1 39 8/11/05 17:54:56
6orrupIIon and haaIIh 40
As part of this legacy, the imposition of a corruption tax for treatment that ought
to be free is likely to have negative consequences for the health of citizens. At worst,
it may lead to the denial of treatment or even people not seeking treatment because
they do not have the money to make payments under the table. Corruption in health
inevitably punishes the elderly, who are most likely to need health care, and the
poor.
The seventh New Europe Barometer (NEB) of the Centre for the Study of Public
Policy has tested the extent to which corruption is bad for a societys health.
2
Between
1 October 2004 and 23 January 2005, it organised nationwide random sample surveys
of the adult populations in eight new EU member states (the Czech Republic, Estonia,
Hungary, Latvia, Lithuania, Poland, Slovakia and Slovenia); two applicant countries
(Bulgaria and Romania); plus Belarus and Russia. National research institutes interviewed
13,499 people face to face, asking questions about their perception of corruption,
health care and such infuences on health as age, education and social class.
When people assess their physical health, the largest group of 39 per cent, not
surprisingly, says it is average; 34 per cent say their health is good; and 10 per cent
describe it as excellent. By contrast, only 14 per cent say their health is bad and 3 per
cent report it is very bad.
3
In Romania, Slovenia and Slovakia, more than half say their
health is good or excellent. Even in Belarus, where one-quarter says their health is bad,
the largest group has average health.
However, almost three-quarters of those surveyed have a negative view of their
countrys health services (Table 2.2). Altogether, 24 per cent describe the system as very
bad, and almost half characterise it as not so good, as against 27 per cent who consider
it fairly good, or very good. The evaluation of health care varies greatly within the
region. In the Czech Republic, an absolute majority gives the health system a positive
endorsement and the same is true in Belarus. By contrast, in Russia and Bulgaria fewer
than one in twelve is positive. Bulgarians and Russians differ only as to whether their
health service is not so good or very bad.
At the same time, there is a widespread perception that the body politic is infected
with corruption. When asked how many offcials are corrupt, 29 per cent say that
practically all offcials are corrupt and an additional 44 per cent see a majority of offcials
as corrupt (Table 2.3). Again, there are big differences between countries. In Romania,
a majority perceive practically all offcials as corrupt, and in Russia 43 per cent do. By
contrast, nearly half of all Estonians and Slovenes polled think corruption affects less
than half of public offcials.
Where corruption appears widespread, people also see major defciencies in health
care (Figure 2.1). Five out of six people who see nearly all offcials as corrupt think their
health system is either very bad or not so good; and almost four-ffths who think a
majority of offcials are corrupt see the health service in negative terms. Among those
who think that less than half the public offcials are corrupt, three in fve still have a
negative view of the health service. Even among the small percentage of citizens in
the region who see very few offcials as corrupt, just under half have a positive view
of their health system.
GC2006 01 part1 40 8/11/05 17:54:56
Tha soaIa oI Iha probIam 41
Table 2.2: Health service seen as not very good
Q. How would you evaluate the current system for health care in this country?
Very Fairly Not so Very
good good good bad
Czech Republic 3 51 39 7
Slovenia 4 42 42 11
Belarus 2 49 38 11
Romania 2 14 66 18
Hungary 1 38 46 15
All NEB countries 1 26 49 24
Estonia 1 24 49 26
Lithuania 1 22 56 21
Slovakia 1 21 52 26
Latvia 1 20 47 32
Poland 1 16 48 35
Bulgaria 1 7 55 38
Russia 1 7 53 40
Source: Centre for the Study of Public Policy, New Europe Barometer VII. Total number of respondents:
13,499. Fieldwork conducted between 1 October 2004 and 23 January 2005.
Table 2.3: Corruption perceived as widespread
Q. How widespread do you think that bribe-taking and corruption are in this country?
Very few public offcials are corrupt; less than half are corrupt; most public offcials are engaged in
corruption; almost all public offcials are engaged in corruption.
Almost all Majority Less than Very few
half
(% replying)
Romania 51 34 14 1
Bulgaria 43 45 10 2
Russia 43 46 8 3
All NEB countries 29 44 22 5
Lithuania 32 50 15 3
Slovakia 30 50 18 2
Hungary 27 36 35 1
Belarus 26 44 21 8
Latvia 24 49 22 6
Poland 22 52 24 2
Czech Republic 21 49 26 5
Slovenia 17 36 33 14
Estonia 12 39 36 13
Source: Centre for the Study of Public Policy, New Europe Barometer VII. Total number of respondents:
13,499. Fieldwork conducted between 1 October 2004 and 23 January 2005.
GC2006 01 part1 41 8/11/05 17:54:56
6orrupIIon and haaIIh 4Z
Figure 2.1: As corruption rises, health service gets worse
Source: Answers to questions in Tables 2.2 and 2.3 gamma correlation: 0.36. Centre for the Study of
Public Policy, New Europe Barometer VII. Total number of respondents: 13,499. Fieldwork conducted
between 1 October 2004 and 23 January 2005.
People with below-average health are most likely to be dissatisfed with their countrys
health system; 78 per cent describe it as not so good or very bad. But being in bad
health is not the chief reason why a health service is viewed negatively. More than
three-quarters of those who rate their health as average also think that health care is
not very good or very bad; and even among those in good or excellent health, two-
thirds view the health care available in negative terms.
An individuals health not only refects the state of the country but also the characteristics
specifc to that person, such as age and education. The extent to which bad government
has a negative effect on individual health, in addition to individual characteristics,
can be determined by multiple regression analysis. It identifes conditions that have a
statistically signifcant infuence on health, net of the effects of other infuences.
Both individual characteristics (age, social status and education) and perceptions of
public services signifcantly and independently infuence the health of individuals
in Central and Eastern Europe and the former Soviet Union. Together, they can account
for 26.8 per cent of the variance in self-assessed health. As expected, age is by far the
single most important infuence: being 60 or over has an even more negative effect on
health than the positive effect of being under 30.
Three other socio-economic characteristics give a signifcant boost to individual
health. The higher a persons social status and education, the better his or her health,
however old they are. The more durable consumer goods there are in the house a
50
40
30
20
10
0
Few
corrupt
Less than
half corrupt
Most
corrupt
Nearly all
corrupt
%
(percentage rating health service very good or fairly good)
GC2006 01 part1 42 8/11/05 17:54:57
Tha soaIa oI Iha probIam 48
proxy for income in countries where subsidies and shadow earnings complicate the
evaluation of conventional wages the better a persons health. The statistic that shows
men are more likely to be healthy than women is a by-product of the higher rate of
male mortality at younger ages, which results in men who do survive into old age on
average being healthier.
The perception of corruption has both a direct and an indirect infuence on health.
After controlling for social characteristics, people who perceive government as more
corrupt are more likely to be in worse health. Corruption also has an indirect effect
because it correlates with a negative assessment of the health service, and a bad health
service is bad for individual health. For individual health, at least, the individual
perception of corruption is more signifcant than the overall national rating.
4
Notwithstanding the widespread perception of inadequate and even corrupt public
services, the welfare values of Central and East Europeans continue to support paying
taxes for better services. However, the more corrupt a system actually is, the less beneft
that individuals will gain from paying higher taxes. In order to improve health in the
region, national governments not only have to spend more money on health care, but
also have to spend that money honestly.
hoIas
1. Richard Rose is professor at the Centre for the Study of Public Policy, University of Aberdeen,
Scotland.
2. The New Europe Barometer survey is fnanced by a grant from the British Economic & Social
Research Council for the analysis of diverging paths of post-communist countries. The health
data was collected with the support of a MacArthur Foundation grant to Professor Sir Michael
Marmot, Department of Epidemiology and Public Health, University College, London.
3. All percentages are based on pooling the 12 NEB national surveys and weighting each equally,
so that each contributes one-twelfth of the total answers reported.
4. The TI Corruption Perceptions Index (CPI) does not register statistical signifcance due to the
fact that the CPI rates the country as a whole; thus the regression analysis assigns the same
CPI score to each individual respondent in a country. However, there is never 100 per cent
agreement within a country as to the degree to which offcials are corrupt. The NEB collects
data from individuals and thus can take into account differences in individual perception
within a country.
6IIItans audII In MaxIoo ravaaIs papar IraII oI oorrupIIon
Helena Hofbauer
1
At the end of 2002, as it was discussing the 2003 budget, Mexicos Congress announced
it would provide 600 million pesos (US$ 56.5 million) of additional funding for
programmes that promoted womens health. The president of the Budget Committee
sent instructions to that effect to the Ministry of Health. Included was a statement
that 30 million pesos (US$ 2.8 million) were to be reallocated to a private organisation,
Provida, as part of the womens health initiative. Originally, the amount had been
allocated to HIV/AIDS public health campaigns.
GC2006 01 part1 43 8/11/05 17:54:57
6orrupIIon and haaIIh 44
Six Mexican civil society organisations (CSOs) Consorcio para el Dilogo Parlamen-
tario y la Equidad; Equidad de Gnero, Ciudadana, Trabajo y Familia; Fundar, Centro
de Anlisis e Investigacin; Grupo de Informacin en Reproduccin Elegida; Letra S,
Sida, Cultura y Vida Cotidiana; and Salud Integral para la Mujer launched an investi-
gation into why the budget had been altered. The six embarked on a time-consuming
piece of detective work lasting 18 months during which they documented evident
irregularities. Much of the CSOs efforts were possible because Mexico implemented a
new Transparency and Access to Public Information Law in June 2002.
The organisations uncovered a funding request that Provida presented to the Ministry
of Health on 3 December 2002 for 30 million pesos, as well as confrmation from both
the ministries of fnance and of health that 30 million pesos were given to Providas
national committee. They also uncovered the signed agreement between the grants
administrator and Provida, a fnancial and social impact report presented by Provida
on the expenditure of the resources and a 6,525-page fnancial fle containing invoices
detailing how the 30 million pesos were spent.
With this knowledge, the CSOs began their own audit trail of how Provida spent
30 million pesos of taxpayers money in 2003. They found evidence of misuse and
corruption. More than 80 per cent of the funds were used to hire the services of a public
relations frm for work such as a campaign against provision of emergency contraception
for women. Money was also spent on an agency importing overpriced medical equipment,
as well as to pay for the rent of a ballroom. The two companies and the owner of the
ballroom shared Providas address, telephone numbers and its administrative director.
The CSOs also found that Provida had purchased luxury pens, clothing and groceries
with some of the funds. Documents showed serious fscal inconsistencies. Receipts dated
October 2003 related to products acquired in July 2003.
In addition the CSOs made a number of observations about procedural violations
that had taken place. First, the president of the Budget Committee is not allowed to
speak for the plenary, or to issue instructions to a minister; second, Congress cannot
allocate money to private organisations, particularly if it is taken away from public
programmes; third, the Ministry of Health can only disburse resources to NGOs through
an open, public process, after soliciting proposals; and fourth, Providas radical stance
contradicts signifcant parts of Mexicos public health policy in that it actively opposes
the prevention of HIV/AIDS via the use of condoms, and systematically rejects the right
to abortion that was granted to raped women.
Armed with this damning evidence, the CSOs unveiled their citizens audit at
a press conference in June 2004 at which they launched a campaign demanding
transparency and accountability, supported by 700 NGOs across Mexico. The campaign
demanded that the Ministry of Health publicly explain its reasons for fnancing a private
organisation that advocated health policies contradicting those of the government;
that the government carry out an offcial audit of the 30 million pesos and clarify the
responsibilities of the government offcials involved and Providas legal representative;
that the 30 million pesos be returned to the state budget; and that legislation be drafted
and implemented to prevent similar transgressions with government money.
The campaign became the focus of national attention, occupying the headlines of
Mexicos news media for a month. As a result of the mounting public pressure, Congress
GC2006 01 part1 44 8/11/05 17:54:57
Tha soaIa oI Iha probIam 46
unanimously voted in July 2004 to call on the Minister of Health to explain the use of
the 30 million pesos and speed up an ongoing offcial audit. Shortly after, the ministry
demanded the return of the 30 million pesos and cancelled its contract with Provida,
suspending the distribution of additional funds to the organisation for 2004.
In September 2004, the Internal Comptroller, who is responsible for initiating audits
within the executive branch of government, issued the results of the offcial audit, which
corroborated the irregularities the CSOs had identifed. At the end of March 2005, the
earliest permissible date, the Auditor General (of the legislative branch) also issued its
results on the case. But the Auditor Generals report went further, noting that 90 per
cent of the money Provida received from the government had been inappropriately
used. As a result, the Senate asked for a judicial process to be started against Provida
and its legal representatives.
2
In April 2005 the Internal Comptroller removed the three offcials at the head of
the health ministry unit who had handed out the resources without a public process;
and banned Providas legal representative, Jorge Serrano Limn, from occupying public
offce and fned him 13 million pesos. The 30 million pesos have not been returned,
the fne has not been paid and the judicial process is still under way.
Nonetheless, the CSOs have effectively promoted the cause for greater transparency
in important ways.
They demonstrated the important role CSOs can play in making government more
accountable by using a countrys legal framework. In particular, they showed the value
of the Transparency and Access to Information Law to enable processes that would not
have been possible three years ago.
This was the frst time CSOs followed a misallocation of resources and its corrupt
expenditure throughout the entire budget process. It was possible to identify what had
happened, to audit the exercise of resources and to reach into the oversight stage of the
process in order to seek redress. The misuse of resources and the corruption highlighted
by CSOs was confrmed by offcial institutions, and action followed.
A legal precedent was established, since the Law of Responsibilities of Public Offcials
(in operation since 1982, with several reforms) was applied for the frst time to an
individual (Serrano Limn), who had made unlawful use of public resources.
Inconsistencies between public health policies and Providas activities were highlighted,
and the care centres that should have been built and run with the 30 million pesos
have since been carefully supervised in order to ensure lawful practices.
The administrative unit in the Ministry of Health responsible for distributing resources
among CSOs reviewed its policies and for the frst time published its procedures in the
public domain.
hoIas
1. Helena Hofbauer is Executive Director of Fundar, Mexico City.
2. www.senado.gob.mx/sgsp/gaceta/?sesion=2005/04/26/1&documento=60
GC2006 01 part1 45 8/11/05 17:54:57
6orrupIIon and haaIIh 46
FIghIIng Iraud and oorrupIIon In 8rIIaIns haIIonaI haaIIh 8arvIoa
Jim Gee
1
Fraud and corruption represent a pincer movement on organisations affected by them.
They deny them the resources they need while undermining the confdence of the
public. For too long, the defence against such attacks has been poorly organised and
unprofessional. In recent years in the United Kingdom, and especially in its National
Health Service (NHS) the third largest organisation in the world, with 1.2 million
staff and an annual budget of 70 billion (US $125 billion) this picture has changed
considerably.
The Counter Fraud Service (CFS) was created in 1998 with overall responsibility to
protect the NHS and its resources from fraud and corruption. Our starting point is to
accurately measure and track losses to fraud and corruption in each area of the NHS
budget to an accuracy of within 1 per cent and to have that independently audited. This
helps to identify the nature and extent of the problem, which is essential to fnding
the appropriate solution. Thus we know that losses to patient fraud have been reduced
from 171 million (US $305 million) in 1999 to 78 million (US $139 million) in 2004
(a reduction of 54 per cent), and losses to fraud by medical professionals have fallen
by about 4354 per cent over the same period. We are currently measuring losses to
payroll fraud involving ghost employees, or where people obtain employment by
using bogus qualifcations and false employment histories. These fgures should be
available in late 2005.
The CFS has the responsibility not only for operational work to counter corruption
(detection, investigation and the seeking of sanctions and redress). It also works to
develop a real anti-fraud and corruption culture, to create a strong deterrent effect, and
to revise policy and systems to prevent the problem recurring. By integrating these two
aspects, we have ensured that we generate not only activity, but also tangible outcomes
in terms of reduced losses to fraud and corruption. As a legal requirement, the CFS is
staffed by professionally trained and accredited counter-fraud specialists, members of
a new profession numbering around 8,500 across the public and private sectors since
its formation by the government in 2001.
The CFS has encountered and dealt with many different aspects of corruption.
Examples in recent years include:
We are suing a number of generic drug companies for 152 million (US $271
million) because we believe they formed a cartel to raise prices for the drugs
warfarin, penicillin and ranitidine.
A chief executive of an NHS Trust who falsifed his qualifcations to obtain the
post resigned to avoid dismissal; a criminal prosecution is under way.
Medical professionals who claimed and pocketed payments for treatments they
did not provide are usually prosecuted criminally, with civil legal action to recover
losses. Finally, they are suspended or removed from professional bodies.
GC2006 01 part1 46 8/11/05 17:54:58
Tha soaIa oI Iha probIam 47
These and other examples where we have detected and stopped corruption total more
than 170 million (US $303 million) since 1999, but this is only part of total fnancial
benefts to the NHS of 675 million (US $1.2 billion), which also includes recovery of
monies lost to fraud and reductions in measured losses due to CFS intervention. This
amounts to a 13:1 return on its budgetary investment, and the equivalent of what it
would cost to build 10 new hospitals.
To achieve this, the CFS has worked to mobilise the honest majority, undertaking more
than 1,400 presentations and awareness sessions reaching hundreds of thousands of
staff and millions of patients. It also seeks to deter the dishonest minority by publicising
the actions taken, with around 400 media articles each year. Detection rates have risen
by several hundred per cent, with a 96 per cent success rate in prosecution, alongside
extensive use of civil law to freeze and recover assets.
There have been four keys to this success. These are:
accurate identifcation of the nature and scale of the problem
comprehensive action to tackle the problem (not limited to traditional
policing)
professional agency staff with the right skills to reduce losses to corruption
permanently
successful mobilisation of the honest majority and the deterrent effect this has
had on the dishonest minority.
The CFS approach is widely recognised as best practice in the UK public sector and
increasingly across Europe, with information being shared via the new European
Healthcare Fraud and Corruption Network.
It is time that work to counter fraud and corruption moves from its pre-professional
period and becomes fully professionalised. No one expects an untrained lawyer to
provide good legal advice or an unqualifed surgeon to operate on a relative. It is equally
unacceptable to take a non-professional approach to the protection of public bodies
against fraud and corruption.
hoIa
1. Jim Gee is chief executive of the National Health Service Counter Fraud Service and director
of Counter Fraud Services in the UK Department of Health.
GC2006 01 part1 47 8/11/05 17:54:58
6orrupIIon and haaIIh 4B
8 6orrupIIon In hospIIaIs
A run-down hospital ward in Tamale, Ghana, March 2004. (Che Chapman)
As the loci of a large proportion of health spending and given their size and complexity
hospitals provide many opportunities for corruption, as Taryn Vian describes. Money
leaks from hospitals through opaque procurement of equipment and supplies, ghost
employees, exaggerated construction costs and infated hospital price tags. In developing
countries the result is a depleted budget for other necessary health care services such
as primary health care programmes.
Ultimately it is patients that suffer, either because they are asked to pay bribes for
treatment that should be free, or because treatment decisions are based on fnancial
motivation rather than medical need. Effects are felt in both the developed and the
developing world. Case studies from around the world provide a glimmer of hope by
GC2006 01 part1 48 8/11/05 17:54:58
6orrupIIon In hospIIaIs 49
showing how low-cost efforts to increase transparency of hospital procurement in
Kenya and waiting lists in Croatia can help reduce corruption.
6orrupIIon In hospIIaI admInIsIraIIon
Taryn Vian
1
The hospital sector represents a signifcant risk for corruption, in both developing and
developed countries alike. In the United States alone, fraud and abuse in health care
has been estimated to cost US $11.9 to 23.2 billion per year; much of this expense is
attributable to hospital-based care.
2
The size and complexity of hospitals allows the possibility for many kinds of
corruption. As many economists have pointed out, corruption is a crime of calculation
and is more likely to occur where budgets are large and rents or possibilities for
people to gain from decisions made by offcials are high. Hospitals meet these criteria
for vulnerability. Globally, hospitals account for 3050 per cent of total health sector
spending (public and private); in some regions, such as Eastern Europe, the percentage
may be as high as 70 per cent.
3
Hospital spending may also include large investments
in building construction and purchase of expensive technologies, areas of procurement
that are particularly vulnerable to corruption. The need to manage multiple stakeholders
with different interests and asymmetries in information at many levels (between medical
personnel and patients, doctors and administrators, and procurement specialists and
clinicians, to name just a few) also creates an environment that is susceptible to
corruption (see Chapter 1).
Corruption in hospital administration has a direct negative effect on access and
quality of patient care. Employee theft of supplies can leave patients without medicines,
and extorted, under-the-table payments create anxiety and reduce access to care. As
resources are drained from hospital budgets through embezzlement and procurement
fraud, less funding is available to pay salaries and fund operations. This in turn leads
to demotivated staff and greater absenteeism as medical personnel seek private income
from outside jobs, again lowering access and decreasing quality of services. Financial
arrangements between hospitals and doctors intended to increase hospitals and doctors
profts can lead to waste of public money, or medical decisions that are not in the
patients best interests. Persistent corruption in the hospital sector makes it harder
to reduce hospital spending as a proportion of overall health expenditures, a goal in
many developing countries where needs can be met more cost-effectively in primary
care settings, such as health centres and maternal and child health clinics. If offcials
in power are gaining personally from the current patterns of spending in the hospital
sector, why would they favour changes to expand primary care, an area where there is
less opportunity for private enrichment?
Table 3.1 provides a typology of corruption in hospital administration. Key areas
of concern include the procurement function; embezzlement and theft; payment
system fraud; and personnel issues such as absenteeism, informal payments and sale
of positions.
GC2006 01 part1 49 8/11/05 17:54:59
6orrupIIon and haaIIh 60
Table 3.1: Major types of corruption in hospital administration
Category Type Description
Procurement Overpayment for goods
and services
Engaging in collusion, bribes and kickbacks
in procurement processes, resulting in
overpayment for goods and contracted services;
not enforcing contractual standards for quality.
Embezzlement
and theft
Embezzlement Diverting budget or user-fee revenue for
personal advantage.
Theft Stealing medicines and medical supplies or
equipment for personal use, use in private
practice or re-sale.
Personnel Absenteeism Not showing up for work or working fewer
hours than required, while being paid as if full
time.
Informal payments Extorting or accepting under-the-table
payments for services that are supposed to be
provided free of charge; soliciting payments in
exchange for special privileges or treatment.
Abuse of hospital
resources
Using hospital equipment, space, vehicles or
budget for private business, friends or personal
advantage.
Favouritism in billing,
spending
Waiving fees or falsifying insurance documents
for particular people; using hospital budget to
beneft particular favoured individuals.
Sale of positions and
accreditation
Extorting or accepting bribes to infuence
hiring decisions and decisions on licensing,
accreditation or certifcation of facilities.
Payment
systems
Insurance fraud and
unauthorised patient
billing
Illegally billing insurance companies,
government or patients for uncovered services
or services that were not actually provided,
in order to maximise revenue. May involve
falsifcation of invoice records, receipt books or
utilisation records, and/or creation of ghost
patients.
Illegal referral
arrangements
Buying business from physicians by creating
fnancial incentives or offering kickbacks
for referrals; physicians improperly referring
public hospital patients to their private
practice.
Inducement of
unnecessary medical
procedures
Performing unnecessary medical interventions
in order to maximise fee revenue.
GC2006 01 part1 50 8/11/05 17:54:59
6orrupIIon In hospIIaIs 61
hospIIaI proouramanI. a hoIbad oI oorrupIIon
Procurement fraud is a large risk in hospitals, as virtually all capital spending involves
procurement, and medicines and supplies are often the next largest recurrent
expenditure item after salaries. Procurement agents may seek bribes or kickbacks from
supply companies, or contractors may engage in collusion or offer bribes to hospital
offcials in order to win contracts.
Evidence from Argentina, Bolivia, Venezuela and Colombia suggests that these
practices drive up the price of supplies purchased. For example, estimated overpayments
in 1998 for seven specifc medications in 32 public hospitals in Colombia were valued
at more than US $2 million per year, an amount that would have paid for health
insurance coverage for 24,000 people.
4
Small hospitals face special challenges in reducing vulnerability to procurement
abuse. Where there are only a few doctors in a specialty, they have more power over
the decisions made by administrators. The doctors may demand that the hospital
purchase certain equipment or supplies for them, or they will move their practice
elsewhere. Some may not consider this corruption but merely an economic driver of
medical infation.
In addition, hospitals may be pressured by consultants to buy more technology than
the hospital can afford to maintain, because the additional equipment enables the
specialist doctors to demand higher fees. This is particularly true in private hospitals,
but may also take place in public hospitals where doctors use public facilities for
private practice (offcially or not), or are able to demand under-the-table payments
from patients.
While essential drug lists and hospital formularies can help by restricting procurement
to pre-approved drugs meeting effcacy, cost and quality standards, private drug
manufacturers or their agents may still try to bribe offcials to see that their medicine
or formulation appears on the list. For example, in Albania, a Ministry of Health offcial
claimed in 2003 that offers had been made to purchase the not-yet-approved list of
new members appointed to the national committees for drug nomenclature and drug
reimbursement. Presumably the bribers wanted the list so that they could individually
approach the new members to try to infuence their selection decisions, perhaps by
offering fnancial incentives for decisions favourable to the bribers. In a similar bid to
infuence medicines purchasing and use decisions, TAP Pharmaceutical Products was
charged with giving inducements directly to Lahey Clinic, a 259-bed US medical centre
and primary care practice, allegedly agreeing to pay some US $100,000 for a Christmas
party, golf tournaments and seminars if the clinic agreed to continue prescribing its
cancer drug Lupron instead of a less expensive rival drug.
5
TAP had already paid a
record US $885 million fne in 2001 to settle similar charges.
Procurement agents may also turn a blind eye when vendors substitute lower-quality
building materials or deliver goods that do not meet contractual expectations for quality,
as in Malaysia, where the Anti-Corruption Agency recently launched a probe into
irregular construction of the Sultan Ismail Hospital.
6
Risk of corruption is higher if
a hospital lacks systems for documenting and controlling contractor performance.
Kenyatta National Hospital in Kenya reportedly lost over US $12 million to procurement
GC2006 01 part1 51 8/11/05 17:54:59
6orrupIIon and haaIIh 6Z
fraud between 1999 and 2002.
7
Problems cited by the press included failure to control
quality of purchases (obsolete items substituted for the modern equipment described in
the bid, or fewer supplies delivered than contracted) and hidden charges or construction
overruns not included in the original procurement contract, as well as non-competitive
bidding processes resulting in higher prices. Hospitals may not have adequate systems
for recording receipt and use of drug orders, leading to situations where they pay for
orders that are never received.
Better administrative systems for procurement and inventory control can help to
prevent corruption by reducing discretion; however, anti-corruption efforts that rely
heavily on administrative controls can be stymied by the problem of collusion. In
Venezuela, researchers suspected that collusion between hospital administrators and
purchasing offcers was feeding the corruption by reducing the probability of detection
and punishment.
8
Transparency and accountability measures must be used to hold hospital administrators
accountable. In Argentina, the government adopted a strategy of monitoring how much
hospitals were paying for medical supplies and disseminated this information among
them. Purchase prices for the monitored items immediately fell by an average of 12 per
cent. Prices eventually began to rise again, but stayed below the baseline purchase prices
for the entire time the policy was in place.
9
The WHO and Health Action International
have also developed a drug-price monitoring tool that could be used for transparency
initiatives.
10
In Bolivia, researchers found that increased citizen health board activism and
supervision of personnel played a role in deterring overpayment for drugs by
procurement agents,
11
while in Uganda, health unit management committees with
community representation began to enforce accountability, particularly in the area of
hospital drug management.
12
Of course, if community board members accept kickbacks
or collude with hospital offcials, the committees will not be effective.
To increase transparency in procurement of medicines, hospitals can channel
decision-making through expert pharmacy and therapeutic committees, or procure-
ment committees. The committee structure helps to balance the infuence of clinicians
with strong personal interests. Pooled procurement decisions for groups of hospitals
may help to increase competition and dissipate power of individual physicians. Some
countries, like Albania, have moved to centralise hospital procurement as a way to
reduce opportunities for corruption. Chiles centralised health procurement agency,
CENABAST, has prevented collusion and lowered prices by introducing computerised,
auction-style bidding (see Corruption in the pharmaceutical sector, Chapter 5, page 76).
Centralised procurement may bring other problems, however, if it is poorly designed and
controlled. And even with effective centralised procurement systems, the risks of bribery
and collusion remain, and must be dealt with through transparency and review.
LmbattIamanI and IhaII
Embezzlement involves the theft of cash payments or other revenue from a hospital
by employees charged with revenue collection. Hospitals with weak fnancial systems
GC2006 01 part1 52 8/11/05 17:54:59
6orrupIIon In hospIIaIs 68
that are not computerised, or are cash rather than accrual-based, are more vulnerable
(see Box 3.1). In developing countries, embezzlement often involves user-fee revenues
collected from sale of drugs or diagnostic tests, and registration fees paid by patients.
One study found that workers pocketed an estimated 6877 per cent of revenues from
formal user-charges in Ugandas sub-hospital clinics.
13
Researchers compared expected
user-fee revenue based on recorded utilisation in 12 facilities, to actual recorded revenue.
Although Ministry of Health guidelines allowed some fee exemptions for the poor,
the study found that in practice those unable to pay were actually turned away, and
estimated that most of the gap in revenue was taken by collectors.
Theft of supplies is another common problem in public hospitals. Although not
all theft can be categorised as corruption, the line is crossed when those entrusted
with power systematically abuse their position to deplete a hospitals resources. There
are indications that the problem is signifcant. In a study in Venezuela, two-thirds of
surveyed medical staff knew of cases where medical supplies had been stolen, while
in Costa Rica over 80 per cent of nurses reported a lot or some theft.
14
Uganda has
huge problems with drug leakage from hospitals and sub-hospital health facilities,
where researchers estimated losses of two-thirds of the purchased drug supply.
15
In
interviews with 53 health workers in Mozambique and Cape Verde, about half of whom
8ox 8.1 6ash ragIsIars In|aoI Iransparanoy and ravanua InIo kanyas
6oasI FrovInoIaI anaraI hospIIaI
In Coast Provincial General Hospital in Kenya, government staff used information from
patient satisfaction surveys to detect fraud in the user-fee collection system.
1
Employees
were allegedly pocketing user fees, draining funds from the hospital. Because systems for
reporting revenue collection were not computerised, it was hard to determine what the
user-fee revenue should have been, and to compare this with actual receipts. Managers
lacked the information they needed to take action.
To combat the problem, management installed a network of electronic cash registers.
Programme implementers had to replace the fee collectors, who were resistant to the
change.
The reform took three months and cost US $42,000. User-fee revenues jumped by
almost 50 per cent in three months with no change in utilisation rates. The new system
revealed other gaps in hospital systems and accountability, which were also addressed.
Within three years, annual user-fee revenues were up 400 per cent. Accountability for
spending the windfall in revenue was addressed by introducing more transparency in the
planning and budgeting process.
Taryn Vian (Boston University School of Public Health)
Note
1. C. Stover, Health Financing and Reform in Kenya: Lessons from the Field. Background document
for end-of-project conference for the APHIA Financing and Sustainability Project (Nairobi: May
2001).
GC2006 01 part1 53 8/11/05 17:55:00
6orrupIIon and haaIIh 64
worked in hospitals, researchers reported frequent misuse of pharmaceutical supply
for personal gain.
16
Misappropriation of drug supply and embezzlement of user-fee revenue in poor
countries are seen by some as a personal coping strategy for deteriorating work
conditions, including falling salaries and irregular pay. Approaches to prevention and
control therefore need to include not only monitoring and control systems for detection
and punishment, but also reforms to payment systems and reforms to strengthen
professionalism. One suggestion, based on feldwork in Mozambique and Cape Verde,
is to introduce legislation that makes the head of an organisation or department
legally responsible for the actions of that body as a way of increasing peer pressure and
accountability.
17
Performance contracting is another way to increase accountability
and provide incentives for performance.
18
nhaaIIhy parsonnaI praoIIoas
Stealing time is another common abuse. A total of 32 per cent of health professionals
interviewed in Peru thought absenteeism was common or very common among hospital
staff,
19
while in Venezuela respondents reported that doctors and head nurses were
absent during 3037 per cent of contracted hours (see A tale of two health systems,
Chapter 1, page 14). Absenteeism has been linked to low salaries and dual-job holding,
20
which some consider a coping mechanism rather than corruption. Many doctors
are also active in the private sector, driven in part by the inadequate compensation
available in the public sector.
21
To reduce absenteeism, institutional controls must be introduced to increase detection,
including personnel supervision, performance measurement systems, and community
participation in hospital management. Researchers noted that while control mechanisms
can help, one size doesnt ft all. The success of strategies to reduce absenteeism in
public facilities will also depend on pay differentials between the public and private
sectors, and whether there are barriers to entry into the private sector. Larger reforms to
civil service policies and public human resource management systems may be needed,
such as shifting from civil service appointments to contractual payment for time and
services rendered. If an employee does not perform, the contract would not be renewed.
This also permits one to pay a higher hourly rate for hours actually worked.
Informal payments defned as payments made by patients for services that are
supposed to be provided free of charge are a serious problem in many middle- and
low-income countries (see Chapter 4, page 62). Under-the-table remuneration has also
been documented in some higher income countries including France and Greece.
22
In addition to causing anxiety and uncertainty among patients, informal payments
can cause poor people to forgo or delay seeking care, and can have negative effects
on the quality of clinical services. Some patients go into debt or sell assets in order to
make informal payments, thus impoverishing themselves. Others seek to keep informal
payments low by skipping levels of care going straight to specialists or the hospital,
for example, instead of using primary care services or general practitioners.
GC2006 01 part1 54 8/11/05 17:55:00
6orrupIIon In hospIIaIs 66
Patients report making informal payments to all kinds of health workers, from guards
and cleaners, to mortuary attendants and lab technicians, to the doctors and nurses
involved in diagnosis and treatment. Some studies have found that patients who are
hospitalised are more likely to make informal payments, and to pay higher amounts,
than patients seeking ambulatory care.
23
In the foreboding words of one Albanian
informant: The most important thing is that you should pay the doctor, because he
will never forget the face of someone who has not paid him for the rest of his life.
24
The fact that it is hard to distinguish informal payments from tips, or gifts given
by patients to express gratitude, makes the problem more diffcult to address. While
informal payments may be seen as a coping mechanism for survival when the salaries of
doctors and nurses fall below a living wage, other payments are clearly bribes extorted
by workers, a practice detected in a Kenyan mortuary and decried by offcials. Mortuary
attendants have also been implicated in bribery and other corruption schemes in South
Africa and Zimbabwe.
25
Involving ordinary citizens in oversight or transparency initiatives may be a useful
complement to regulatory and bureaucratic reforms to address informal payments. One
hospital in Cambodia has had success in reducing informal payments by formalising
user fees and promoting professionalism among staff. The hospital created individual
contracts with personnel and increased pay scales while enforcing accountability and
sanctioning poor performance.
26
8ox 8.Z hospIIaI WaIIIng IIsIs opan Ior soruIIny In 6roaIIa
The Croatian health sector is perceived to be among the most corrupt sectors in the
country.
1
It is not surprising then that instances of patients paying bribes to reduce time
spent on waiting lists are thought to be commonplace. To curb this problem, the health
ministry launched a pilot initiative to publish open waiting lists a measure obliging
hospital executives to disclose lists to patients showing them their position in the line-up
to receive medical treatment. Lists are made accessible at hospital and clinic reception
desks, and patients that do not want to have their names made public can ask to be
listed by number instead. Complaints about irregularities can be made to the head of
the hospital or to the Health Ministry.
With the help of TI Croatia, waiting lists at two major hospitals in Zagreb, Dubrava
and Sveti Duh were published in hard copy and on the Internet in late 2004 and 2005.
A hotline run by TI Croatia to monitor the effectiveness of the initiative received 90 calls
about the Dubrava Hospital waiting list within the frst few months starting in October
2004. In one case, a patient had waited two years for heart surgery but, after lodging a
complaint with TI Croatia, was operated on within two weeks. The pilot initiative is set
to become a precedent in curbing corruption in health care delivery by making it more
open and transparent.
Ana First (TI Croatia)
Note
1. Transparency Internationals Global Corruption Barometer 2004, a public opinion survey, ranked
the health services as the second most corrupt institution in Croatia, second only to the legal
system/judiciary and equal to political parties and parliament.
GC2006 01 part1 55 8/11/05 17:55:00
6orrupIIon and haaIIh 66
As in other sectors, private interests may also affect the selection and promotion of
staff to fll hospital positions, with posts going to the highest bidder or most connected
individuals, rather than to candidates with the best qualifcations. One study found that
auxiliary nurse-midwives pay bribes of six or seven times the monthly salary to obtain
positions in Uttar Pradesh state, India.
27
Also in India, the Delhi High Court found
that the president of the Indian medical council had accepted bribes to allow medical
colleges to sell seats to local students.
28
The cost of this type of corruption can be
very serious, affecting both the clinical practice of medicine, and the management of
hospital systems and performance. To reduce vulnerability, hospitals can try to open up
the hiring and promotion decision-making process, making criteria more transparent.
Performance monitoring is also essential to provide accountability.
1usI WhaI Iha dooIor ordarad. oorrupIIon In paymanI sysIams
Other forms of corruption including insurance reimbursement fraud, treatment
decisions based on fnancial motivation rather than the medical need and improper
referral relationships between doctors and hospitals (sometimes involving kickbacks)
can be traced to various forms of payment systems.
Reimbursement-system fraud may occur in countries with social insurance funds or a
sizeable private health care insurance market (see Chapter 1). Losses can be substantial:
the US government has estimated that improper Medicare fee-for-service payments,
including non-hospital services, may be in the range of US $11.923.2 billion per year,
or 6.814 per cent of total payments.
29
This sum must be interpreted with caution as it
may include unintentional mistakes or controversial decisions about what is labelled
necessary care, but it gives a sense of the magnitude of the problem. Health care fraud
includes false billing of insurance funds or governments for medical services that are not
supposed to be covered, services that were not actually delivered (sometimes because
the person is dead or does not exist, so-called ghost patients) or services that were not
medically indicated. It also includes the practice of upcoding diagnosis related groups
(DRGs), that is, classifying a case as more complicated or as having co-morbidities in
order to obtain reimbursement at higher rates.
Whether insurance systems are involved or not, hospitals and doctors may have
fnancial incentives to use increased resources in providing patient care. This is referred
to as provider-induced demand. Where services are needed, increased demand can be
good; however, fnancial incentives sometimes cause doctors to provide unnecessary
treatments, or marginally useful diagnostic tests. Fee-for-service payment systems
have been associated with increased utilisation of resources, sometimes to the point
of inappropriate use, as providers try to maximise their revenue by providing more
care. For example, researchers in Peru documented excessive caesarean section rates
in the Social Security Institute and private hospitals where doctors were paid on a fee-
for-service basis.
30
It is important to note that while demand may rise due to fnancial
incentives, it may still fall within the range of normal medical judgement. Where
provider-induced demand becomes abuse is when it is excessive and outside the range
normally considered medically indicated, yet this is far from simple to determine.
GC2006 01 part1 56 8/11/05 17:55:00
6orrupIIon In hospIIaIs 67
Less recognised but equally harmful from the viewpoint of patients may be the risks
introduced by managed care capitation payments, where hospitals and doctors may
engage in fraud resulting in underutilisation of care in order to maximise proft (see
Corruption in health care systems, Chapter 1, page 19). Again, it is hard to determine
where underutilisation falls outside the normal range and becomes abuse.
Another area of concern is when hospitals enter into fnancial relationships with
physicians to increase hospital referrals. Where hospitals are reimbursed by the state or
private insurers based on patient admissions or days of care delivered, it can be advan-
tageous for them to increase the number of patients admitted and to maintain high
occupancy (see the Columbia/HCA case, Corruption in health care systems, Chapter
1, page 20). One way to do this is to offer advantages to physicians who refer patients
to the hospital. Yet introducing fnancial incentives for referrals can present a danger:
even if the hospital is not best suited to meet a particular patients medical needs, the
physician may still refer the patient there in order to gain the fnancial advantage.
Financial incentives are sometimes used to promote medically needed care offered
at the most appropriate level, so it is not the use of fnancial incentives per se that
creates the danger for corruption. But the situation must be monitored and controlled
to prevent abuse. US federal law prohibits physician self-referrals, and a federal statute
proscribes kickbacks. Applying these laws in Nebraska, one hospital was charged
with underwriting a loan, paying consultants and providing free drugs and medical
equipment to a doctor in exchange for referrals.
31
The defnition of corruption in other situations is not so clear, as when a private 231-
bed hospital in the United States owned by Tenet, a large for-proft hospital corporation,
was charged with using relocation agreements to bribe doctors. Over a period of several
years, the hospital paid US $10 million to doctors who agreed to relocate their practices
to the area.
32
Although federal law specifcally prohibits hospitals from paying or
otherwise compensating doctors for referrals, the question was whether the relocation
agreements were devised to get around this law. The court case ended in a mistrial as
the jury could not agree on whether this was a violation of the law.
Payment system reforms are important to reduce vulnerability to this type of
corruption. In northern European countries, such as Finland, Sweden and the United
Kingdom, health reforms have shifted health care provision from fixed-budget
bureaucratic institutions to contract payments based on performance.
33
While this
increased operating effciency, it also required the state to play a more sophisticated
role in regulating services. Because it is diffcult to detect and control where utilisation
falls outside the range of normal practice, regulators may have more success with
approaches that reward providers for quality improvement.
34
k prasorIpIIon Ior raIorm
Strategies to prevent corruption in hospitals must be tailored to the particular ownership
structure, policy environment and health-fnancing situation in the country. The types
of corruption one will fnd, and the resources available for preventing corruption, are
likely to be different in low-income countries, compared with high-income countries.
GC2006 01 part1 57 8/11/05 17:55:00
6orrupIIon and haaIIh 6B
Yet the range of interventions for reducing vulnerability to corruption does include
some standard components. Once the types of corruption have been identifed and
prioritised, reform strategies such as those below should be considered and adapted.
These include strengthening management systems and tools, creating incentives,
increasing the likelihood of detecting corruption as well as the consequences of getting
caught, and developing better information and transparency initiatives to hold hospital
offcials and medical personnel to account.
8ox 8.8 ho brIbas Ior haaIIhy busInass. IndIas TransasIa 8IomadIoaIs
1
Indias leading manufacturer of high-tech diagnostic machines to check for life-threatening
blood diseases is Transasia Biomedicals, based in Mumbai. The brainchild of Suresh Vazirani,
Transasia began marketing imported diagnostic equipment in 1985, only branching into
manufacturing eight years later with the help of international manufacturers, such as
Sysmex, Wako and Nittec in Japan, Finlands Biohit and Trace in Australia.
What marks out Transasia is the dogged stance it takes against corruption. Vazirani
says he has never paid a paisa in bribes, but that avoiding corruption takes up more of
his time than any other issue. When he wanted to install a fountain in the lunch area,
two offcials demanded a US $100 bribe for a licence. It took four years in court, and
US $4,000, to deal with the case.
Vaziranis interest in fghting corruption stems from his nine years as a volunteer with
Moral Re-Armament (now Initiatives of Change), running industrial leadership training
courses. There he would urge businessmen not to be corrupt, he recalls. Thats all
very well, they would reply, but youve never run a business. You dont know what
its like.
He and a friend decided to go into business in 1979 and as the company grew from a
modest importer to a global player exporting to over 30 countries, so did the opportunities
for corruption. Vazirani risked losing a DM 20 million (US $12.6 million) sales contract
to Germany because a customs offcer wanted a bribe to release imported components.
Rather than pay, Vazirani left the components in the warehouse for three months. He
went to the top customs offcials and appealed to their sense of national pride. The
components were released just in time.
Recently, a politician suggested to Vazirani that it would be an opportunity if they each
pocketed part of the World Bank aid the politician had received to improve health care.
Yes, and is it an opportunity if we land up in hospital needing urgent care ourselves?
replied Vazirani. At this, the politician changed his tune, realising that Vazirani was not
to be bought.
In September 2003, Vazirani was a keynote speaker at the launch in Mumbai of
Transparency Internationals new Business Principles for Countering Bribery. Corruption
is a big road block to progress, he says. Because of it everything goes wrong. The
intimidation leads to wrong decision-making. Transasia can be an example. But many
more companies need to be.
Michael Smith (For A Change Magazine)
Note
1. Excerpt from For A Change Magazine, December 2003/January 2004.
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6orrupIIon In hospIIaIs 69
Managerial systems and tools
Important managerial systems and tools for preventing corruption in hospitals
include hospital drug formularies, review committees to certify need for new drugs or
equipment, competitive bidding and other best-practice procurement procedures, and
inventory systems to safeguard supplies. Each management system should have clearly
defned levels of responsibility and approval of decision-making, with appropriate
checks and balances. In addition to procurement, other management systems include
budgeting and planning systems to prevent spending that favours pet projects or people
and is not needs-based, and internal fnancial control systems to prevent theft and
embezzlement.
Anti-corruption strategies in the hospital sector need to be one step ahead of different
actors trying to abuse entrusted resources, and to penalise corrupt practices. Fraud
control programmes have proven effective in reducing corruption; for example, the
US federal government gets a return of US $8 on every US $1 spent on fraud control.
35
It recovered US $8 billion over 15 years through enforcement of the False Claims Act,
about half of which was health-related.
36
In addition to fnancial benefts, fraud control
efforts can also have health benefts and change patterns of care in desirable ways.
37
Incentives and consequences
There are conficts of interest inherent in most hospital payment systems, and the
infuence of payment systems on health care utilisation is a well-studied topic in health
policy literature. It is an area where careful monitoring and continuous analysis is
needed to ensure that patient safety and well-being are not being compromised by
actions taken to maximise providers income. A promising new area of research is in
performance-based contracting, especially payment systems that reward quality. At
the same time, it is important to promote laws and codes of conduct that explicitly
regulate hospitals and hospital administrators engagement in practices where confict
of interest is likely to be a problem (for example, owning supply companies), and that
encourage and reward professionalism.
Transparency and information
Since collusion among hospital personnel can subvert management control reforms,
transparency is an essential anti-corruption strategy. In the hospital sector, transparency
initiatives that should be considered include public access to procurement bidding
results, monitoring of procurement prices paid (as in the Argentinian example discussed
above), analysis of procurement bids for evidence of collusion, and setting performance
standards for hospitals and suppliers. This type of information, when shared with other
hospitals and citizen health boards or oversight committees, can both detect corruption
and serve as a deterrent.
Anti-corruption strategies should not target only agents or offcials working in
hospitals: many forms of hospital corruption are promoted by the producers or dealers
of medical equipment and drugs. Laws and codes of conduct for businesses supplying
hospitals should also be revised and enforced to prevent offers of bribes. Transparency
GC2006 01 part1 59 8/11/05 17:55:01
6orrupIIon and haaIIh 60
can also be effective here, through the publication of report cards monitoring the
compliance of private companies with these laws and codes of conduct. In addition,
in centralised, public health systems the government can create a blacklist of suppliers
caught bribing. Alternatively, the government can also share whitelists of suppliers
who consistently meet or exceed standards of performance.
Anti-corruption programmes should support health-sector fnancing and structural
reforms to assure that public systems are not over-promising and under-delivering.
Hospital systems and the medical personnel who staff them should be organised to
provide incentives for improved performance. This is especially important in resource-
constrained countries, where pressures to engage in corruption as a survival strategy
may be strong. To prevent corruption and promote health, hospitals need management
systems that are transparent, accountable and fair to both patients and providers.
hoIas
1. Taryn Vian is assistant professor at the Boston University School of Public Health, where
she conducts research and teaches courses on health care management and prevention of
corruption in the health sector. Carol Karutu assisted in researching this paper and Rich
Feeley provided feedback on an earlier draft.
2. D. Becker, D. Kessler and M. McClellan, Detecting Medicare Abuse, Journal of Health Economics
24(1), January 2005.
3. R. Taylor and S. Blair, Public Hospitals: Options for Reform through Public Private Partnerships,
(Public Policy for the Private Sector Note Number 241) (Washington, DC: World Bank, 2002);
J. Healy and M. McKee, Reforming Hospital Systems in Turbulent Times, Eurohealth 7(3),
2001.
4. R. Di Tella and W. D. Savedoff, Shining Light in Dark Corners in R. Di Tella and W. D.
Savedoff (eds) Diagnosis Corruption: Fraud in Latin Americas Public Hospitals (Washington,
DC: Inter-American Development Bank, 2001).
5. Boston Globe (US), 7 April 2004.
6. Bernama (Malaysia), 27 September 2004.
7. The East African (Kenya), 10 March 2003.
8. M. H. Jaen and D. Paravisini, Wages, Capture and Penalties in Venezuelas Public Hospitals,
in Di Tella and Savedoff, Diagnosis Corruption.
9. E. Schargrodsky, J. Mera and F. Weinschelbaum, Transparency and Accountability in
Argentinas Hospitals, in Di Tella and Savedoff, Diagnosis Corruption.
10. See www.haiweb.org/medicineprices/
11. G. Gray-Molina, E. Perez de Rada and E. Yez, Does Voice Matter? Participation and Controlling
Corruption in Bolivian Hospitals, in Di Tella and Savedoff, Diagnosis Corruption.
12. D. Kyaddondo and S. R. Whyte, Working in a Decentralised System: A Threat to Health
Workers Respect and Survival in Uganda, International Journal of Health Planning and
Management 18(4), OctoberDecember 2003.
13. B. McPake, D. Asiimwe, F. Mwesigye et al., Informal Economic Activities of Public Health
Workers in Uganda: Implications for Quality and Accessibility of Care, Social Science and
Medicine 49(7), 1999.
14. Di Tella and Savedoff, Diagnosis Corruption.
15. McPake et al., Informal Economic Activities.
16. P. Ferrinho, C. M. Omar, M. D. Fernandes, P. Blaise, A. M. Bugalho and W. Van Lerberghe,
Pilfering for Survival: How Health Workers Use Access to Drugs as a Coping Strategy, Human
Resources for Health 2(1), 2004.
17. Ibid.
GC2006 01 part1 60 8/11/05 17:55:01
6orrupIIon In hospIIaIs 61
18. Management Sciences for Health, Using Performance-Based Payments to Improve Health
Programmes, The Manager 10, 2001.
19. L. Alcazar and R. Andrade, Induced Demand and Absenteeism in Peruvian Hospitals, in Di
Tella and Savedoff, Diagnosis Corruption.
20. Schargrodsky et al., Transparency and Accountability, and P. Ferrinho, W. Van Lerberghe, I.
Fronteira, F. Hipolito and A. Biscaia, Dual Practice in the Health Sector: Review of Evidence,
Human Resources for Health 2(14), 2004.
21. R. Gruen, R. Anwar, T. Begum, J. R. Killingsworth and C. Normand, Dual Job Holding
Practitioners in Bangladesh: An Exploration, Social Science and Medicine 54(2), 2002.
22. Ferrinho et al., Pilfering for Survival.
23. P. Belli, G. Gotsadze and H. Shahriari, Out-of-pocket and Informal Payments in Health Sector:
Evidence from Georgia, Health Policy 70(1), October 2004; T. Vian, K. Gryboski, Z. Sinoimeri
and R. Hall, Informal Payments in the Public Health Sector in Albania: A Qualitative Study.
Final Report. Partners for Health Reform Plus Project (Bethesda, US: Abt Associates, Inc.,
2004); D. R. Hotchkiss, P. L. Hutchinson, M. Altin and A. A. Berruti, Out-of-pocket Payments
and Utilization of Health Care Services in Albania: Evidence from Three Districts (Bethesda,
US: Partners for Health Reformplus, 2004).
24. T. Vian, T. Gryboski, Z. Sinoimeri and R. Hall, Informal Payments in Government Health
Facilities in Albania: Results of a Qualitative Study, forthcoming in Social Science and Medicine,
2005.
25. The Nation (Kenya), 8 February 2001; Panafrican News Agency, 19 July 2003; African Business
(UK), January 2004.
26. S. Barber, F. Bonnet and H. Bekedam, Formalising Under-the-table Payments to Control
Out-of-pocket Hospital Expenditures in Cambodia, Health Policy and Planning, July 2004.
27. R. Balakrishnan, cited in B. Lee, M. Poutanen, L. Breuning and K. Bradbury, Siphoning off:
Corruption and Waste in Family Planning and Reproductive Health Resources in Developing Countries
(Berkeley: University of California Press, 1999).
28. The Lancet (UK), 358, 2001.
29. Becker et al., Detecting Medicare Abuse.
30. Alcazar and Andrade, Induced Demand and Absenteeism.
31. See note 27.
32. Modern Healthcare 33, 2003.
33. R. B. Saltman, Regulating Incentives: the Past and Present Role of the State in Health Care
Systems, Social Science and Medicine 54, 2002.
34. New York Times (US), 13 March 2005.
35. J. A. Meyer and S. E. Anthony, Reducing Health Care Fraud: An Assessment of the Impact
of the False Claims Act. Report prepared by New Directions for Policy (Washington, DC:
Taxpayers Against Fraud, 2001).
36. Pharmaceutical Executive 21(11), 2001.
37. Becker et al., Detecting Medicare Abuse.
GC2006 01 part1 61 8/11/05 17:55:01
6orrupIIon and haaIIh 6Z
4 InIormaI paymanIs Ior haaIIh oara
Television spot, autumn 2004, highlighting the problem of informal payments for health care
in Lithuania. (TI Lithuania)
Informal payments charges for services or supplies that are supposed to be free are
common in many parts of the world, especially in developing and transition countries.
While it is diffcult to draw a line between voluntary gift and mandatory payment,
and between payments that should be considered bribes or extortion, and those that
are better understood as a coping mechanism for underpaid caregivers, there is less
disagreement about the damaging effects these payments have on health systems
worldwide.
Sara Allin, Konstantina Davaki and Elias Mossialos look at the causes and consequences
of informal payments in Central and Eastern Europe and the Commonwealth of
Independent States, where informal fnancing is a legacy of communist health care
systems. They argue that raising the wages of health professionals alone is unlikely
to eliminate the problem and point to a number of essential policy measures, such as
developing appropriate incentives and suitable information systems to support the
accounting and auditing of payments. A case study from Hungary shows that, despite
GC2006 01 part1 62 8/11/05 17:55:01
InIormaI paymanIs Ior haaIIh oara 68
the relatively small sums involved, informal payments can lead to a massive distortion
of the health system. The example from Morocco demonstrates that small, under-the-
table payments can be a serious obstacle to poor patients accessing medical care.
FayIng Ior Iraa haaIIh oara. Iha oonundrum oI InIormaI
paymanIs In posIoommunIsI Luropa
Sara Allin, Konstantina Davaki and Elias Mossialos
1
Informal payments for health care in the countries of Central and Eastern Europe (CEE)
and the Commonwealth of Independent States (CIS the former Soviet Union excluding
the Baltic states) are widespread. Informal, under-the-table or envelope payments
are typically defned as direct payments by patients for services they are entitled to
for free, usually in a public health system. Informal payments range from the ex ante
cash payment to the ex post gift-in-kind. While the common practice of gift giving as
an expression of gratitude is, in principle, benign, informal payments that resemble
fee-for-service have potentially serious implications.
They can undermine offcial payment systems, distort the priorities of the health
system, reduce access to health services and impede health reforms. They can also
provide undesirable incentives and encourage unprofessional behaviour, including
rent-seeking behaviour by health workers. It is diffcult to disentangle the specifc
form of informal payment and decipher what constitutes corruption; the different
manifestations of informal payment can be placed on a continuum of gravity ranging
from nuisance to obstacle to barrier and, ultimately, to self-exclusion.
2
Reducing the
extent of informal charging is far from straightforward and represents an enormous
task for policy-makers.
Informal payments exist for several reasons, including economic ones such as a
general scarcity of fnancial resources in the public system; and socio-cultural ones,
such as the lack of trust in government and a culture of tipping. Most of the CEE
and CIS countries health systems were modelled on the Soviet Semashko system of
universal health care coverage, with a virtually exclusive role for the state in fnancing
and delivery. Informal payments became a common feature of these health systems,
since the state could not deliver what it promised. Following the economic and social
crisis with the fall of communism and the break-up of the Soviet Union, health care
suffered even further in terms of resource availability and service quality. Health system
characteristics that may help explain the prevalence of informal payments include an
excess supply of capital and human resources, low salaries, lack of accountability and
government oversight, and an overall lack of transparency. Human resource shortages
may also drive informal payments as it may lead to providers giving priority to those
patients that can afford to pay. A paucity of private services may also drive informal
payments, as wealthier patients have fewer options outside of the public system. Also,
the population may not be adequately informed of the health services they are entitled
to free of charge.
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6orrupIIon and haaIIh 64
Some scholars argue that informal payments arose as a reaction by dissatisfed patients
and providers to shortcomings within the health system during the communist era.
3
Given the defciencies regarding quality and availability, there were no opportunities for
dissatisfed patients to opt out, as there was no private sector alternative, nor to voice
their complaints, as these were regarded as direct criticism of the government. Providers
were faced with low salaries and no explicit state-organised rationing mechanisms.
Thus informal payments became an established practice and served as an alternative
method of enabling patients to pay for better quality.
Throughout the 1990s, staff salaries in CEE countries were, and many continue to
be, very low and payments were often delayed. In Lithuania and Ukraine, health care
workers are reported to have waited up to three months to be paid, with even longer
waiting times in Russia.
4
Money was instead sought directly from patients and provided
to staff. While these informal payments allowed health care staff to continue providing
services during periods of economic diffculty, the demand for payments also resulted
in the exclusion of those unable to pay. Those most severely affected were the poorest
and the chronically ill.
Tha soaIa oI InIormaI paymanIs
The clandestine nature of informal payments makes accurate accounting diffcult. By
defnition, informal payments are made without any record of the transaction and are
often illegal, making both patients and providers reluctant to discuss them.
5
Furthermore,
interpretation of what constitutes an informal payment differs across regions and
countries, making generalisations and cross-country comparisons inappropriate. For
example, discrepancies in the perceived nature of informal payments have been shown
between providers and the public in Albania, with providers perceiving payments as gifts
and the public viewing fees as necessary to receive services.
6
Despite these diffculties,
recent surveys and qualitative studies indicate that informal payments have come to
represent a large proportion of total health expenditure in CEE and CIS countries.
Informal payments constitute 84 per cent of total health expenditure in Azerbaijan
7
and out-of-pocket payments contribute around 7080 per cent of total health spending
in Georgia, half of which is estimated to be informal.
8
They are also an important
form of health care fnancing in other countries, representing 56 per cent of total
health expenditure in the Russian Federation, and 30 per cent in Poland.
9
In Tajikistan,
household spending on health averages US $8.58 per person per annum compared
to government expenditure of US $3.75.
10
Similarly, the Albanian Living Standards
Measurement Survey of 2002 estimated out-of-pocket (both formal and informal)
expenditures constituted more than 70 per cent of total health expenditure.
11
Survey data of the prevalence of informal payments among service users highlight
the severity of the problem and identify substantial diversity across countries. Informal
payments are mainly associated with in-patient care settings, particularly surgery, and
several surveys have found that they tend to be more common in large towns and
cities. A 1999 World Bank/USAID survey observed that 71 per cent of GP visits and 59
per cent of specialist visits involved payments in Slovakia.
12
In Latvia, the TI Annual
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InIormaI paymanIs Ior haaIIh oara 66
Report 2000 estimated that approximately 25 per cent of patients made informal
payments sometimes, while 5.7 per cent made payments on almost every visit. A
regional breakdown showed that Riga had the highest proportion of under-the-table
payments, with 46.1 per cent of Riga respondents having made such payments.
13
In
Bulgaria, informal payments are more common in the capital city, Sofa, with 51 per
cent of survey respondents reporting paying without a receipt for a doctor or dentist.
14
In Romania, informal payments are prevalent and account for 41 per cent of total
out-of-pocket expenditure.
15
A recent survey of public perceptions conducted by the
Centre for Policies and Health Services revealed that 39 per cent of people with high
incomes paid unoffcial fees or gifts for medical services in 2001, while 33 per cent of
people with below-average income paid unoffcial fees or gifts.
16
There is evidence in some countries of an increasing trend in the proportion of health
service visits incurring charges throughout the 1990s. Between 1993 and 1998, the
number of patients in Slovakia who paid for hospital admissions grew by approximately
10 per cent.
17
In Bulgaria, out-of-pocket payments (including both formal and informal
payments) increased from 9 per cent of total expenditure in 1992 to 21 per cent in
1997.
18
In Kyrgyzstan, while 11 per cent of patients who visited a physician reported
paying informally in 1993, 50 per cent did so in 1996.
19
In Kazakhstan, while out-
of-pocket payments were, at least offcially, virtually non-existent prior to 1991, by
1996, 30 per cent of visits were charged either formally or informally.
20
It is not clear
whether these changes refect a real increase in informal payments or an increase in the
willingness of individuals to report them, and surveys have not dealt with this issue.
Tha roIa oI physIoIans
The role of physicians in shaping expectations regarding informal payments is crucial.
The status of the profession can also shape physicians attitudes toward accepting
payments directly from patients. Evidence on private expenditures in Poland reveals
that informal payments nearly double physicians formal salaries, suggesting overall
that managing existing resources poses a more diffcult challenge than fnding new
resources. There is also a direct beneft for hospital physicians, where informal payments
constitute 46 per cent of all patient expenditure in hospitals, thereby leading to an
increase in physician salaries by 15 per cent.
21
In Bulgaria, doctors allegedly receive informal payments of up to US $1,100,
signifcantly augmenting the average monthly salary of US $100.
22
Evidence from
Bulgaria also suggests that the unoffcial cost of an operation accounted for more than
80 per cent of the average monthly wage.
23
With health workers in Tajikistan among
the lowest paid in the country, informal payments and gifts-in-kind represent the main
source of income for many providers.
24
By contrast, informal payments are not high
in the Czech Republic where doctors salaries have risen above the rate of infation of
average wages. A 2000 survey of health care staff and public offcials revealed that 5 per
cent of Czech doctors confessed to accepting something more than a small gift.
25
However, poor pay alone does not seem to explain physicians readiness to accept
informal payments. Doctors in Bulgaria, Slovakia and the Czech Republic were more
GC2006 01 part1 65 8/11/05 17:55:02
6orrupIIon and haaIIh 66
likely than the average government offcial to have reported a second income, and were
also well above average in their reporting of having a family income that was enough
for a fair or good standard of living. More signifcantly, while poor pay increased the
willingness to accept gifts, it was those with the highest salaries and the highest family
income who received such payments more frequently, a likely result of the positions of
power held by these individuals.
26
It is not enough, therefore, to increase the salaries
of doctors in line with or even above general wages or general public sector incomes.
For example, in Greece, substantial increases to hospital physician salaries after the
introduction of a national health service in the early 1980s had no impact on the
prevalence of informal payments.
27
Tha ImpaoI oI InIormaI paymanIs
The impact of informal payments on the health system is diffcult to measure. Payments
that solely express gratitude in the form of a donation and are given willingly after a
service is delivered may not have any adverse impact on effciency, quality or equity.
However, in countries where this gratitude form of payment is common, the fee-for-
service type of informal payment that physicians may demand and may determine access
to and/or quality of services has serious adverse effects on effciency and equity.
Informal payments can be viewed either as contributing to the cost of services, or as
an abuse of power by the physician since the patient is placed in a situation with little
choice of provider and immediate need of service. The two types of informal payment
require different policy responses: the former calls for increasing health resources, in
part by formalising payments, while the latter necessitates regulating and monitoring
providers.
28
However, in either case, it is likely that the practice of informal payments
contributes to resource allocation that is distorted away from the social optimum:
rather than being allocated to those in most need, health services will instead favour
those who are able to pay, or are easily coerced into paying.
The impact of informal payments on quality is uncertain. Some argue that the quality
of services is better for those who pay informally, while others contend that payments
lead to unnecessary additional services. Using data from a survey of hospital patients
in Kazakhstan in 1999, Thompson and Xavier found that informal payment and the
amount paid are generally associated with better-quality services. This is evidenced
by decreased waiting time, longer length of hospital stay and patients subjective
ratings of quality.
29
But if service quality is improved when payment is made, the
benefts are restricted to that individual. Moreover, physicians are likely to keep the
payment for their own personal gain rather than improve services by investing it in
the facility. As a result, improved medical equipment, more effcient heating systems
and infrastructure, raised nursing standards and other necessary elements of a health
system are neglected.
There is little evidence on how informal payments affect utilisation, but patients
who cannot afford the extra cost are either unable to obtain treatment or they cannot
access the same quality of services or have to wait longer for care. Poorer patients have
to make signifcant sacrifces in order to pay for essential health care services, as seen
GC2006 01 part1 66 8/11/05 17:55:02
InIormaI paymanIs Ior haaIIh oara 67
in Romania.
30
In Kyrgyzstan, one in three patients reported borrowing money for in-
patient care, and in rural areas, 45 per cent of in-patients sold produce or livestock to
cover hospital costs.
31
In Georgia, qualitative evidence highlights several examples of
sacrifces people have to make for health services, such as paying 12 lari for treatment
for poisoning (compared to the average monthly salary of 15 lari), while others are
forced to borrow money or sell household valuables to pay for health services.
32
Evidence suggests that informal payments are regressive: although poor individuals
pay less in absolute terms than the rich, they pay more as a proportion of their income.
This is the case in Albania, Bulgaria, Georgia, Kyrgyzstan, Kazakhstan and Moldova. In
Kazakhstan, the poor spent 252 per cent of their monthly income on in-patient care,
compared to only 54 per cent among the better off for the same type of services.
33
The
percentage of household income spent on informal payments in the late 1990s ranges
from 4.1 per cent in Romania, 4.4 per cent in Bulgaria, 9.1 per cent in Albania, to
20.6 per cent in Georgia.
34
In Georgia, 94 per cent of survey respondents were unable
to seek health care in 1997 due to its high cost, similar to fndings from Albania and
Tajikistan.
35
Likewise, surveys conducted in 2001 found that in Armenia and Georgia,
over 70 per cent of people reporting illness but not seeking care reported not seeking
care because they could not afford it.
36
In addition to the fnancial barriers imposed
by fees, patients in some countries are further deterred by the uncertainty about prices
caused by informal payments. Nonetheless, there is no evidence as to whether offcial
fees affect equity more strongly than informal payments do.
In some countries, providers may make exemptions for low-income households and
engage in price discrimination. Results from a recent study in Georgia suggest that
informal payments depend to some extent on the providers assessment of a patients
ability to pay which, though vague and likely inaccurate, may minimise the fnancial
barrier to access.
37
Nevertheless, the reverse has also been seen, with evidence from
Armenia suggesting a refusal to care for people unable to pay informal fees.
38
One of the most important implications of informal payments is that they undermine
governments efforts to improve accountability and contribute to the growth in
corruption endemic in many CEE and CIS countries. The relationship between
corruption and informal payments is complex and bidirectional. To simplify, a lack
of resources generates the need for additional income, hence informal payments are
made and over time become established practice. This, coupled with a lack of regulatory
capacity and a lack of monitoring and payment systems that are not linked to output,
exacerbates existing corruption in public policy. The existence of informal payments
is at odds with transparent public policy and erodes trust in government.
FoIIoy opIIons
In order to reduce informal payments, serious efforts are needed to rebuild lost trust in
health care, raise salaries, ensure good quality of care and improve accountability and
transparency. Governments should be explicit and reasonable in defning a benefts
package of services provided at a suffciently high standard for everyone within the
GC2006 01 part1 67 8/11/05 17:55:02
6orrupIIon and haaIIh 6B
funding that is available. Efforts should be made to adequately inform the population
of the benefts package provided by the state and any services that do incur charges.
One possible policy option is to formalise informal payments and develop appropriate
exemption schemes. However, formalising informal payments will not solve the
problem since informal payments may continue to exist alongside the formal charges,
which has been the case in Georgia and Bulgaria.
39
One diffculty that governments
face in converting informal payments into formalised cost-sharing arrangements is
securing compliance from providers, many of whom may lose income. Experience
from low-income countries suggests that a successful conversion to formal cost-sharing
depends on the ability of government to regulate providers and set priorities or limit the
services on offer.
40
For example, in Bulgaria, payments were formalised in 1997 with no
signifcant increase in revenue (less than 1 per cent of municipal health expenditure)
and there is no evidence that exemptions are being used.
41
While the formalisation
of informal payments is one possible option, it is essential that these payments be
transparent and monitored in order to ensure they actually replace informal payments.
Moreover, funds should remain in the health sector, with decentralised retention of
revenue to allow local improvements in quality of care. If payments translate into staff
bonuses, these should refect performance in order to provide incentives to improve
quality and productivity.
In addition to formalising informal payments, private sector involvement can take two
forms: private provision and private health insurance. Some argue that allowing private
sector involvement in health care delivery may help curb the rise in informal payments
by allowing wealthier patients an alternative to the public system, and offering providers
an alternative or supplementary salary. Private health care organisations have developed
signifcantly in Lithuania, for example, and the number of physicians working in the
private sector has increased in recent years. Surveys in that country reveal a decline in
informal payments corresponding with the growth of private providers.
42
This trend
seems to follow the Czech experience regarding the role and compensation of providers,
where there is a clear division in earnings between physicians in private practice and
those employed by the state, although average earnings of public physicians have stayed
above the average national earnings and informal payments are rare.
43
However, perverse incentives associated with permitting private practice among
public physicians may arise, which may compromise the quality of care and increase
waiting times of individuals who cannot afford to pay for private care. It is possible
that allowing private practice may boost incomes and lead to a reduction in informal
payments but, if public time and facilities are used for private practice, resources are
directed to the wealthier individuals and away from those who cannot afford to pay.
Also, physicians may make cross-referrals from their public to their private practices,
in order to generate more income.
Private insurance may also be an option to formalise informal payments while also
pooling risks. However, informal payments and cultural tendencies regarding the
fnancing of medical care may restrict the growth of private insurance. Patients may
be more comfortable paying physicians and other providers directly, while paying
third-party entities may be viewed as needlessly meddling with the doctorpatient
GC2006 01 part1 68 8/11/05 17:55:02
InIormaI paymanIs Ior haaIIh oara 69
relationship and reducing assurances of quality care.
44
In Slovakia, informal payments
are signifcant and the market for private medical insurance is not substantial. This is
despite the fact that a 2001 Agency Markant survey found that one-third of respondents
were distrustful of the General Health Insurance Company while almost two-thirds did
not trust the Ministry of Health.
45
At the same time, indiscriminate support of private sector expansion and encouraging
individuals to opt out of the public system may not be such a good idea since there
is a risk that the majority of quality-conscious patients would leave the public sector,
and it is likely to lead to a two-tier system: a poorly performing public and a well
performing private one. Enough fnancial resources should rather be made available
to provide the services of a realistic beneft package at a reasonably good standard to
everybody, and new innovative methods of accountability should be made available
for the transparent handling of local performance problems. The key issue is to ensure
a high quality of care.
Although one possible policy approach is to shift toward more decentralised social
insurance models of health system organisation, this may not necessarily reduce
the extent of informal payments. While surveys conducted before and after the
implementation of a national insurance scheme in Lithuania reveal a decline in the
extent of informal payments,
46
no decrease was observed after the implementation
of a national health insurance system in Romania, despite the fact that monthly
contributions under the Romanian system are compulsory regardless of whether any
services are actually received.
47
The ability to improve effciency and quality without jeopardising equity critically
depends on a number of policy measures, including the skills and capacity of staff,
the development of appropriate provider incentives, and the existence of suitable
information systems to support the accounting and auditing of payments. Health
reforms should also target excess capacity, since incentives created by informal
payments can lead to overuse of available staff. Reducing the number of physicians,
where appropriate, can also help increase wages and the professional status of medical
staff, although wages alone are unlikely to have long-term effects. Evidence supporting
the view that increased wages reduce informal payments may be found in the Czech
Republic, where a reduction in number of Czech physicians was accompanied by salary
increases, and in Poland, capitated primary care physicians, who were the highest paid,
were the only ones not making additional charges.
48
The challenges facing CEE and CIS countries regarding informal payments are great.
They represent an important source of revenue in countries in which pre-payment
systems have collapsed, so phasing them out without developing suitable alternatives
may be damaging. It is clear that multiple, concurrent strategies are needed to eliminate
informal payments and to convince the population that good-quality health services
can be available without paying under the table. The frst step is for governments to
acknowledge the existence and full impact of informal payments and to develop more
appropriate and affordable benefts packages, and information and monitoring systems
with genuine penalties for infringement. This is also contingent upon the existence of
political will to address corruption and lack of transparency in broader public policy.
GC2006 01 part1 69 8/11/05 17:55:03
6orrupIIon and haaIIh 70
hoIas
1. Sara Allin is a research offcer in health policy at LSE Health and Social Care, London School
of Economics and Political Science, and at the European Observatory on Health Systems and
Policies. Konstantina Davaki is a research offcer in health and social policy at LSE Health and
Social Care. Elias Mossialos is a professor of health policy in the Department of Social Policy,
London School of Economics and Political Science, co-director of LSE Health and Social Care
and research director of the European Observatory on Health Systems and Policies.
2. J. Killingsworth, Formal and Informal Fees for Health Care (Manila: WHO Regional Offce for
the Western Pacifc, 2003).
3. P. Gal and M. McKee, Informal Payment for Health Care and the Theory of INXIT,
International Journal of Health Planning and Management 19, 2004.
4. J. Healy and M. McKee, Health Sector Reform in Central and Eastern Europe, Health Policy
and Planning 12(4), 1997.
5. To our knowledge, no country explicitly accepts informal payments in their legislation, though
countries vary in the degree to which restrictions are enforced. In Bulgaria, for example,
offcial attitudes to informal payments are ambiguous; between 1989 and 1997 there was
no formal ban and a 1997 decree outlining services for which a fee applied left provisions
vague and subject to local discretion (D. Balabanova and M. McKee, Understanding Informal
Payments for Health Care: The Example of Bulgaria, Health Policy 62, 2002).
6. T. Vian, K. Gryboski, Z. Sinoimeri and R. H. Clifford, Informal Payments in the Public Health
Sector in Albania: A Qualitative Study (Bethesda, US: Partners for Health Reformplus Project,
Abt Associates, Inc., 2004).
7. M. Lewis, Who is Paying for Health Care in Eastern Europe and Central Asia? (Washington,
DC: World Bank, 2000).
8. P. Belli, G. Gotsadze and H. Shahriari, Out-of-pocket and Informal Payments in the Health
Sector: Evidence from Georgia, Health Policy 70, 2004.
9. Lewis, Who is Paying for Health Care?
10. J. Falkingham, Poverty, Out-of-pocket Payments and Access to Health Care: Evidence from
Tajikistan, Social Science and Medicine 58, 2004.
11. M. E. Bonilla-Chacin, Health and Poverty in Albania: Background Paper for the Albania Poverty
Assessment, Europe and Central Asia Sector for Human Development (Washington, DC: World
Bank, 2003).
12. L. Vagac and L. Haulikova, Study on the Social Protection Systems in the 13 Applicant Countries:
Slovak Republic Country Report (Brussels: Commission of European Communities, 2003).
13. Ibid.
14. D. Balabanova and M. McKee, Understanding Informal Payments for Health Care: The
Example of Bulgaria, Health Policy 62, 2002.
15. P. Belli, Formal and Informal Household Spending on Health: A Multi-country Study in Central and
Eastern Europe (Cambridge, MA: Harvard School of Public Health, 2003).
16. V. Mihai, Study on the Social Protection Systems in the 13 Applicant Countries: Romania Country
Report (Brussels: Commission of the European Communities, 2003).
17. Vagac and Haulikova, Study on the Social Protection Systems: Slovak Republic.
18. Balabanova and McKee, Understanding Informal Payments for Health Care.
19. J. Falkingham, Barriers to Access? The Growth of Private Payments for Health Care in
Kyrgyzstan, EuroHealth 4, 1998/99.
20. T. Ensor and L. Savelyeva, Informal Payments for Health Care in the Former Soviet Union:
Some Evidence from Kazakhstan, Health Policy and Planning 13(1), 1998.
21. M. Chawla, P. Berman and D. Kawiorska, Financing Health Services in Poland: New Evidence
on Private Expenditures, Health Economics 7, 1998.
22. T. Ensor, Informal Payments for Health Care in Transition Economies, Social Science and
Medicine 58, 2004.
23. E. Delcheva, D. Balabanova and M. McKee, Under-the-counter Payments for Health Care:
Evidence from Bulgaria, Health Policy 42, 1997.
GC2006 01 part1 70 8/11/05 17:55:03
InIormaI paymanIs Ior haaIIh oara 71
24. Falkingham, Barriers to Access?
25. W. L. Miller, A. B. Grodeland and T. Y. Koshechkina, If You Pay, Well Operate Immediately,
Journal of Medical Ethics 26, 2000.
26. Ibid.
27. E. Mossialos, S. Allin and K. Davaki, Analyzing the Greek Health System: A Story of
Fragmentation and Inertia, Health Economics 14(51), 2005.
28. Ensor, Informal Payments for Health Care in Transition Economies.
29. R. Thompson and A. Xavier, Unoffcial Payments for Acute State Hospital Care In Kazakhstan.
A Model of Physician Behaviour with Price Discrimination and Vertical Service Differentiation.
Discussion Paper 124/2002 (Brussels: LICOS Centre for Transition Economics, 2002).
30. Belli et al., Out-of-pocket and Informal Payments.
31. Lewis, Who is Paying for Health Care?
32. G. Gotsadze, S. Bennett, K. Ranson and D. Gzirishvili Health Care-seeking Behaviour and
Out-of-pocket Payments in Tbilisi, Georgia, Health Policy and Planning 20(4), 2005; Belli et
al., Out-of-pocket and Informal Payments.
33. A. Sari, J. Langenbrunner and M. Lewis, Affording Out-of-pocket Payments for Health Care
Services: Evidence from Kazakhstan, Eurohealth 6(2), 2000.
34. Lewis, Who is Paying for Health Care?
35. Ibid.
36. D. Balabanova, M. McKee, J. Pomerleau, R. Rose and C. Haerpfer, Health Service Utilisation
in the Former Soviet Union: Evidence from Eight Countries, Health Services Research 39,
2004.
37. Belli et al., Out-of-pocket and Informal Payments.
38. Lewis, Who is Paying for Health Care?
39. Belli et al., Out-of-pocket and Informal Payments; Balabanova and McKee, Understanding
Informal Payments for Health Care.
40. A. Mills and S. Bennett, Lessons on Sustainability from Middle to Lower Income Countries
in E. Mossialos, A. Dixon, J. Figueras and J. Kutzin (eds) Funding Health Care: Options for Europe
(Buckingham: Open University Press, 2002).
41. Balabanova and McKee, Understanding Informal Payments for Health Care.
42. A. Dobravolskas and R. Huivydas, Study on the Social Protection Systems of the 13 Applicant
Countries: Lithuania (Brussels: Commission of the European Communities, 2003).
43. M. Rokosov, P. Hva, J. Schreygg and R. Busse, Health Care Systems in Transition: Czech Republic
(Copenhagen, WHO Regional Offce for Europe on behalf of the European Observatory on
Health Systems and Policies, 2005).
44. E. Mossialos and S. Thomson, Voluntary Health Insurance in the European Union: A Critical
Assessment, International Journal of Health Services 32(1), 2002.
45. Vagac and Haulikova, Study on the Social Protection Systems: Slovak Republic.
46. Dobravolskas and Huivydas, Study on the Social Protection Systems: Lithuania.
47. Mihai, Study on the Social Protection Systems: Romania.
48. Lewis, Who is Paying for Health Care?
III, Iaa or brIba? InIormaI paymanIs In hungary
Pter Gal
1
After 15 years of reform, informal payments for health care, a legacy of the socialist
health care system, still generate heated debates in Hungary. In 2004, a young father
set up a website, halapenz.hu,
2
where parents of newborn babies were invited to share
their experiences about the obstetrician that delivered the baby, including how much
they paid for the service. What makes this story remarkable is that Hungary has a social
GC2006 01 part1 71 8/11/05 17:55:03
6orrupIIon and haaIIh 7Z
insurance system in which virtually everybody is entitled to receive almost all health
services, free of charge. The doctors who appeared on the list were quick to react,
demanding the website be shut down which was unsurprising since such payments
are subject to income tax and should have been declared. The case attracted strong
media attention, especially when the website was shut down after the ombudsman
said it violated the doctors right to privacy. The incident sparked an intense debate
about the legality of informal payments, the motivation of the patients and whether
or not the practice should be banned. But after a couple of months, interest faded and
it was back to business as usual.
hoW WIdaspraad ara InIormaI paymanIs?
Research has shown consistently that informal payments are widespread in the health
sector in Hungary, but the fndings vary widely as to the magnitude. An analysis of
available data shows that the share of informal payments was 1.54.5 per cent of
total health care expenditure in Hungary in 2001.
3
This amounts to 13.5 per cent of
yearly net income for the average household, even if we take into account that only
one-third of households reported expenditures on informal payments in 2001.
4
This
does not seem much in comparison with other former communist countries, where
the majority of health expenditures are informal payments (see Paying for free health
care, page 64).
To understand the impact of informal payments, however, the aggregate total of
money is less important than its distribution. Surveys in Hungary have shown that 90
per cent of payments go to medical doctors and to particular specialities and services,
with deliveries and surgical procedures being the best paid.
5
Using the low estimate and
distributing the amount equally among doctors in specialities where informal payments
exist, income from informal payments contributes about 6075 per cent of physicians
offcial net salary. This suggests that the signifcance of informal payments stems not
from their overall magnitude but from the consequences of their unequal distribution.
The case of Hungary shows that policy-makers should not ignore the phenomenon of
informal payments, even though the total sums involved are small.
Tha prassura Io pay
Determining whether informal payments are fees, gifts or bribes is important in
determining what can be done to curb them but, more importantly, whether they
should be eliminated at all.
6
It is not easy to dismiss the donation explanation of
informal payments. In Hungary, many surveys found that the majority of patients
paid the doctor out of gratitude, or at least the majority said they were motivated by
gratitude when they made the payment.
7
On the other hand, a more thorough analysis
reveals subtle contradictions, which indicate that surveys are not always the best tool
to capture patients true motivation.
Indeed, in our survey, follow-up interviews with respondents reveal that the motivation
behind informal payments is multifaceted and that even in apparently straightforward
GC2006 01 part1 72 8/11/05 17:55:03
InIormaI paymanIs Ior haaIIh oara 78
cases of gratitude payment there is always pressure to pay.
8
For instance, patients take
it for granted that a chosen doctor must be paid extra or, in certain cases, patients
feel that they must give something, if the doctor pays more than usual attention.
These fndings suggest that informal payment is rarely motivated by gratitude alone.
Yet despite the arguments against it, the gratitude motive has deeply infltrated the
explanation of the phenomenon in Hungary and is stubbornly adhered to by patients,
doctors and policy-makers alike.
At the systemic level, informal payments can rather be explained as the response
of patients and doctors to the shortages generated by the states socialist health care
system. Though several systemic features contributed to this shortage, the most notable
was the low salaries of health care professionals. Low salaries alone created shortage,
either because doctors lowered their performance (No one can expect me to work hard
for such a low remuneration!) or because they had to take part-time jobs and made
patients suspicious about the quality of the provided service (Can I be certain that this
overworked doctor will provide me with the service I need?). Taking into account the
information asymmetry between patients and doctors, low salaries could also erode
trust (Is it realistic to expect this underpaid doctor to do everything to cure me?).
Hence shortage does not need to be real to generate informal payments.
Lassons Irom Iha hungarIan axparIanoa
Informal payments in Hungary seem to stem from a reaction by dissatisfed patients
and doctors to the shortage generated by the socialist health care system, which was
long on promise and short on delivery. Patients and doctors adapted to the situation by
reinterpreting the declared but unfulflled offcial entitlement to comprehensive high-
quality care and a decent salary for honest work. Where the reassessment of patients
and doctors coincided, a new, unwritten set of entitlements emerged.
The health sector reforms of the past 15 years have not fundamentally changed this
set-up. Informal payments continue to be a challenging problem for health policy since
they have the embedded incentives of a fee-for-service policy, without the transparency
and control of formal out-of-pocket payments. Neither taxing informal payments nor
legally enforcing non-payment are viable policy options since both patients and doctors
have seen unrealistic rules fouted. Successful policies have to tackle shortage in the
health sector, either by curtailing the generous benefts package and/or incorporating
additional funds by formalising informal payments as co-payments.
9
Mapping informal payments could help in the design of a co-payment system that
would be accepted by the population, but it cannot be assumed that the existence of
a formal out-of-pocket payment system will necessarily prevent patients from paying
extra. Indeed, payment is likely to continue until patients are wholly convinced the
system will deliver effective care without additional incentives. Hence attempts to
eliminate informal payments require concerted action to rebuild the lost trust in health
care. Local initiatives such as the Hungarian care coordination pilot,
10
which builds
on partnership and participation, can help to re-establish the trust-based relationship
between the public and physicians, and thus provide a different set of expectations for
GC2006 01 part1 73 8/11/05 17:55:03
6orrupIIon and haaIIh 74
their future encounters.
11
Under this programme, local health care providers (doctors,
clinics or hospitals) assume responsibility for the whole spectrum of care for residents
in their area, and they are provided with data on their patients by the national health
insurance fund to monitor actual service utilisation.
Nevertheless, any reforms have to take into account the political complexities of
the current system, as well as the resistance that will inevitably ensue if attempts to
eliminate informal payments are made. Though important, recognising that the concept
of gratitude payment is no more than a convenient myth that has been used to make
an unacceptable phenomenon acceptable is only the frst step towards the formulation
of more effective policies in this area.
hoIas
1. Pter Gal is assistant professor at the Health Services Management Training Centre, at
Semmelweiss University, Hungary.
2. Hlapnz is the Hungarian term for informal payment. It literally translates to gratitude
payment.
3. Pter Gal, Informal Payments for Health Care in Hungary (London: London School of Hygiene
and Tropical Medicine, University of London, 2004).
4. Hungarian Central Statistical Offce, Yearbook of Household Statistics 2001 (Budapest: Hungarian
Central Statistical Offce, 2002).
5. For a summary of these surveys, see Pter Gal, Tamas Evetovits and Martin McKee, Informal
Payment for Health Care: Evidence from Hungary, Health Policy (forthcoming).
6. Pter Gal and Martin McKee, Fee-for-service or Donation? Hungarian Perspectives on
Informal Payment for Health Care, Social Science and Medicine 60, 2005.
7. For a summary of the fndings of surveys see Gal, Informal Payments for Health Care in
Hungary.
8. Ibid.
9. Pter Gal and Martin McKee, Informal Payments for Health Care and the Theory of Inxit,
International Journal of Health Planning and Management 19, 2004.
10. Pter Gal, Health Care Systems in Transition: Hungary (Copenhagen: WHO Regional Offce
for Europe on behalf of the European Observatory on Health Systems and Policies, 2004).
11. Gal and McKee, Fee-for-service or Donation?
8ox 4.1 InIormaI paymanIs Iaka a IoII on Moroooan paIIanIs
My husband injured his hand at work and was taken to a public hospital. He had to
pay 300 dirhams (US $33) to get an X-ray and 200 to have the injury stitched. He then
had to pay another 500 dirhams just to be allowed to stay in the hospital.
(Woman interviewed in Casablanca)
When my wife went to the hospital they examined her and prescribed some pills. They
said that none were available there, but if we paid 20 or 30 dirhams (US $23), someone
could provide the free medication. The problem is, we cant afford the drugs.
(Man interviewed in Casablanca)
4
GC2006 01 part1 74 8/11/05 17:55:04
InIormaI paymanIs Ior haaIIh oara 76
Four out of fve people interviewed in a Transparency International (TI) Morocco survey
in 2002 described corruption in the public health system as common to very common.
1
Morocco has a system of poverty certifcates, designed to guarantee the poor access to
basic care, but this system has been prone to corruption and a market for obtaining the
certifcates has developed. The health minister summed up the problem by admitting that
56 per cent of those that have the means to pay are benefting from public hospitals,
while 15 per cent of the countrys poorest are paying out of their pockets.
2
According to TI Moroccos study, which surveyed 1,000 households,
3
of those who
had been in contact with members of the public health service, 40 per cent admitted to
making an illicit payment for a service or supply that was supposed to be free. Of those
who required hospital treatment, 59 per cent admitted to paying to be examined or
admitted into hospital, while 26 per cent paid for treatment. When asked whether the
payments had achieved results, 81 per cent said that the expected result had been reached,
compared to 3 per cent who claimed that the bribe was ineffectual. This success rate
has to be qualifed by the fact that 85 per cent of citizens who paid bribes to public health
offcials were entitled by law to receive the service for free. The average size of the bribe
was 140 dirhams (US $15).
While informal payments can be seen as a coping mechanism for poorly paid health
workers, everyone pays for corruption in this sector. Citizens who do not consent to making
informal payments do not receive access to care. Public hospitals pay because potential
revenue is lost, goes unrecorded or is diverted into the hands of medical staff who abuse
their position to extort from patients, and equipment and medicines are wasted or are
sub-standard. The credibility and perceived integrity of health personnel suffers. The cost
for the state is a failed public health policy.
To remedy this situation, hospital staff must be made aware of the duties they have
to their patients, and both health system workers and users must be made aware of
patients rights. Pay structures and working conditions in hospitals must be re-evaluated
and whistleblowers who denounce corrupt practices need protection.
Azeddine Akesbi, Siham Benchekroun and Kamal El Mesbahi (TI Morocco)
Notes
1. TI Morocco, La Corruption au Maroc, Synthse des rsultats des enqutes dintgrit (Corruption in
Morocco, a summary of the National Integrity System survey) (Rabat: TI Morocco, 2002). The
interviews cited here are from a focus group discussion.
2. La Vie Economique (Morocco), 4 February 2005.
3. Of the 1,000 interviewed, 80 per cent came from big cities and 20 per cent from rural municipalities.
Of those surveyed 79 per cent were men and 21 per cent were women.
GC2006 01 part1 75 8/11/05 17:55:04
6orrupIIon and haaIIh 76
6 6orrupIIon In Iha pharmaoauIIoaI saoIor
A young medicine vendor from a so-called ground pharmacy offers black market drugs to
clients in a street in Libreville, Gabon, 29 August 2003. (Desirey Minkoh/AFP/Getty Images)
The pharmaceutical sector faces many challenges that are not addressed in this volume,
including patterns of research and patent systems that do not seem to be meeting all
public health needs, particularly in eradicating devastating tropical diseases. Corruption
adds a potentially deadly element when patients cannot afford extortion payments for
the drugs they need, or they are sold counterfeit medicines.
In this chapter, Jillian Clare Cohen argues that heavy government regulation in the
pharmaceutical chain while essential to safeguard the population against sub-standard
drugs and unfairly priced goods makes this sector particularly prone to corruption.
In recent years, much discussion has centred on the close ties between physicians
and the pharmaceutical, biotechnology and medical device industries which, when
unchecked, can lead to corrupt practices. Jerome Kassirer highlights the conficts of
interest that may arise when doctors feel indebted to drugs representatives, or when
scientists are on the payroll of companies whose drugs they are hired to evaluate.
GC2006 01 part1 76 8/11/05 17:55:04
6orrupIIon In Iha pharmaoauIIoaI saoIor 77
Efforts are being made to improve the situation. Representatives of the pharmaceutical
industry and of physicians describe the voluntary codes set up to reduce potential
conficts of interest. Civil society and concerted efforts by courageous regulators can
help curb corruption in the pharmaceutical industries both legal and counterfeit as
the experiences from India, Thailand and Nigeria show.
FharmaoauIIoaIs and oorrupIIon. a rIsk assassmanI
Jillian Clare Cohen
1
Pharmaceuticals are indispensable to health systems. They can complement other types
of health care services to reduce morbidity and mortality rates and enhance quality of
life for many patients. Because pharmaceuticals have curative and therapeutic qualities,
they cannot be regarded simply as ordinary commodities. Access to medicines is often
about life and death. This is illustrated most dramatically in sub-Saharan Africa where
almost 30 million people are infected with HIV/AIDS and the majority lack access to
anti-retroviral therapies.
In a broader context, access to essential medicines has become a central topic at the
international policy-making level where it is increasingly viewed as a fundamental right,
with human rights law placing obligations on states to ensure access.
2
This includes
duties on governments to ensure that pharmaceutical systems are institutionally sound
and transparent and that there are appropriate mechanisms to reduce the likelihood
of corruption, which can deny medicines to those in greatest need.
A major conundrum in international drug policy is the fact that, despite international
aid and a plethora of programmes devoted to improving pharmaceutical access, there
is a morally worrying drug gap. The WHO continues to estimate that one-third of the
global population lacks regular access to essential medicines.
3
A number of determinants
contribute to this drug gap, including market failures, government ineffciencies,
poverty and corruption.
For example, OECD countries generally devote US $239 in annual spending on
drugs per head, compared to less than US $20 in developing countries and US $6 in
sub-Saharan Africa.
4
Pharmaceuticals are the largest public health expenditure after
personnel costs in most low-income states, and often the largest household health
expenditure of all.
5
One of the most important differences between industrialised and
developing countries is that in the latter pharmaceutical expenditures are anywhere
from 5090 per cent of total individual out-of-pocket expenditures.
6
In such countries,
illness is a major cause of household poverty. Corruption exacerbates this drug gap:
when offcials accept kickbacks for purchasing medicines, pharmaceutical expenditure
is reduced and fewer of the right drugs get to the right people when they need them.
Many determinants are responsible for disparities in access to medicines, but
little research has been devoted to just how corruption impacts on drug availability.
Fortunately, this area is gaining interest and a number of studies have begun to address
this issue.
7
The pharmaceutical system is susceptible to corruption for a variety of
GC2006 01 part1 77 8/11/05 17:55:04
6orrupIIon and haaIIh 7B
reasons. One of the most signifcant is the degree of government involvement in its
regulation: studies from other sectors have found that the incidence of corruption is
noticeably higher when the state retains a major involvement in the economy and its
bureaucracy is pervasive.
8
Without robust institutional checks, government regulators
can make discretionary decisions rather than decisions based on uniform criteria. In
addition, wide information asymmetries exist between patient and physician (see
Chapter 1). Patients trust their doctor to prescribe the most effective drug for their
condition, but the doctors decision as to which drugs to prescribe may be infuenced by
pressure from pharmaceutical companies. There are often poorly documented processes
in the quality control system that can lead to the manufacture of sub-standard drugs.
This occurred in Brazil when a well known pharmaceutical manufacturer was found to
8ox 6.1 8 pharmaoauIIoaI oompany IInad Ior paymanIs Io oharIIy haadad
by FoIIsh haaIIh oIIIoIaI
1
In June 2004, the pharmaceutical company Schering-Plough agreed with the Securities and
Exchange Commission (SEC) to pay a fne of US $500,000 for violations of the books and
records and internal controls provisions of the Foreign Corrupt Practices Act (FCPA).
According to the SECs fndings, the Polish subsidiary of the New Jersey-based company,
Schering-Plough Poland (S-P Poland), made payments amounting to approximately US
$76,000 between February 1999 and March 2002 to a foundation for the restoration of
Silesian castles, the Chudow Castle Foundation. The foundation was run by the director
of the Silesian Health Fund,
2
one of 16 regional state-run Polish health authorities which
provides funding for the purchase of pharmaceutical products by hospitals and other
medical centres.
The SEC alleged that these payments were made to induce the director to buy S-P
Polands products for his health fund. It alleged that, in order to conceal the nature of the
payments, the S-P Poland manager deliberately set them at or below his approval limit
and provided false medical justifcations for them in documents submitted to the parent
companys fnance department.
Although the SEC conceded that the foundation was a bona fde charity and that the
donations were made without the knowledge or approval of the US parent company, it
charged that the parents internal controls were inadequate to detect and prevent the
fnancial irregularities committed by its Polish subsidiary. Although the SEC did not go so
far as to state that the payments were bribes, it did fnd that the manager viewed them
as necessary, in order to infuence the action of the government offcial.
This case highlights that companies should not only have clear policies covering
charitable donations, their permitted amount and approval procedures, but should
conduct due diligence across their organisation. The case also underscores the aggressive
stance of the SEC in holding suppliers accountable for the actions of their subsidiaries.
Transparency International
Notes
1. This text is based on Wilmer Cutler Pickering Hale and Dorr LLP, Foreign Corrupt Practices Update,
30 June 2004, www.wilmerhale.com
2. Rzeczpospolita (Poland), 11 June 2004.
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6orrupIIon In Iha pharmaoauIIoaI saoIor 79
have manufactured sub-standard contraceptives.
9
Finally, the pharmaceutical market is
so lucrative that it attracts entrepreneurs who are both honest and, more perplexingly,
dishonest. All of these factors expose the pharmaceutical system to the possibility of
corruption.
This essay focuses primarily on the role of government, since state intervention,
particularly through regulation, is vital to the pharmaceutical sector. There are two
central reasons why governments regulate the pharmaceutical market: frst, to ensure
that health policy and other governmental interventions, such as quality assurance of
drugs and fair drug pricing, enhance the health of the population; and second, to ensure
that industrial policies strengthen economic competitiveness of the pharmaceutical
sector and improve innovation and effciency. These two objectives can sometimes lie
at cross-purposes. If regulators are subject to pressure from commercial groups, health
objectives can be compromised.
kay daoIsIon poInIs
The pharmaceutical system is technically complex and replete with a number of core
decision points.
10
Each decision point needs to function optimally so that the system
as a whole offers good-quality, cost-effective, safe and effcacious medicines. Figure
5.1 shows key processes in the selection and delivery of pharmaceutical products and
illustrates the potential for corruption that exists at any one of its decision points
(post-manufacturing) unless there are solid institutional checks and balances in place.
For example, procurement is particularly susceptible to corruption unless there are
open bidding processes, good technical specifcations, and consistent and transparent
Efficacy
Labelling
Marketing
Use
Warnings
Full registration
Re-evaluation
of older drugs
Determine budget
Assess morbidity
profile
Determine drug
needs to fit
morbidity profile
Cost-benefit
analysis of drugs
Consistency with
WHO criteria
Determine model
of supply/distribution
Reconcile needs
and resources
Develop criteria
for tender
Issue tender
Evaluate bids
Award supplier
Determine
contract terms
Monitor order
Make payment
Quality assurance
Receive and
check drugs
with order
Ensure
appropriate
transportation
and delivery to
health facilities
Appropriate
storage
Good
inventory
control of
drugs
Demand monitoring
Consultation with
health
professional
In-patient care
Dispensing of
pharmaceuticals
Adverse drug
reaction
monitoring
Patient
compliance with
prescription
Service
delivery
Distribution Selection Procurement Registration
Figure 5.1: Key processes in the selection and delivery of pharmaceutical products
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6orrupIIon and haaIIh B0
procedures for redress if needed. While the design of good institutions with oversight
is crucial for the reduction of corruption, there is also a signifcant role for civil society.
If community groups closely monitor pharmaceutical companies and regulators, there
is a greater likelihood that corruption can be caught or even prevented out of fear of
disclosure (see Boxes 5.2 and 5.3).
Registration
The frst decision point in the pharmaceutical chain is registration, which was originally
introduced to protect patients from catastrophes like the thalidomide cases in the
1950s, and evaluates a drugs effcacy against a specifc disease and its possible side-
effects. The process regulates the labelling, marketing, usage, warning and prescription
requirements for a drug. Registration procedures need to be transparent and applied
uniformly, and should leave no room for individual discretion. The registration process
should guarantee drug safety and effcacy, but these guarantees risk being eroded by
the pharmaceutical industry lobby. A high-profle inquiry into risks posed by the pain
pills Vioxx, Bextra and Celbrex in 2004 highlighted already existing concerns regarding
the US Food and Drug Administrations (FDAs) capacity as an unbiased regulatory
body (see The corrupting infuence of money in medicine, page 88). Critics point
to the fact that between 1997 and 2004, 12 major prescription drugs, with a market
value of billions of dollars, were recalled by the FDA or withdrawn by companies.
According to Sheldon Krimsky of Tufts University, the rise in for-proft clinical trials,
fast-tracking of drug approvals, governmentindustry partnerships, direct consumer
advertising and industry-funded salaries for FDA regulators has contributed to degrading
the institutional integrity of the FDA, suggests regulatory capture of the FDA by the
pharmaceutical industry to some degree and also illuminates the need for the insti-
tution to demonstrate more independence from its stakeholders.
11
Meanwhile, in
low-income countries, regulatory agencies are often weak or non-existent due to lack
of resources.
Selection
Drug selection processes should ensure that the most cost-effective and appropriate
drugs for a populations health needs are chosen fairly. The WHO Model List of Essential
Medicines is a helpful framework in this regard for most developing countries because
it establishes priority areas of treatment and covers the most common diseases.
12
But
this can open a new avenue for corruption since manufacturers have a strong interest
in getting their products selected as essential medicines. If institutions are weak and
individuals have incentives to engage in corrupt activities, the selection process can
be replete with kickbacks and payoffs so that drugs on a national drug list may not
necessarily refect appropriate and cost-effective drugs (see Corruption in hospital
administration, Chapter 3, page 51).
However, there are methods that can reduce the likelihood of corruption in the
selection process and promote sound, evidence-based decision-making. The pharmaco-
economic techniques used by Australia and the Canadian province of British Columbia
GC2006 01 part1 80 8/11/05 17:55:05
6orrupIIon In Iha pharmaoauIIoaI saoIor B1
have proved helpful in ensuring that objective decision-making takes place if the
correct models and techniques are employed. Pharmaco-economics, or outcomes
research, uses cost-beneft, cost-effectiveness and cost-utility analyses to compare the
economics of different pharmaceutical products, or to compare drug therapies with
other medical treatments.
Drug selection committees must be composed of impartial persons with the
appropriate technical skills. Their members must be obliged to declare any conficts
of interest, and meetings should be regular and well publicised so that the public
can observe proceedings. Minutes of meetings should be posted on the Internet and
decisions clearly justifed. In the event of a potential breach, an appeal process must
be in place that ensures due process.
Final selection criteria should be based on discussions and acceptance by key
prescribers, and the WHO criteria for selection should be used as a basis for decision-
making. These are: relevance to the pattern of prevalent diseases; proven effcacy and
safety; evidence of performance in a variety of settings; adequate quality, including
bio-availability and stability; favourable cost-beneft ratio in terms of total treatment
cost; and preferences for drugs that are well known to have good pharmaco-kinetic
properties. Lastly, all drugs listed on a government essential medicines list should be
identifed by generic name.
Procurement
Procurement is the principal interface between the public system and drug suppliers,
and its goal is to acquire the right quantity of drugs in the most cost-effective manner.
This involves inventory management, aggregate purchasing, public bidding contests,
technical analysis of offers, proper allocation of resources, payments, receipts of drugs
purchased and quality control checks.
Procurement is often poorly documented and processed, which makes it an easy
target for corruption. Drug procurement is even more vulnerable to corruption than
contracting in other sectors. This is due to several factors, including: the method to
determine the volume of drugs needed is often subjective; there are diffculties in
monitoring quality standards in drug provision; suppliers use different prices for the
same pharmaceutical products and can artifcially infate prices; some marketing practices
by pharmaceutical companies induce demand for products; and an additional challenge
is posed by emergency situations, which call for speedy and adequate intervention.
The best protection against corruption is open, competitive procurement that
prevents personal discretion in the selection of suppliers, and requires clear criteria for
the selection and process of winning bids. However, procurement procedures require
ongoing monitoring, including reviews from the inspector generals offce.
13
Strong oversight mechanisms can drastically reduce corruption. A World Bank
study from 2001 examined the use of an electronic bidding system for pharmaceutical
purchases in Chile.
14
Contrasting the innovative Chilean system to other procurement
practices, the authors argued that outcomes are greatly improved by the adoption
of good incentive structures for public offcials and the reduction of informational
asymmetries through the posting of drug prices on the Internet.
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6orrupIIon and haaIIh BZ
A comprehensive study of corruption in the pharmaceutical system in Costa Rica found
that in many cases competition was reduced, or procedures were followed incorrectly.
15
Some health care professionals and pharmaceutical company executives alleged that
participants in public tenders had on occasion colluded to extend the purchasing cycle
as long as possible. This was done by submitting frivolous appeals, which were then
extensively contested by both sides, or by delaying the delivery of drugs for unfounded
reasons. The effect of these long delays was the eventual depletion of the social security
systems inventory resulting in direct purchases from private suppliers. These purchases
were then made at much higher unit prices than would be obtained through formal
bidding processes. Studies from Argentina and Bolivia show that increased transparency
and citizen participation in the procurement process can reduce corruption and cut
costs considerably (see Corruption in hospital administration, page 52).
Distribution
Distribution in the pharmaceutical system ensures drugs are allocated, transported
and stored appropriately at all points where they are to be dispensed. This involves
central and regional warehouses, pharmacies and service foors. Information must
fow easily through every level of the system to control inventory movements and
deliveries. In addition, the system requires storage facilities, including refrigeration
units, to guarantee the integrity of the drugs and good security to minimise the risk of
theft. The electronic monitoring of transport vehicles and careful checking of delivery
orders against inventories of products delivered are some of the methods that can
reduce this likelihood.
In one Central American country, inventory records showed that stocks of oral
antibiotic eye treatment and other products were intentionally oversupplied because
government purchasers received commissions for their orders.
16
This demonstrates
one way that corruption can drain public expenditure on pharmaceuticals and have
the greatest impact on the poor.
Service delivery
Service delivery involves the participation of physicians, pharmacists, nurses and other
health care providers who diagnose patients and identify what drugs a patient should
consume to treat a particular disease. This is the decision point at which patients should
experience the benefts of the entire system. Here physicians prescribe, pharmacists
dispense and nurses administer drugs to treat patients. Health providers ideally utilise
evidence-based practice to provide effective therapy to their patients.
The interface between the pharmaceutical industry and physicians is an area that
is particularly susceptible to corruption, as service delivery can be infuenced by the
marketing practices of the pharmaceutical industry (see The corrupting infuence of
money in medicine, page 86).
Some physicianindustry interaction is necessary to educate doctors about the
therapeutic qualities of new drugs. However, there is compelling evidence that suggests
that the motivation is often not health education, but proft maximisation. A 2000
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6orrupIIon In Iha pharmaoauIIoaI saoIor B8
study by Wazana found that physician interaction with the pharmaceutical industry
was associated with increased requests for additional drugs on hospital formularies
and changes in prescribing practice.
17
The infuence of industry on physicians is an
issue of concern in both developed and developing countries. But it can be particularly
dangerous in developing and transition countries where doctors make paltry salaries
and may rely heavily on gifts (both monetary and material) from the pharmaceutical
industry to supplement their livelihood.
The US authorities have recently demonstrated concerted efforts to address
inappropriate marketing practices by some pharmaceutical companies. In 2001, TAP
Pharmaceutical Products was required to pay one of the largest fnes in the industrys
history, with the government demanding US $875 million for civil liabilities and criminal
charges.
18
Other governments are introducing stricter laws and regulations. For example,
in April 2005 a report by the UKs House of Commons Health Select Committee on
The Infuence of the Pharmaceutical Industry recommended greater transparency in
drug regulation processes, reduction in the excessive promotion of medicines, tougher
restrictions on physicians to avoid inappropriate prescribing and an end to Department
of Health relationships with the drugs industry in favour of the Department of Trade
and Industry.
19
Following press accounts of the free trips pharmaceutical companies
offer medical doctors and the lavish parties thrown for them,
the Deputy Mayor of
Social Affairs and Public Health of Helsinki, Paula Kokkonen, banned all trips funded
by the pharmaceutical industry for the capitals medical doctors.
20
In view of the potential for undue infuence on prescribing behaviour, global standards
have been developed and a number of professional bodies, including pharmaceutical
industry associations, have enacted codes of conduct that detail best practice in
minimising corruption (see Promoting trust and transparency in pharmaceutical
companies, page 92, and Fighting corruption: the role of the medical profession, page
94). Whether such guidelines have made an impact is questionable. The WHO issued
its Ethical Criteria for Medicinal Drug Promotion in 1988, but a 1997 WHO roundtable
discussion concluded that inappropriate drug promotion is still a problem in developing
and industrialised countries.
21
Even though the criteria have been disseminated widely,
their effective implementation is a major problem, as governments need to revise
legislation and regulation, and to promote them forcefully in medical schools and
associations.
While self-regulatory codes of conduct may be benefcial, they should not delay
meaningful reform in terms of external, enforceable regulations. Current voluntary codes
are not audited or enforced with meaningful penalties, or overseen by independent and
objective observers.
22
More robust policies are needed to address the serious conficts
of interest that arise in the service delivery segment of the pharmaceutical system.
6ounIarIaII madIoInas. Iha bad and Iha ugIy
When institutions are weak and unable to regulate the pharmaceutical sector accurately,
they increase the opportunities for corruption, including the manufacture of counterfeit
drugs, a problem that precedes the frst decision point in the pharmaceutical chain
GC2006 01 part1 83 8/11/05 17:55:05
6orrupIIon and haaIIh B4
in Figure 5.1. For example, regulators may receive kickbacks to ignore makers of
counterfeit products, or customs agents may be paid to turn a blind eye to their import
or export.
In 2001, China had roughly 500 illegal medicine manufacturers and Laos around
2,100 illegal medicine sellers. In Thailand, sub-standard medicines account for 8.5
per cent of those on the market.
23
India plans to introduce the death penalty for the
manufacture or sale of counterfeit medicines that cause grievous harm. Profting from
spurious drugs that might harm or kill innocent people is equivalent to mass murder,
said Health Minister Sushma Swaraj recently.
24
Meanwhile, an estimated 192,000 people
died last year in China because of fake drugs.
25
Regulatory bodies in the South need
resources to root out corruption and stem the fow of counterfeit drugs. The success
of Nigerias National Agency for Food and Drug Administration and Control is one
example of what can be achieved through strong leadership (see page 96).
MovIng IorWard. hoW Io do baIIar?
Corruption in any one of the critical decision points in the pharmaceutical system can
be harmful to a countrys ability to improve the health of its population by limiting
access to high-quality medicines and reducing the gains associated with their proper
usage. While corruption affects the entire population, it is typically the poor who are
most susceptible when offcials hoard drugs, or waste resources on the wrong kind of
medicines. Good governance is therefore a sine qua non for ensuring better access to
essential medicines.
Greater transparency in the pharmaceutical system will help to improve drug access.
Honest assessment of the institutional robustness at all core decision points in the
pharmaceutical system is the frst necessity. Governments need to know what areas of
the system are less than optimal and vulnerable to corruption. There is a need for more
monitoring of how pharmacies, hospitals and health care providers are reimbursed for
drugs. Further research is needed to determine what systems offer the best incentives
for providers to behave honestly and control fraud. Second, consumer groups and
other third parties need to be vigilant about monitoring both the public and private
pharmaceutical systems to ensure they are directed towards the public interest.
While international statements and professional guidelines on best practice are
well intentioned, they are meaningless unless they are properly enforced. Individual
governments must have the courage to enact and, most importantly, to implement
policies and processes which encourage ethical behaviour and punish frms and
individuals for corrupt actions. If this happens, hopefully we will see a change for the
better in terms of ensuring that people in need get the right drugs at the right time.
hoIas
1. Jillian Clare Cohen is assistant professor in the Leslie Dan Faculty of Pharmacy at the University
of Toronto and Director of the Comparative Program on Health and Society at the University
of Torontos Munk Centre for International Studies.
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6orrupIIon In Iha pharmaoauIIoaI saoIor B6
2. Philippe Cullet, Patents and Medicines: the Relationship between TRIPS and the Human
Right to Health, International Affairs 79(1), 2003.
3. Michael R. Reich, The Global Drug Gap, Science 287(5460), 197981, 17 March 2000.
4. WHO Medicines Strategy: Framework for Action in Essential Drugs and Medicines Policy 20022003.
(Geneva: WHO, 2000), www.who.int/medicines/strategy/strategy.pdf
5. Ramesh Govindaraj, Michael Reich and Jillian Clare Cohen, World Bank Pharmaceuticals
Discussion Paper (Washington DC: World Bank, 2000).
6. Ibid.
7. For example, the World Bank, the WHO and USAID have all commissioned studies in recent
years on the issue of corruption in the pharmaceutical system.
8. Ian E. Marshall, A Survey of Corruption Issues in the Mining and Mineral Sector, Mining,
Minerals and Sustainable Development Project (London: International Institute for
Environment and Development, 2001).
9. Jillian Clare Cohen, Public Policies in the Pharmaceutical System: The Case of Brazil,
(Washington DC: World Bank, 2000).
10. This section borrows heavily from Jillian Clare Cohen, James Cercone and Roman Mayaca,
Improving Transparency in the Pharmaceutical System: The Case of Costa Rica, internal
study, World Bank, October 2002.
11. Sheldon Krimsky, A Dose of Reform: But Do the FDAs Actions Go Far Enough? The Star
Ledger, 20 February 2005.
12. See www.who.int/medicines/publications/essentialmedicines/en/
13. USAID, A Handbook on Fighting Corruption, Center for Democracy and Governance
(Washington, DC: USAID, 1999).
14. Jillian Clare Cohen and Jorge Carikeo Montoya, Using Technology to Fight Corruption in
Pharmaceutical Purchasing: Lessons Learned from the Chilean Experience (Washington, DC:
World Bank Institute, 2001).
15. Cohen et al., Improving Transparency in the Pharmaceutical System.
16. Management Sciences for Health, with the WHO, Managing Drug Supply (West Hartford, US:
Kumarian Press, 1997).
17. Ashley Wazana, Physicians and the Pharmaceutical Industry: Is a Gift Ever Just a Gift?,
Journal of the American Medical Association 283(3), 19 January 2000.
18. US Department of Justice, press release, 1 October 2001. Available at: www.usdoj.gov/opa/
pr/2001/October/513civ.htm See also Corruption in hospital administration, Chapter 3,
page 51.
19. The UK parliamentary report is available at www.parliament.the-stationery-offce.co.uk/pa/
cm200405/cmselect/cmhealth/42/42.pdf
20. Kauppalehti Presso (Finland), 11 December 2004.
21. See the Drug Promotion Database website at www.drugpromo.info/about.asp#1
22. The Code of Marketing Practices of Canadas Research-Based Pharmaceutical Companies from
January 2005 is a case in point. See www.canadapharma.org/Industry_Publications/Code/
code_e05Jan.html (accessed 15 March 2005).
23. British Medical Journal 327(1126), November 2003.
24. British Medical Journal 327(414), August 2003.
25. PharmaBiz.com, 18 March 2005.
Tha oorrupIIng InIIuanoa oI monay In madIoIna
Jerome P. Kassirer
1
Pharmaceutical, device and biotechnology companies have created new drugs and
devices that have prolonged the lives and improved the health of millions of people.
Many interactions between academic scientists and industry have been responsible for
such advances, and these collaborative research projects should be encouraged. Yet the
GC2006 01 part1 85 8/11/05 17:55:06
6orrupIIon and haaIIh B6
collaborations sometimes go beyond research and merge into marketing by physicians
who become paid company consultants or speakers. The fnancial relationships between
the pharmaceutical industry and physicians yield a subtle form of corruption, one that
escapes legal supervision and challenges.
My comments apply principally to the United States, but the manifestations are
similar in countries all over the world. In recent years, the pharmaceutical, device and
biotechnology industries have spent some US $16 billion annually in the United States
on marketing to physicians.
2
Of this, more than US $2 billion was spent on meals,
meetings and events alone.
3
Companies seek to infuence doctors with US $ 1,0005,000
honoraria (or more) to participate in their speakers bureaus and hire them as well
paid consultants and members of their advisory boards. They also bombard doctors
with journal ads, and almost 90,000 friendly drug salesmen.
4
They pay academic
physicians to help them develop educational materials and befriend medical students
and doctors with gifts of textbooks, stethoscopes, and free lunches and dinners. Such
payments can lead some physicians to act in their own best interests rather than in the
interests of their patients. There can be a fne line between legitimate marketing outlays
by a pharmaceutical company and an unethical practice. But when compensation
to salespeople and medical professionals translates into higher sales revenues, the
temptation to cross the line becomes especially great.
Tha anIIoamanIs on oIIar by pharmaoauIIoaI oompanIas
The attempt to seduce young people is particularly worrisome. Some years ago, I
witnessed a typical drug company-sponsored lunch at an academic medical centre.
Two well dressed pharmaceutical representatives had brought food for a regular teaching
conference for the house staff. One by one, house offcers and medical students arrived
to join a buffet line and were greeted warmly by the male drug rep with How was
your weekend? or Howre you doing? These reps were obviously a familiar presence.
The line moved slowly because it took some time to scoop up the food, and the two
drug reps used the opportunity to make a sales pitch. One was stationed strategically
at the beginning of the line, and the other at the end. The reps were describing two of
the companys popular new (and expensive) products, as well as recommendations for
dosages.
5
The seduction moves on to the dinner hour as well. One evening in a pizza
parlour, I observed a resident with his team of interns and students enjoying pizza and
beer with a drug representative. There were two costs for the free food and drinks. The
resident had to listen to the drug reps sales pitch during the meal, and at the end of
the party he was given a pile of reprints to take back to the rest of his team.
These trinkets and meals are simply marketing ploys, intended at minimum to
ingratiate the drug rep to the doctor, perhaps to raise awareness of certain products
and, at the other extreme, to create a sense of indebtedness. Such indebtedness is
problematic, however, because the physicians obligation to the drug salesman or his
company often conficts with his obligation to his patients. The prescribing practices
of physicians have been examined in a few studies in relation to some kind of exposure
to a drug company promotion.
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6orrupIIon In Iha pharmaoauIIoaI saoIor B7
In one, 40 physicians who requested additions to their hospitals drug formularies
were compared to 80 who had not requested any new drugs.
6
Statistically, doctors
who requested the additions were 9 to 21 times more likely to have eaten free meals
provided by the companies, to have accepted drug company money to attend or
speak at a company-sponsored symposium, or to have received research support from
the companies. An independent review (in the same study) indicated that the newly
requested drugs had little or no advantage over the drugs already available.
Another study of the prescribing practices of 10 physicians who had attended
company-supported symposia in resort locations showed a two- to threefold increase in
the physicians use of the drugs in the months after their trip.
7
Interestingly, a majority
of physicians attending the symposia claimed that they would not be infuenced by
the enticements; most dismissed the possibility defying common sense that all of
these efforts by industry could affect them.
FInanoIaI oonIIIoIs oI InIarasI In madIoaI rasaaroh
Fundamentally, big business and physicians alike are involved in a charade. The drug
companies say that marketing helps to educate doctors so they can prescribe drugs more
appropriately. At the same time, the companies press their drug salesmen to push the
newest products, and they allow their surrogate intermediaries, the medical education
companies, to advertise their services as persuasive education. And the physician-
recipients of drug company largesse act as if they were immune to its infuence.
Physicianindustry involvement is widespread. A 1996 survey showed that half of full
professors and lesser fractions of more junior faculty who conduct life science research
have substantial fnancial arrangements with industry, and disclosures at medical
meetings and in published journal articles confrm the widespread involvement.
8
During
my tenure as editor-in-chief of the New England Journal of Medicine, we only allowed
physicians to write review articles and editorials if they had no fnancial conficts with
a company whose products (or their competitors) were featured in the article. Finding
authors without such conficts became progressively more diffcult during the 1990s
and, by the end of the decade, we often had to reject several prominent potential
authors before we found one who had no conficts. Finally, an industry-connected
legal group admitted the extent of involvement. It wrote: It is widely acknowledged
that most of the top medical authorities in this country, and virtually all of the top
speakers on medical topics, are employed in some capacity by one or more of the
countrys pharmaceutical companies.
9
Several specifc examples will illustrate the problem: one involving practice guidelines;
the second, a human research study; a third involving radiological diagnosis; and the
fourth, a decision by the Food and Drug Administration (FDA).
Four oasa sIudIas Irom Iha nIIad 8IaIas
The National Cholesterol Education Program at the National Institutes of Health
regularly updates its practice guidelines when new data become available. The latest,
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6orrupIIon and haaIIh BB
reported in July 2004, was a combined effort of the American Heart Association, the
American College of Cardiology and the National Institutes of Health. These three
organisations selected nine individuals to analyse all the clinical trials that had been
published since the previous guidelines and come up with new recommendations. The
group was impressive. It consisted of a nutritionist, the chief of the molecular disease
branch at the National Institutes of Health, a well known pharmacologist, a former
president of the American Heart Association and other well regarded cardiologists. Their
recommendations included greater lowering of low-density lipoprotein (LDL) with
diet, exercise and treatment with statins. Later, it was revealed that seven of the nine
participants had fnancial arrangements as paid speakers or consultants for companies
that make statins. They had these arrangements not with just one company, but three
to fve of them. These connections made it diffcult to know whether the relations of
these high-level physicians with the statin manufacturers may have infuenced their
recommendations.
10
In 1999, a 17-year-old boy died at the University of Pennsylvania four days after
receiving genes imbedded in a common cold virus. The boy had only a mild defciency of
a particular enzyme, but was participating in the research because he thought the results
might help others. Neither he nor his parents had been told that the experiment had
previously shown some toxicity; nor were they told that both the principal investigator
and the university had fnancial stakes in a company that might have benefted from
the outcome of the work. The principal investigator denied that money had anything to
do with his decision or the institutions decision to move ahead with these studies.
11
An interesting study was reported in the journal Academic Radiology in 2004. It was
a re-analysis of 492 chest X-rays read by 30 radiologists employed by law frms who
were suing companies for people exposed to agents that damage the lungs. To explain
the fndings, I will call these 30 the hired hands. The authors of the study had the
same chest X-rays re-read by six radiologists who were not paid by lawyers. I will call
these radiologists the independents. All 36, the hired hands and the independents,
were certifed B readers by a federal agency, meaning that they all had undergone the
same training to interpret chest X-rays. The results are interesting: the hired hands
diagnosed 9697 per cent of flms as abnormal, whereas the independents said only
46 per cent were abnormal. The hired hands said none of the flms were completely
normal, whereas the independents said 38 per cent were normal. One does not need a
chi square test to appreciate the gross discrepancy in these interpretations.
12
In mid-February 2005, an advisory panel of the FDA met to assess whether the
risk-beneft profle of various Cox-2 inhibitors made by Merck and Pfzer warranted
removing the drugs from the market. This was a highly visible decision because of the
increased risk of cardiovascular complications of some of the drugs, especially Vioxx,
and because of Mercks decision only weeks before to take Vioxx off the market. The
32-person panel voted 31:1 to keep Celebrex on the market; there seemed to be little
controversy about this decision. However, the votes on Bextra and Vioxx were much
closer. The panel voted 17:13 to keep Bextra on the market, and 17:15 to allow Vioxx
to return to the market. But there was a hitch: it was later learned that 10 of the panel
members had fnancial ties to both companies that made these two drugs, and that
GC2006 01 part1 88 8/11/05 17:55:06
6orrupIIon In Iha pharmaoauIIoaI saoIor B9
these company-paid physicians had voted 9:1 in favour of keeping both drugs on the
market. If none of these conficted panel members had voted, the recommendation
would have been not to allow either on the market. The votes would have been 12:8
opposed for Bextra and 14:8 opposed for Vioxx. Bextra has since been removed from
the market, but both Vioxx and Bextra could return if the FDA follows the advisory
boards recommendations.
13
The FDA decision will affect millions of people as well as
the enormous profts of two major pharmaceutical companies.
14
Though these examples are worrisome with respect to their effect on patient care,
and cannot be condoned from an ethical construct, none constitutes either fraud or
overt corruption. None is punishable by legal means and any sanction would have to
come from state or professional organisations, but these bodies rarely impose any (see
below). Each example strongly suggests a pattern of overt bias, but the problem with
each is trying to assess an individuals motivation. One possibility is that none of the
tilt towards company products was intentional, yet the close ties between physicians
and companies yielded biased recommendations in some subconscious way. It is even
possible that the recommendations these physicians made were completely objective,
and that anyone else with the same expertise would have come up with exactly the
same conclusions. Finally, it is possible that some doctors on industry payrolls are
knowingly greedy and that they are intentionally profting at the expense of the validity
of information that doctors use in their daily practices. In the latter case, we must
assume that they perceive the consequences of their actions on patient care to be
negligible. These examples illustrate the essential problem with fnancial conficts of
interest: we dont know what to believe.
15
k IhraaI Io Iha pubIIos IrusI
Extensive analyses of the effects of fnancial conficts of interest have documented
its corrosive infuences on patient care, medical information and the publics trust
in the profession.
16
These huge fnancial subsidies can infuence the validity of the
information that doctors use every day in their practices. It tends to distract faculty
into emphasising proftable research and to neglect their teaching duties. It replaces
openness with secrecy, privatises knowledge and replaces part of the social commons
by commercialising discovery. It has also created a culture in which the design of
studies is sometimes jiggered to create positive results; in which unfavourable results
are sometimes buried; in which communication of results is sometimes hindered for
commercial reasons; and in which bias in publications and educational materials has
sometimes gone unchecked.
17
All of this amounts to a serious threat to public trust in
medicine. These fnancial conficts can undermine the faith of the public in medical
research, threaten government funding, reduce enrolment in clinical trials and damage
the trust between patients and their doctors.
In the United States, some progress has been achieved in dealing with fnancial
conficts. The Association of American Medical Colleges has issued new guidelines for
individuals and institutions,
18
while many medical schools are now in the process of
revising their confict-of-interest policies. The National Institutes of Health, in response
GC2006 01 part1 89 8/11/05 17:55:07
6orrupIIon and haaIIh 90
to a public outcry about important fnancial connections of several of its senior scientists,
issued strict guidelines in 2005 that effectively limit investigators from having these
associations.
19
The United States Congress has also expressed an interest in the concerns
raised here.
20
The pharmaceutical companies and the American Medical Association
have both issued guidelines about physician engagement in company programmes, but
neither has precluded marketing of products by physician-consultants or speakers.
Far more work on this is needed. All gifts from the industry should be prohibited, even
items that might be considered useful in a doctors practice or education. Consultations
with industry for anything except scientifc matters should also be prohibited, while
marketing by physicians of drugs or devices in which they have a fnancial interest
should be outlawed. Physician participation in company-sponsored speakers bureaus
should be excluded. Clinical practice guideline committees and FDA advisory panels
must contain a minority of individuals with fnancial conficts of interest. Positions
of journal editors, offcers of major professional organisations and leaders of medical
centres and academic institutions should be preserved only for individuals without
conficts. Given that complete elimination of all fnancial conficts of interest is unlikely,
the full disclosure of relevant fnancial conficts on an easily searchable website should
be introduced.
It is diffcult to understand why the standards on conficts of interest in medicine
should be lower than those of other professions, such as the media. Reporters for
the most ethical media outlets such as the New York Times and CNN are not allowed
to accept any gifts, meals, honoraria or paid consulting arrangements.
21
This is an
exceptionally high standard, but one medicine must adopt. The bar must be raised if
we are to maintain the publics trust in medicine.
hoIas
1. Jerome P. Kassirer is distinguished professor at Tufts University School of Medicine and adjunct
professor of medicine and bioethics at Case Western Reserve University. He was editor-in-chief
of the New England Journal of Medicine from 1991 to 1999.
2. Boston Globe (US), 10 March 2004.
3. Jerome P. Kassirer, On The Take: How Medicines Complicity With Big Business Can Endanger Your
Health (New York: Oxford University Press, 2004).
4. B. Darves, Too Close for Comfort? How Some Physicians are Re-examining their Dealings
with Drug Retailers, ACP Observer, July/August 2003.
5. Journal of the American Medical Association (US), 284(21567), 2000.
6. Journal of the American Medical Association (US), 271(6849), 1994.
7. Chest (US), 102(27073), 1992.
8. New England Journal of Medicine (US), 335(17349), 1996.
9. D. J. Popeo and R. A. Samp, comments of the Washington Legal Foundation to the Accreditation
Council for Continuing Medical Education concerning request for comments on the 14
January 2003 draft: Standards to Ensure the Separation of Promotion From Education Within
the CME Activities of ACCME Accredited Providers, Washington Legal Foundation, 2003.
10. Washington Post (US), 1 August 2004.
11. Washington Post (US), 30 December 2001.
12. J. N. Gitlin, L. L. Cook, O. W. Linton and E. Garrett-Mayer, Comparison of B Readers
Interpretations of Chest Radiographs for Asbestos-related Changes, Academic Radiology
11(84356), 2004.
GC2006 01 part1 90 8/11/05 17:55:07
6orrupIIon In Iha pharmaoauIIoaI saoIor 91
13. Despite the FDA ruling in February 2005 in favour of allowing Vioxx back on the market, at
this writing Merck had decided against its return.
14. New York Times (US), 25 February 2005.
15. Kassirer, On The Take.
16. Ibid., and Sheldon Krimsky, Science in the Private Interest: Has the Lure of Profts Corrupted
Medical Research? (Lantham: Rowman and Littlefeld, 2003).
17. Ibid.
18. Association of American Medical Colleges (AAMC), Protecting Subjects, Preserving Trust,
Promoting Progress I: Policy and Guidelines for the Oversight of Individual Financial Interests
in Human Subjects Research, AAMC Task Force on Financial Conficts of Interest in Clinical
Research, December 2001; Protecting Subjects, Preserving Trust, Promoting Progress II:
Principles and Recommendations for Oversight of an Institutions Financial Interests in
Human Subjects Research, AAMC Task Force on Financial Conficts of Interest in Clinical
Research, October 2002.
19. www.nih.gov/about/ethics_COI.htm
20. waysandmeans.house.gov/hearings.asp?formmode=view&id=2933
21. Ethical Journalism: Code of Conduct for the News and Editorial Departments, New York
Times (US), January 2003.
FromoIIng IrusI and Iransparanoy In pharmaoauIIoaI oompanIas.
an IndusIry parspaoIIva
Harvey Bale
1
The twentieth century saw enormous improvements in overall health care standards in
the developed world. Yet in both the developed and developing worlds, patients are still
in need and are waiting for treatments, cures and vaccines for AIDS, cancer, diabetes,
heart disease, Alzheimers disease and many hundreds of other debilitating and life-
threatening conditions. Even older diseases, once thought conquered or controlled,
such as tuberculosis, malaria and polio, are re-emerging as clear and present dangers
because of resistance to existing treatments or failings in immunisation programmes.
Biological resistance to current treatments for HIV/AIDS infections is on the rise, making
it imperative that industry and governments continue to fund heavily research into
this as well as other diseases.
According to surveys by member associations of the International Federation of
Pharmaceutical Manufacturers Associations (IFPMA), industry currently spends more
than US $50 billion in research and development into fnding drugs and vaccines
annually worldwide. The industry is subject to a high degree of government regulation
at every nearly stage of its activity. The large interface between industry and government
throughout the life cycle of medicinal products poses continuous risks of corruption.
Before clinical trial tests can begin, government must approve them. Before a drug is
approved after such trials, another formal approval is needed in every country where
the drug or vaccine is to be used by patients, physicians and nurses. Many countries
set prices another government decision. Before companies invest they need to have
their ideas and innovation protected against copiers another government function.
Furthermore, where poor countries are concerned about certain epidemic threats, like
GC2006 01 part1 91 8/11/05 17:55:07
6orrupIIon and haaIIh 9Z
HIV/AIDS or malaria, companies work with governments and NGOs to fnd ways to
get medicines to those who cannot afford them. Governments must be involved,
from customs authorities to regulators to health ministry and local offcials, to ensure
the medicines get to intended patient groups. All of these points of governmental
intervention raise the possibility of corrupt practices entering to distort and damage
the development and delivery of new drugs and vaccines to patients.
Corruption in the pharmaceutical supply chain can take many forms: products can
be diverted or stolen at various points in the distribution system; offcials may demand
fees for approving products or facilities, for clearing customs procedures, or for setting
prices; violations of industry marketing code practices may distort medical professionals
prescribing practices; demands for favours may be placed on suppliers as a condition
for prescribing medicines; and counterfeit or other forms of sub-standard medicines
may be allowed to circulate. While corruption carries economic costs, corruption adds
further costs to the end goal of patient well-being.
Given the impact of corruption, the IFPMA and other industry bodies have taken
signifcant steps to address the dangers of corruption. But the industry and other
stakeholders must intensify efforts to prevent and avoid abuses.
The need to minimise the chances of corruption in the distribution chain is well
illustrated by the diversion of heavily discounted GlaxoSmithKline (GSK) anti-retroviral
(ARV) HIV/AIDS drugs from Africa to Europe unearthed in the summer of 2002. GSK
had committed to providing its full range of ARVs at not-for-proft prices to the worlds
poorest countries. These prices were, on average, 70 per cent less than developed world
prices. Registration of special access packs in target countries would have taken between
6 and 18 months. With the HIV/AIDS epidemic spreading quickly, GSK was anxious
to respond to the global crisis as quickly as possible. GSKs initial consignments to
Africa were therefore dispatched in European packaging. The medicines had originally
been sold by GSK at not-for-proft prices to an NGO and the procurement arm of a
ministry of health, for distribution to African HIV patients. In the beginning of the sales
programme, the company had not received approval for box designs to differentiate the
countries to which they were destined as such approvals take time; and some of the
ARVs were diverted by West African public offcials, almost undetected, back into the
European market, with traders making substantial profts and patients in Africa being
denied access to the medicines they desperately needed. Prosecution is under way for
those involved in this scheme, which should help send the signal that this behaviour
cannot be tolerated. In the meantime, GSK has developed access packages for its main
ARVs that are differentiated from developed country packs.
Another area where the industry has been active in recent years is in strengthening
its product-promotion practices. The prescribing behaviour of medical professionals,
who are frequently paid poorly under national health care systems, may be affected
by the compensation offered by suppliers for administering their products or services,
rather than by the interests of their patients. Though the direct evidence is thin that
prescribing behaviour is directly and signifcantly affected by trips and gifts from the
industry, there are cases that involve travel including coverage for spouses, despite
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6orrupIIon In Iha pharmaoauIIoaI saoIor 98
the fact that the IFPMA Code and various national codes forbid spousal travel to
be sponsored by companies to educational symposia. Companies belonging to the
IFPMA adhere to a marketing and promotion code that requires that companies
refrain from offering inappropriate hospitality or gifts to medical professionals that
would tend to infuence them in the prescription of pharmaceutical products. The
IFPMA Code is supplemented by its national member associations, by individual
company ethical marketing codes and by a variety of measures that seek to redress the
situation when violations of the codes occur. The code is based on self-regulation, but
its application is obligatory. These codes are activated by complaints that are made
to IFPMA or its member associations by physicians, other medical professionals or
other interested parties, and violations are accompanied by publicity or fnes paid in
some countries.
Transparency is important in many other areas. Signifcant new initiatives have been
introduced over the past two years regarding the pharmaceutical industrys approach to
clinical trials. In a few cases, companies have been accused of disclosing and publishing
only favourable clinical results. To increase the transparency of companies clinical
trials undertaken to develop new drugs and vaccines and recognising that there are
important public health benefts associated with making clinical trial information more
widely available to health care practitioners, patients and others easily accessible
web-based clinical trial registers have been set up by companies to publicly record
relevant details of the trials they are conducting. Beginning in summer 2005, the
industry is making public the results of all clinical trials that have taken place and also
information on those just being initiated, from the frst stage of patient registration
and enrolment through to fnal outcomes. At the same time, to make trial information
easily accessible to those seeking information, the IFPMA is establishing a web-based
search portal, linking the various clinical trial registries for information on ongoing
clinical trials and databases for the summary results of completed clinical trials. This
one-stop location will simplify and ease access for patients and medical professionals
to the company registries and data.
Health care expenditures, and spending on innovative pharmaceuticals, will inevitably
increase throughout the world. Whereas the past 20 years have seen an informatics
revolution, the next quarter-century will witness major advances in the biosciences.
Public confdence in the pharmaceutical industry is crucial and companies are taking
signifcant steps through their member associations to maintain and improve public
trust. To ensure that patients are able to beneft from medical advances, it is also
important to ensure that access be addressed, and one way will be to help prevent the
selective allocation of health care by those in the public or private sector on the
basis of bribery and corruption.
hoIa
1. Harvey Bale is director-general of the International Federation of Pharmaceutical Manufacturers
and Associations.
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6orrupIIon and haaIIh 94
FIghIIng oorrupIIon. Iha roIa oI Iha madIoaI proIassIon
John R. Williams
1
Physicians are human beings and, like everyone else, are subject to the temptation
to put their own interests above those of others. As self-regulating professionals, they
have less oversight than many other individuals and consequently more opportunity
to conceal unethical behaviour. On the other hand, they belong to a profession that
has high ethical standards and that encourages and expects its members to uphold
these standards.
Physicians encounter corruption in health care at all levels: in government, hospitals
and other health care institutions, and in their own practice. For the most part, they
are among the victims of corruption, seeing resources that should go to patient care
or professional development siphoned off for other purposes. In some cases, however,
they may be benefciaries of corruption, insofar as they personally receive part or all
of the resources that have been designated for other legitimate purposes.
The extensive guidance for physician behaviour provided by their professional
associations seldom includes a responsibility for dealing with corrupt practices by non-
physicians. It is quite a different matter when it comes to themselves and their colleagues.
The World Medical Association (WMA) International Code of Medical Ethics exhorts
physicians to always maintain the highest standards of professional conduct ...; not
permit motives of proft to infuence the free and independent exercise of professional
judgement on behalf of patients ; deal honestly with patients and colleagues, and
strive to expose those physicians defcient in character or competence, or who engage
in fraud or deception.
2
These general principles have been elaborated in detail in policy
statements from the WMA and its national medical association members.
It should be noted that the word corruption seldom appears in medical association
policy statements. These deal with unethical or unprofessional behaviour and
practices that cover a wide spectrum from impoliteness to various degrees of confict of
interest to euthanasia. Corruption would be considered an extreme form of confict of
interest whereby physicians receive substantial personal beneft at the expense of others,
whether individuals, institutions or society in general. Most professional guidance
deals with softer forms of confict of interest where it is not immediately obvious
that wrongdoing is involved.
In what follows, I describe activities designed to prevent or deal with such conficts
of interest between physicians and the pharmaceutical industry.
The conficts of interest inherent in the relationships of physicians and industry
are described elsewhere in this volume (see The corrupting infuence of money in
medicine, page 87). Beginning in the late 1980s, the World Health Organization (WHO),
industry groups and national medical associations began to produce guidelines for
such relationships. In 1988, the WHO Assembly adopted a resolution endorsing a
set of ethical criteria for medicinal drug promotion.
3
In 1991 the Canadian Medical
Association adopted guidelines for physicianpharmaceutical industry relationships,
4
followed by many other professional organisations, including the American Medical
GC2006 01 part1 94 8/11/05 17:55:08
6orrupIIon In Iha pharmaoauIIoaI saoIor 96
Association in 1992,
5
the Finnish Medical Association in 1993,
6
the Australian Medical
Association in 1994,
7
the Israeli Medical Association in 2004
8
and the World Medical
Association in 2004.
9
These guidelines deal with gifts to physicians, continuing medical
education/professional development, industry-sponsored research and drug samples.
Though their primary concern is to avoid conficts of interest between physicians and
patients, they are equally applicable to conficts between the interests of physicians
and those of society in general, for example regarding cost-effectiveness in prescribing
drugs that are paid from public sources.
The principal reason why the WMA took so long to produce its guidelines is the
great variation in access of physicians to continuing professional development activities
throughout the world. In less developed countries, the pharmaceutical industry is often
the only source of funding for physicians to attend conferences, whereas in wealthier
countries such a relationship would be considered an unacceptable confict of interest
for physicians.
These guidance documents are directed to individual physicians, organisers of
educational events and medical associations. Though they are ethical rather than
legal in nature and therefore not generally binding, various mechanisms exist for
turning them into enforceable rules, whether for those who offer confict-of-interest
incentives (for example, the pharmaceutical industry) or for those to whom they are
offered (physicians and other health professionals). The pharmaceutical industry is
increasingly subject to laws and regulations regarding its educational and promotional
activities with physicians.
10
In some countries medical conferences are not eligible
for continuing professional development credits unless they follow strict rules for
industry sponsorship.
11
Some physician licensing bodies are beginning to defne
acceptable limits for industryphysician relationships and warning physicians that
overstepping these limits will result in disciplinary action. Progress in this area has
been slow for several reasons; for example, the diffculty of monitoring physician
relationships with industry and the need to address more serious instances of physician
misconduct, such as murder and the sexual abuse of patients. Unless the medical
licensing authorities defne more precisely the rules for physician behaviour regarding
conficts of interest and can obtain extra resources to enforce them, the individual
consciences of physicians will have to be the principal resource for identifying and
dealing with conficts of interest.
Several educational programmes are available to inform physicians how to avoid
confict-of-interest situations with industry. The American Medical Association has
developed an on-line resource for self-study by physicians,
12
and a group of health care
providers has developed the No Free Lunch website
13
to encourage their colleagues
to maintain complete independence from industry in their clinical and educational
activities. In the feld of medical research, where there have been many reports of
unethical conduct in recent years, educational resources for the responsible conduct
of research are plentiful and many institutions now require researchers to demonstrate
familiarity with the basic principles of responsible conduct of research.
The effectiveness of educational measures in this area is difficult to measure.
Enforcement mechanisms may be somewhat more effective but are expensive to
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6orrupIIon and haaIIh 96
implement. The best hope for improving physician behaviour is a combination of
reasonable and well publicised standards; continuing education about the standards
and their foundations (beginning in medical school and continuing at all other levels);
peer pressure from colleagues and medical associations; stricter government regulation
of industry involvement in medical research and practice; and the threat of disciplinary
action for egregious breaches of the standards. However, unless all interested parties
cooperate to address conficts of interest in health care, it is unlikely that progress will
ever be achieved.
hoIas
1. John R. Williams is director of ethics at the World Medical Association. The views expressed
in this article are his own, not those of the World Medical Association.
2. www.wma.net/e/policy/c8.htm
3. World Health Organization, Ethical Criteria for Medicinal Drug Promotion (Geneva: WHO,
1988).
4. www.cma.ca//multimedia/staticContent/HTML/N0/l2/where_we_stand/physicians_and_the_
pharmaceutical_industry.pdf
5. www.ama-assn.org/ama/pub/category/4001.html
6. www.laakariliitto.f/e/ethics/industry.html
7. www.ama.com.au/web.nsf/doc/WEEN-5GJ7MH
8. www.pharma-israel.org.il/eng/htmls/article.aspx?C1004=578&BSP=4
9. www.wma.net/e/policy/r2.htm
10. See Susan Chimonas and David J. Rothman, New Federal Guidelines For Physician
Pharmaceutical Industry Relations: The Politics Of Policy Formation, Health Affairs 24(4),
2005 and House of Commons Health Committee, The Infuence of the Pharmaceutical
Industry, 22 March 2005, www.parliament.the-stationery-office.co.uk/pa/cm200405/
cmselect/cmhealth/42/42.pdf
11. For example, the Standards for Commercial Support of the US Accreditation Council for
Continuing Medical Education, available at www.accme.org/dir_docs/doc_upload/68b2902a-
fb73-44d1-8725-80a1504e520c_uploaddocument.pdf
12. www.ama-assn.org/ama/pub/category/8405.html
13. www.nofreelunch.org/
Tha IIghI agaInsI oounIarIaII drugs In hIgarIa
Dora Akunyili
1
The presence of sub-standard and counterfeit drugs on Nigerias streets escalated after
the distribution of pharmaceuticals was denationalised in 1968. The lack of proper
regulation and monitoring meant that import licences were readily issued to non-
professional companies and drug regulations were fouted with impunity. Companies
producing quality drugs found it diffcult to compete with those who skimped on active
ingredients, or relabelled expired drugs for resale. The result for the user of the fake
pharmaceuticals was often prolonged illness, organ damage or death.
Though counterfeit drugs remain a serious problem in Nigeria, the situation has
changed since 2001 thanks to a combination of mass education campaigns targeted
as potential users of counterfeit drugs, and a more rigorous testing and enforcement
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6orrupIIon In Iha pharmaoauIIoaI saoIor 97
regime. Nigerias National Agency for Food and Drug Administration and Control
(NAFDAC) has been at the centre of these efforts. A baseline study conducted in April
2001, as the current NAFDAC directors took offce, showed that 68 per cent of the drugs
available in Nigeria were not registered with NAFDAC, which is taken as an indication
of counterfeiting.
2
A repeat of the study in 2004 revealed an 80 per cent reduction in
the level of counterfeit drugs in the country.
The manufacture of counterfeit drugs is a global problem, but opinions as to what
constitutes counterfeiting vary from country to country, making it diffcult to control.
The WHO describes counterfeit medicine as one that is deliberately and fraudulently
mislabelled with respect to identity and/or source. Counterfeiting can apply to both
branded and generic products, and counterfeit products may include products with
the correct ingredients or with the wrong ingredients, without active ingredients, with
insuffcient active ingredients or with fake packaging.
3
In Nigeria NAFDAC has identifed each form of counterfeit drug. These include drugs
that contain no active ingredient but are made up merely of lactose, chalk or olive
oil; herbal preparations that are toxic, ineffective or mixed with orthodox medicine;
expired drugs that have been relabelled; drugs that are issued without publishing the
full name and address of manufacturer; and drugs that have not been certifed and
registered by NAFDAC.
6orrupI oIIIoIaIs proIaoI oounIarIaIIars
The counterfeiting of medicine is fnancially lucrative, as several organised crime
syndicates have discovered. Moreover, it entails relatively low risks compared to narcotics
or gun traffcking. The low risk may be deliberate: according to the WHO, corruption
and confict of interests are the driving forces behind poor regulation which, in turn,
encourages drug counterfeiting. Corruption and conficts of interests result in laws not
being enforced and criminals not being arrested, prosecuted and convicted.
4
An example of how authorities collude with organisations that fake or sell counterfeit
drugs is the falsifcation of shipping manifests. In 2002, a 20-foot container of Napfen
(ibuprofen tablets) imported through Apapa Port was falsely declared as containing
motorcycle spare parts in order to evade NAFDAC regulations. The consignment was
released by custom offcials but later intercepted by NAFDAC offcials. Similar-sized
containers intercepted later that year contained hidden Gentamycin injections and
Seven Seas Cod Liver Oil in one case, and Tramal capsules imported from Pakistan in
a second. The drugs were discovered by the Port Inspection Directorate, which was
established by the present NAFDAC administration.
Early on in the current administration, NAFDAC agents were themselves discovered
to have engaged in corrupt practices in a series of high-profle cases. Two NAFDAC
offcials at Port Harcourt were dismissed and publicly reproached for releasing imported
products without inspection in 2002. In Akwa Ibom state, two NAFDAC staff members
were caught extorting money from the Nigerian Association of Patent Medicine Dealers
and were dismissed in 2003.
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6orrupIIon and haaIIh 9B
Until recently, NAFDAC staff were allowed to collect cartons of expensive products
as samples, which they could then sell off. This led to the practice of deliberate
oversampling and sparked industry complaints. NAFDAC subsequently adopted clear
sampling guidelines and disseminated information about correct sampling sizes to
employees and the industry. New guidelines also prohibit NAFDAC staff from accepting
free transportation, lunch or gifts from the companies they are inspecting. Instead,
inspectors are provided with all the necessary resources to carry out their tasks.
The registration process produces another opportunity for corruption by NAFDAC
staff. It is still common for it to take two years or more to register a product, although
recent streamlining and automation of the process have shortened the process to two or
three months in most cases. The lengthy exceptions are partly due to ineffciency, but
corruption also plays a role, with NAFDAC staff dragging their heels and extorting bribes
from applicants to speed up the process. Staff guidelines have been disseminated among
industry members so that manufacturers might be less vulnerable to extortion. NAFDAC
offcers face suspension, demotion or dismissal if they are found to be corrupt.
InadaquaIa IagIsIaIIon oonIrIbuIas Io Iha probIam
Nigeria has a multiplicity of drug control laws that have become unwieldy, overlapping
and sometimes conficting. The result is a legal framework that fails to deter counterfeiters
or that moves so slowly once allegations of wrongdoing have been identifed that the
suspect is rarely brought to trial.
Penalties for some offences related to counterfeiting are not commensurate with
the severity of the crime. For example, the maximum punishment for contravening
the decree on counterfeit or fake drugs and unwholesome processed food is less than
N500,000 (US $3,600), or a prison sentence of between 5 and 15 years. NAFDAC does
not believe that this level of punishment deters offenders and is calling for amendments
to the law.
Judicial authorities have on occasion failed to act against counterfeiters or importers
of fake drugs, even when NAFDAC has provided evidence of wrongdoing. For example,
a well known importer of fake drugs, Marcel Nnakwe, was arrested three times in 1997
for importing more than N19 million worth (around US $137,700), but was protected
by a judge who issued an interlocutory injunction restraining NAFDAC from taking
any further action without court clearance.
One month after the present NAFDAC administration took office, a team of
regulatory consultants and legal experts were invited to review existing obsolete laws
and recommended detailed amendments. These have been reviewed and at the time
of writing were before the National Assembly.
IsorImInaIory raguIaIIon by axporIIng oounIrIas
In many countries more lenient control of drugs for export has compromised the quality
of drugs on the international market. A case that came to light in Nigeria recently
involved the importation of poorly packaged, fake paracetamol tablets labelled not for
use in Southeast Asia. The poor regulation of exports from manufacturing countries
GC2006 01 part1 98 8/11/05 17:55:08
6orrupIIon In Iha pharmaoauIIoaI saoIor 99
exposes those countries with non-existent or weak regulations to the dumping of
counterfeit pharmaceuticals.
There are 84 pharmaceutical manufacturing companies in Nigeria, which together
produce less than 30 per cent of the countrys drug requirements: the rest is imported.
Most counterfeit drugs are imported from Asia, more than 98 per cent from China
and India. Nineteen pharmaceutical companies, mainly Indian and Chinese, were
blacklisted and banned from exporting drugs to Nigeria in 2001, and a further 12 were
debarred in 2004. NAFDAC recently prohibited the importation of products marked
for export only.
Other factors that militate against effective regulation and encourage counterfeiting
include: ignorance and poor public awareness of the problem; the chaotic drug
distribution system; misleading advertising; the demand for drugs exceeding supply;
inadequate funding of regulatory authorities; lack of cooperation between government
agencies; false declarations by importers; the sophistication of clandestine drug
manufacturing; and the irrational use of drugs, making demand diffcult to control.
hkFk6s roIa and IuIura
NAFDACs dual strategy of creating a strong regulatory environment, while encouraging
intolerance of counterfeit drugs through public enlightenment campaigns, seems to
be working. Jingles, media interviews, public alerts and notices in the national press
publicising drugs identifed as fakes are helping to lift the shroud of secrecy from the
problem.
5
Efforts have been made to stop fake drug imports at source; surveillance at all
ports of entry has been beefed up; many counterfeit drugs already in circulation have
been mopped up by the agency; good manufacturing practices of local manufacturers
are being monitored; and registration guidelines have been streamlined and are being
strictly enforced.
But success comes at a cost. Testament to NAFDACs achievements over the past few
years is the vehemence with which corrupt manufacturers have sought to block our work.
During my time as head of NAFDAC, my family and I have been the victims of numerous
death threats and in December 2003 we narrowly escaped an assassination attempt.
Efforts to tackle counterfeit medicines must be redoubled. While national measures
are working, the international community must realise that poor nations lack the funds,
manpower and technology to fully address the problem. NAFDAC strongly advocates
for harmonised regulation of pharmaceutical products on the international market and
the establishment of an international convention for the control of counterfeit drugs
similar to the one on psychotropic substances. The international community should
recognise the control of counterfeit drugs as an international health emergency.
hoIas
1. Dora Akunyili is director general of the National Agency for Food and Drug Administration
and Control (NAFDAC), Nigeria. Her fve-year mandate expires in April 2006. She was the
winner of TIs Integrity Award in 2003.
2. Ijeoma Nnani et al., Baseline Study to Ascertain the Level and Quality of Unregistered Drugs
on the Market (NAFDAC, 2001).
GC2006 01 part1 99 8/11/05 17:55:08
6orrupIIon and haaIIh 100
3. WHO Drug Information 6(2), 1992.
4. WHO (1999) Counterfeit Drugs. Guidelines for the Development of Measures to Combat Counterfeit
Drugs (Geneva: WHO, 1999).
5. Ibid., and D. N. Akunyili, Understanding the Problem: The African Perspective with Special
Emphasis on Nigeria, Global Forum on Pharmaceutical Anti-Counterfeiting (2225 September
2002), Geneva Switzerland.
8ox 6.Z 6orrupIIon In Iha MInIsIry oI FubIIo haaIIh, ThaIIand
1
The Rural Doctors Forum (RDF)
2
of Thailand traces its origins to the student demonstrations
of 1973 and an ideological commitment to serving the rural public. This political
commitment initially placed it in a diffcult position in relation to the government. Towards
the end of the 1970s, however, the head of the RDF was given a position in the Ministry
of Health, which increasingly came to accept the Forum as a means of resolving the
problems involved in decentralising health services to the rural areas.
3
In 1998, the RDF departed from its role of supporting the ministrys work to expose
corruption in the procurement of medicines and medical supplies. It claimed that its
members had been ordered by the central authorities to procure supplies from some
companies, rather than others, at prices two to three times higher than normal. It also
alleged that senior administrators had put in place a regime that fostered corruption
by cancelling medicine price ceilings and changing budgeting arrangements so as to
make provincial-level offcials, rather than offcials in individual hospitals, responsible for
procurement. The latter move made it easier for administrators in central government to
interfere with the procurement process for personal gain.
The RDFs chairman wrote an open letter to the prime minister asking for an investigation.
The RDF and another professional association, the Rural Pharmacists Forum (RPF), began
to collect evidence on corruption and encouraged their members to step forward as
witnesses. They also approached existing networks of NGOs, including the Drug Study
Group and Consumers Protection Group, to form a coalition of 30 organisations against
medical supplies corruption. The coalition provided information to the media and the
public, and petitioned the court to force the countrys National Counter Corruption
Commission to release information on the case. The court decided in its favour and the
information was released.
The committee set up to investigate the case confrmed that there was indeed corruption
among politicians and civil servants in the ministry.
4
It recommended that the procurement
system be reformed to promote transparency and accountability, and that those guilty of
corruption be punished through a free and neutral committee. Two ministers resigned
as a result,
5
and several senior and mid-level offcials were dismissed or reprimanded.
Rakkiat Sukthana, Public Health Minister at the time of the scandal, was later found guilty
of accepting bribes from drug companies, and began serving a 15-year prison sentence
in November 2004.
6
Despite this victory, there continue to be calls for other politicians and high-level
offcials to face legal sanctions.
7
It was widely felt that the committees recommendations
for reforming the procurement system to prevent corruption were ignored.
8
But the
improved coordination among civic organisations, which previously knew little about
each others work, is likely to help them to promote transparency and exert pressure on
government in future.
9
4
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6orrupIIon In Iha pharmaoauIIoaI saoIor 101
The role of the RDF and RPF in the case was particularly important because of the
position of members of the associations in the Ministry of Public Health. Most were
medical professionals and had privileged access to information, such as changes in budget
allocations, yet were able to maintain their independence, rather than being drawn into
the corruption.
10
This degree of independence can be attributed both to the fact that
many rural doctors were involved in public health NGOs, and to the RDFs history as a
force for public health reform.
11
Stuart Cameron (Institute of Development Studies, UK)
Notes
1. This essay draws from N. Trirat, Two Case Studies of Corruption in Medicine and Medicine
Supplies Procurement in the Ministry of Public Health: Civil Society and Movement Against
Corruption, Institute of Development Studies, UK: Civil Society and Governance Programme
Working Paper, 2000; S. Wongchanglaw, Case Study: Citizen Mobilisation in the Fight
Against Corruption: The Case of Health-Care Funding in Thailand, paper written for the Open
Government Forum held in Seoul, February 2003, see www.thinkcentreasia.org/documents/
healthcarecorruptionthailand.html; U. Tumkosit, Two Case Studies of Corruption in Medicine and
Medicine Supplies Procurement in the Ministry of Public Health: A Framework of Relationships
between Civil Society and Good Governance, Institute of Development Studies, UK: Civil Society
and Governance Programme Working Paper, 2000.
2. Sometimes referred to as the Rural Doctors Society.
3. Trirat, Two Case Studies of Corruption.
4. Wongchanglaw, Case Study.
5. Dr Rakkiat (alternative spelling, Rakkied) Sukthana resigned on 15 September 1998 and Deputy
Public Health Minister Teerawat Siriwanasarn resigned on 20 September 1998.
6. The Nation (Thailand), 2 November 2004.
7. Pasuk Phongpaichit, Corruption, Governance and Globalisation: Lessons from the New Thailand,
Corner House Briefng 29, 2003, www.thecornerhouse.org.uk/item.shtml?x=51987
8. Trirat, Two Cases of Corruption.
9. Wongchanglaw, Case Study, and Tumkosit, Two Case Studies.
10. In one sense, it [the RDF] is inside the ministry it is attacking ... But in another sense, the Rural
Doctors Society is not an offcial part of the ministry structure. It is just a chomrom (club). See
C. Noi, Six Rules for Fighting Corruption, The Nation (Thailand), 15 November 1998. Available
at www.geocities.com/changnoi2/ruraldoc.htm
11. Trirat, Two Cases of Corruption.
8ox 6.8 MaIpraoIIoa In Iha IIIoa oI Iha rug 6onIroIIar In karnaIaka, IndIa
1
The Karnataka Lokayukta (KLA) is a statutory judicial body charged with improving standards
of public administration in the state of Karnataka, India. Although other Indian states also
have lokayuktas, the KLA is exceptional in that it is better funded its annual budget for
200203 was around Rs72 million (around US $1.7 million) and is proactively led by
a high-profle retired judge, Justice Venkatachala. It is able to investigate grievances and
complaints against public bodies through the police, and direct the relevant authorities
to take corrective action when a grievance is justifed. Its actions in the health sector
have included paying unannounced visits to hospitals to check for bribes being paid, and
requesting hospitals to display citizens charters detailing which drugs are available, the
fees for services, and what kind of facilities and services are offered.
NGOs occasionally make vital contributions to the KLAs investigations. A medical doctor
and activist from Drug Action Forum (DAF), a group aiming to raise awareness about
4
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6orrupIIon and haaIIh 10Z
drugs promotion and policy, made a complaint to the KLA in 2003, alleging malpractice
in the Offce of the Drug Controller (ODC). A preliminary investigation revealed a number
of irregularities. The offces mandate is to ensure that only authorised drugs of specifc
quality are sold. Many drugs were found to be sub-standard, but the test results were
only available after several months and no action had been taken to withdraw them. Nor
had any action been taken against the companies manufacturing the drugs. In this way,
suffcient time had passed for all of the sub-standard drugs to be sold to the public.
It was discovered that companies that paid bribes were allowed to circumvent drugs
standards, and those that refused to pay were harassed. Other irregularities included non-
enforcement of price controls and accepting kickbacks. The ODCs remit also included
granting licences to blood banks, but it did this with little regard for enforcement of
standards or monitoring. The investigation found that a complaint had been fled about
a blood bank in the district of Gulbarga that had provided HIV-positive blood; no action
was taken in response.
The KLA responded to these fndings by calling a meeting of over 50 offcers from
the ODC. It was claimed at the meeting that each drugs inspector was required to give
Rs20,000 (around US $460) every six months to the Drugs Controller, who then passed it
on to the Minister of Health.
2
Hearings were open to the media, with politically damaging
consequences for former ministers who had also been implicated. In a bid to limit the
damage, the ODC suspended the three offcers who were cooperating with the inquiry,
but the KLA threatened to hold the government in contempt of court for obstruction of
justice if it did not reinstate the men and protect them from further harassment.
The KLAs fnal report of the investigation called on the government to suspend the
ODCs top three offcials, but did not implicate the Minister of Health.
3
The three offcials
were duly suspended on grounds of misconduct and dereliction of duty in October 2004.
4
The Lokayuktas powers have limitations: it is not able to remove someone from offce
without the permission of central or state government, or of a senior offcial in the same
department as the accused. It therefore depended on pressure from the public, via media
exposure, to push the government into acting on its recommendations. It is not yet clear
whether this pressure has been suffcient to bring about sustainable reform in the ODC.
DAFs involvement in the case was instrumental. There are obvious diffculties for
ordinary individuals who make a complaint to a judicial body like the KLA. The judicial
process is slow and cumbersome, and can seem daunting. Patients may lack information
about their entitlements or health standards, and may fear losing access to services if
they fle a formal complaint. Moreover, expert pressure groups like DAF can provide the
detailed information that may be necessary in order to proceed with an investigation.
Stuart Cameron (Institute of Development Studies, UK)
Notes
1. This essay draws from two articles by Asha George, We Need to Fix This Leaky Vessel and Small
Steps Ahead published in Humanscape Magazine 10(9) 2003, and 10(10) 2003, respectively.
See www.humanscape.org/Humanscape/new/sept03/weneedto.htm and www.humanscape.
org/Humanscape/new/october03/smallsteps.htm The issues were uncovered by Anuradha Rao,
in Karnataka Lokayukta: Initiatives in the Public Health Sector: A review, Mimeo, Bangalore:
Public Affairs Centre, 2003.
2. Humanscape Magazine 10(10), 2003.
3. Deccan Herald (India), 1 October 2003; The Hindu (India), 1 October 2003.
4. Deccan Herald (India), 3 October 2004. The offcials were the Drugs Controller, Anand Rajashekar, the
Additional Drugs Controller, H. Jayaram, and the Deputy Drugs Controller, B. G. Prabhakumar.
GC2006 01 part1 102 8/11/05 17:55:09
6orrupIIon and hIVlkI8 108
6 6orrupIIon and hIVlkI8
Some 5,000 demonstrators take part in a protest march to the Constitutional Court in
Johannesburg on 2 May 2002 to protest the governments appeal of a court ruling forcing it
to provide a key AIDS drug to HIV-positive pregnant women. (Themba Hadebe/AP)
While the corruption that affects HIV/AIDS prevention and treatment does not look
very different from corruption found in other areas of the health sector, the scale of
the pandemic, the stigma attached to the disease and the high costs of drugs to treat
it magnify the problem. The response to HIV/AIDS must involve an increase in funds
available to purchase drugs. But scaling up budgets without paying due regard to
the anti-corruption mechanisms needed to ensure their proper use provides further
opportunity for corruption. A case study from Kenya shows a worst-case scenario, of
corruption and profigacy at the national AIDS body set up to coordinate prevention
programmes. An examination of the Global Fund fnds that including all stakeholders
in the design of programmes, from governments and NGOs to the sufferers themselves,
could help provide a safeguard against corruption.
GC2006 01 part1 103 8/11/05 17:55:09
6orrupIIon and haaIIh 104
Tha IInk baIWaan oorrupIIon and hIVlkI8
Liz Tayler and Clare Dickinson
1
While it is diffcult to draw a causal link between corruption and the spread of HIV,
there is ample evidence that corruption impedes efforts to prevent infection and treat
people living with AIDS in many parts of the world. The mechanics of corruption
affecting the prevention and treatment of HIV/AIDS are not substantively different from
those affecting the health sector more generally: opaque procurement processes, the
misappropriation of funds earmarked for health expenditure and informal payments
demanded for services that are supposed to be delivered free. What are different are
the scale of the problem and the nature of the disease a chronic, usually fatal and
often-stigmatised disease that can be contained only with expensive drugs. Moreover,
the individuals responsible for tackling corruption may themselves be severely affected
by AIDS. These factors create particular vulnerabilities to corruption.
There are multiple opportunities for corruption in the prevention and treatment of
AIDS. In prevention programmes, corruption occurs when false claims are presented
for awareness-raising activities that never took place, or for materials that were never
purchased. Corruption occurs in programmes aimed at alleviating the socio-economic
effects of the disease on victims and their families, such as feeding programmes or
support for school fees. Corruption can also contribute directly to infection when
relatively low-cost measures, such as the use of sterile needles and the screening of
blood donations, are ignored because a corrupt procurement or distribution process
holds up supplies. Alternatively, health workers may use non-sterile equipment as an
additional source of income by extorting illicit payments from patients who demand
clean equipment.
But it is treatment programmes that are most vulnerable. Money for high-value drugs
can be embezzled at any number of points in the procurement and distribution chain.
At the grand end of the scale is theft by ministries and national AIDS councils of funds
allocated for treatment, and the misappropriation or counterfeiting of medicine. At the
petty end are doctors who extort tips for medicines and patients who sell their own
medication because it is the only valuable commodity they have.
The international response to the epidemic has increased in recent years and there
is pressure to spend large sums of money in countries with limited capacity to oversee
their proper usage. The IMF reports that HIV/AIDS resources fows were US $5 billion
in 2003 and US $8 billion in 2004. With this much money in play, and with donors
insisting that disbursement be the standard metric for judging programme success,
recipient nations will fnd ways to absorb the funds, whether legally or illegally. The
prime requirement for recipient nations seems to be spend it or lose it.
The numbers of people infected with HIV are high and rising. In sub-Saharan Africa
overall, 7 per cent of women and 2 per cent of men aged 1524 are infected.
2
In
Botswana, Swaziland and Zimbabwe, over 25 per cent of the adult population is now
HIV infected. In Asian countries the rates are generally lower, but they are rising fast.
The impact of a large proportion of a community becoming sick and dying is unclear.
GC2006 01 part1 104 8/11/05 17:55:10
6orrupIIon and hIVlkI8 106
Some have suggested that more widespread corruption might be a result of increased
short-termism as those infected seek fnancial security by any means possible for the
families they will leave behind, and informal structures emerge to meet the vast needs
that formal health systems are failing to meet.
3
6orrupIIon In Iha IraaImanI oI hIVlkI8
Relatively effective drug treatment has changed the nature of HIV/AIDS in the West.
Increasingly, it is seen as a condition people can live with. Hospitalisation and death rates
have fallen, and anti-retroviral drugs (ARVs), when properly administered, offer people
with HIV many extra years of productive life, depending on when treatment begins.
In Africa, it is estimated that people live an average six and a half years after infection.
If ARV treatment is started at the appropriate time, life expectancy is doubled or tripled.
Over the past decade, ARV treatment has gone from being something that even people
in developed countries could not afford to a treatment that over 700,000 people in
developing countries now receive. The WHO is attempting to get 3 million people onto
treatment by 2005 under its 3 by 5 initiative.
Even with this massive and rapid scaling-up, treatment is not available to all who
need it. This is no different from other health services in Africa and the rest of the
developing world where many are excluded through fnancial or cultural constraints,
or because of the distance to health facilities. Access to ARV sharpens these issues,
however. Demand frequently exceeds supply even when there is an offcial policy to
determine who gets treatment, such as a cut-off point based on blood test results (the
CD4 count). Those whose result is not quite bad enough may try to use fnancial,
political or other inducements to get onto treatment programmes. A 29-year-old
Nigerian father of three spoke for many across the continent in the 2005 civil society
organisation statement to the African Union Summit of Heads of States: The ARVs
that come to the centre are not given to those of us who have come out to declare our
status, but to those big men who bribe their way through, and we are left to suffer
and scout round for the drug.
4
Where ARVs are provided for free or at heavily subsidised rates through donor-funded
programmes, requests for top-up payments are common. The Malawi Network of People
Living with HIV/AIDS (PLWHA) reported instances of abuse from hospital workers
demanding sexual, monetary or material favours in return for proper medication and
care. Those who refuse are either neglected or receive sub-standard care. In cases where
PLWHA do report receiving high-quality care, it is followed by suspicion by other care
providers and patients that those who furnish it are receiving bribes.
5
Those that get onto programmes offering free or highly subsidised drugs receive a
valuable commodity. They and their family will have other needs as well, and many
elect to share or trade their drugs to meet these needs. There is a ready market for
ARVs. In Tsavo Road, Nairobi, huge quantities are traded every day.
6
Some come from
patients, others leak out of the health system, and a large proportion is counterfeit.
The drugs are often cheap and there are fewer stigmas, no hassle and no waiting. Some
vendors sell their own treatment drugs; some are registered on multiple programmes
GC2006 01 part1 105 8/11/05 17:55:10
6orrupIIon and haaIIh 106
and have ARVs to spare; and others have access to the supply chain through central
and hospital pharmacies.
People buy drugs from informal sources like Tsavo Road because it is convenient and
anonymous. The problem with doing so is that ARVs are effective only when there is
rigid adherence to the treatment protocol. Buying treatment from those who know
little about the appropriate combinations, side-effects or dosage, and substituting one
drug for another depending upon availability, means treatment is likely to become
ineffective and result in the development of resistance to ARVs. Moreover, the product
may be expired or fake.
The WHO estimates that the global market in fake and sub-standard drugs is worth
US $32 billion or around a quarter of all drugs used in developing countries.
7
Well
substantiated reports from Ethiopia,
8
DRC
9
and Cote dIvoire
10
indicate that the
problem may be even greater and is increasing. Given the demand for, and value of
the drugs, faking ARVs is potentially much more proftable than faking other drugs.
Corruption contributes to the extent of the problem when regulatory authorities turn
a blind eye to counterfeiting or public offcials receive inducements to procure from
less reputable suppliers, as Dora Akunyili describes (see The fght against counterfeit
drugs in Nigeria, Chapter 5, page 97).
Concerted advocacy by civil society groups and governments, and competition from
generic and research-based companies have been extremely effective in lowering the price
of ARVs in the developing world, resulting in a system of differential pricing between
OECD countries and developing countries. A months supply of GlaxoSmithKlines
Combivir, for example, costs around US $610 in Britain and US $20 in Uganda, Tanzania
and Kenya. The potential proft from re-importation or smuggling is large for vendors
in developing countries and drugs brokers in developed countries. How much of a
problem this is in reality is controversial, however, and there have been allegations
that the pharmaceutical countries are exaggerating the scale of the problem in order
to dampen pressure for differential pricing.
11
Competition in the supply of ARVs has not stopped corruption in national
procurement processes. For example, the Romanian government has launched an
investigation following allegations by US Ambassador Michael Guest that ARVs
were being sold at prices 50 per cent higher than in the United States and that the
health ministry had engaged in corrupt dealings with drug suppliers. A government
watchdog agency reported in April 2003 that the ministry had ignored an agreement
with GlaxoSmithKline to reduce the price of its ARVs by up to 87 per cent
12
and
denied drug importation contracts to foreign companies, granting them instead to
four local ones. These levied taxes and commissions were worth up to 55 per cent of
the drugs value.
haIIonaI programmas. naW approaohas and roIas
Where systems are weak and corruption endemic, it is diffcult to disentangle corruption
from mismanagement and system failure as the root cause of poor HIV/AIDS responses.
Nigerias ARV programme attracted much criticism in 2003 when treatment centres
GC2006 01 part1 106 8/11/05 17:55:10
6orrupIIon and hIVlkI8 107
began handing out expired drugs and rejecting patients.
13
But it is not yet clear whether
the prime cause was corruption or a weak drug procurement, supply and distribution
service that was unable to respond to the demands that the rapid scaling-up of the
programme had placed upon them.
Fresh approaches have developed involving new actors and sectors not traditionally
involved in health programmes, such as education, security, agriculture and social
services. National AIDS commissions have been established to coordinate the response
in many countries. They are often seen as a donor construct, however, and the extent to
which they have been assimilated into domestic governance systems is variable. Kenya
provides an example of the worst-case scenario: its agency was discredited when it was
discovered that senior staff had paid themselves infated salaries and allowances (see
Corruption in Kenyas National AIDS Control Council, page 112).
In Zimbabwe the government has imposed an AIDS levy since 2000 whereby
employees contribute 3 per cent of their gross salaries towards a fund administered by
the National AIDS Council (NAC). It is estimated that the government collects about
US $20 million per year through this mechanism, but no information about how the
fund is used and who benefts from it has ever been made public. In March 2005, the
health ministry ordered an audit of the NAC, but at the time of writing it had not yet
been published.
Civil society organisations (CSOs) are increasingly seen as important providers of
services and receive substantial grants to do so, but the transaction costs of processing
and monitoring CSO applications are very high. An attendant risk is that CSO directors
will siphon off their funding. For example, the director and senior staff at the Zimbabwe
National Network for People Living with HIV/AIDS were suspended after allegations of
corruption.
14
The network received more than US $1.8 million from the NAC between
2003 and 2004.
Tha InIarnaIIonaI rasponsa. mora monay
The sums now being disbursed to tackle HIV/AIDS are huge compared to the existing
budgets of many countries.
15
In Ethiopia, Liberia and Malawi, the money allocated
by global health partnerships such as the Global Fund to Fight AIDS, Tuberculosis
and Malaria represents more than a doubling of the health budget. Funds from the
World Bank and the US Presidents Emergency Project for AIDS Relief (PEPFAR) are
also massive.
While the need for money is undisputable, the systems to use these funds appropriately
are poorly developed. The fact that the performance of a grant or loan is assessed by
how rapidly it is disbursed gives incentives to donor and recipient to allocate the money
carelessly. For corrupt offcials, rapidly expanding budgets offer greater scope to siphon
off signifcant volumes without anyone noticing. This is especially true where health
systems are fragile, where there is a lack of monitoring and oversight, and where the
capacity to channel the money effectively is limited.
Beyond the immediate risk of money being squandered by corruption, commentators
such as Stephen Knack
16
suggest that development assistance may actually reduce
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6orrupIIon and haaIIh 10B
8ox 6.1 kooounIabIIIIy In a IIma oI orIsIs. oorrupIIon and Iha IobaI Fund
The Global Fund to Fight AIDS, Tuberculosis and Malaria was established in January
2002. At the time, international efforts were failing to dent a death toll of 6 million
people each year who die of illnesses that in rich countries are controlled or cured. Its
foundation coincided with growing concern that corruption was lessening the impact
of development aid.
The Global Funds mandate was simple: to provide a massive infusion of fnancing for
efforts to combat these three diseases in developing countries. Its role would be limited to
supplying funding rather than, as has classically been the case in development assistance,
bundling fnancing with technical support to prepare and implement programmes. This
model was developed out of a recognition that adequate capacity existed at local level
to scale up disease control interventions, should suffcient fnancing be made available.
No country offces would be established, and instead the Global Fund would be created
with a small board supported by a small Secretariat in Geneva.
1
To date, the Global Fund has approved proposals totalling almost US $3.5 billion for
combating the three diseases in nearly 130 countries. More than US $1.41 billion was
disbursed as grants in the organisations frst three years, and the fgures are growing
rapidly. The countries being fnanced are among the most corrupt in the world: 23 of the
25 lowest-ranked countries in Transparency Internationals 2004 Corruption Perceptions
Index have received money from the Global Fund.
2
Working in countries where corruption is endemic, and under pressure to work fast,
the Global Funds approach has been to include parties from government, civil society,
the private sector, UN and donor agencies, and people affected by the diseases in
Country Coordinating Mechanisms that have responsibility for submitting proposals
and overseeing the use of funds. The idea is that the different stakeholders will exert
peer pressure to promote more effective implementation and reduce the likelihood of
money disappearing.
But the experience to date with this approach to ensuring accountability has been
mixed.
3
In Armenia, Cambodia, Ghana and Rwanda, the country bodies have taken on
active roles in overseeing implementation, including developing monitoring tools and
operating procedures. In other countries, however, they have been appropriated by a
single constituency typically the government particularly in Eastern Europe and central
Asia; have fallen prey to competing political agendas; or simply have not met regularly
enough to ensure any adequate oversight role.
A second aspect of the Global Funds accountability system is that ongoing funding
is performance-based. Global Fund resources are provided as advances and the fnancial
reporting requirements are generally quite streamlined. But expenditure reporting is
required to be linked with programme monitoring and evaluation, shifting the focus
from inputs (whether or not a computer was bought or a shipment of drugs arrived
at the port, for example) to outputs (such as whether the fnancing was used to scale
up interventions against AIDS, tuberculosis or malaria). If expenditures occur without
demonstrable results, it is an immediate red fag that corruption may be diverting resources
away from their intended purposes. This enables the Global Funds Local Fund Agent
(LFA)
4
to pay increased attention to the recipients fnancial records.
However, LFAs are more familiar with fnancial data than health outcomes and have not
always adequately addressed this weakness by bringing in outside expertise. Adding to
4
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6orrupIIon and hIVlkI8 109
the quality of governance in recipient countries. Donors may set up parallel systems
to avoid the risk of corruption, but this means taking talent and capacity away from
the offcial government system, with the concomitant that governments and offcials
become more accountable to the donor than to their own constituents. PEPFAR is an
example of an approach that combines a political imperative to spend money rapidly
within narrow political constraints.
the problem, the contracting system does not systematically ensure that an LFA working
in a very corrupt country has more resources at its disposal than one working in a country
with robust accountability systems. The Global Fund has terminated grant agreements
because of corruption concerns in two cases, Ukraine and Uganda. In both cases, the
corruption was detected as a result of a combination of the work of the LFA and that of
partners in the country.
A third innovation of the Global Fund is its transparency. The Global Fund makes
information about the dates and amounts of every disbursement available on its website
and in its publications. The ideal is that the government and non-government partners
with a stake in the programme will use this information to ensure that resources are not
diverted.
There are concerns that this vision is losing some of its clarity, however, as the Global
Fund Secretariat grows in size and slowly takes on more responsibility for doing the work
that its partners were originally expected to be able to assume. This has arisen both because
of pressure on the new organisation to prove itself and because partners have tended to
view the Global Fund as yet another external body coming in to fnance its own projects,
rather than one that simply provides additional resources to a national response that all
parties would support.
Given the Global Funds short history, it is diffcult to assess fairly how well these
various accountability and transparency mechanisms are working. What speaks in the
organisations favour is that it has been willing to amend its processes as corruption
concerns emerged; for example, in deciding in mid-2005 to set up an Offce of the
Inspector General to tackle suspected fraud and abuse. It has also begun to introduce risk
management principles into its operations, both to allocate staff resources appropriately
and to tailor procedures and responses to varying contexts.
Toby Kasper
5
Notes
1. Of the 19 board members, 14 are from national governments or regional groups, generally
represented by health ministries, HIV/AIDS committees, and development cooperation ministries.
Three are from non-governmental organisations and two are from the private sector. Two of the
NGO members were from developing country NGOs, while the 14 governmental representatives
were evenly divided between developing and developed countries.
2. Transparency International, Global Corruption Report 2004, available at www.transparency.org/
cpi/2004/cpi2004.en.html#cpi2004
3. See www.theglobalfund.org/en/apply/mechanisms/casestudies/default.asp
4. The Global Fund Secretariat does not have any offces outside Geneva, so it contracts independent
frms to assess the capacity of the principal recipients of the funds to handle the large volume of
resources and to monitor implementation. The LFAs are generally accountancy frms (particularly
PricewaterhouseCoopers and KPMG), selected through a competitive tendering process.
5. The author worked at the Global Fund to Fight AIDS, Tuberculosis and Malaria from August 2002
until March 2004, initially responsible for the management of a portfolio of countries and later
as policy manager.
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6orrupIIon and haaIIh 110
In an attempt to prevent this, some donors mainly European, but also the Global
Fund (see page 108) are moving towards budget support, essentially putting their
money through government channels. While recognising the fduciary risk, they believe
that the benefts improved effciency, legitimacy in focusing on public fnancial
management and support to domestic accountability outweigh the disadvantages
in many countries.
6ouId mora ba dona Io mInImIsa oorrupIIon?
As with attempts to tackle corruption in the health sector generally, the terms and
conditions of health workers should be improved in parallel with the introduction of
mechanisms to increase their accountability to the communities they serve. However,
though paying health workers and civil servants more is necessary, it is not enough
to limit corruption, as the Nigerian experience in 2000 illustrated. And minimising
the opportunities for corruption without providing alternative sources of income may
induce health workers to give up, resulting in an escalation of the human resource
crisis in the health sector.
Increasing transparency is vitally important in health services. The public needs to
be more aware of the eligibility criteria for ARV programmes, which should ideally
become more consistent within and across countries. They need to be aware of what
they have to pay and what they will receive. The quantities and values of drugs supplied
at each level of the system should be well publicised, and health workers should have to
account for them. There also needs to be a mechanism whereby people can complain
without fear of victimisation.
Pharmaceutical companies also need to take action. To minimise the risk of drugs
for developing countries being reimported, GlaxoSmithKline is rebranding and
changing the colour of ARVs sold in developing countries. An alternative approach is
to develop different branding and packaging for products designed for use in developing
countries.
The EU employs a system of registration whereby products are given a number
and bar code, and can be identifed by customs or drug brokers if reimported. Tight
monitoring of pharmaceutical sales within the United States and Europe is an important
disincentive to reimportation, and needs to be maintained. However, implementation
of the recent WTO agreement regarding compulsory licences, and the export and import
of generic varieties of drugs may restrict the availability of cheap generic varieties of
drugs, providing additional scope for bureaucratic corruption.
Donors have an important role to play in minimising corruption, one that is not
specifc to HIV/AIDS treatment or prevention programmes. With vast resources fowing
in for HIV/AIDS, however, a new paradigm has been created that distorts the donor
recipient relationship. What rich nations view as the provision of funds to purchase
AIDS medicines, many in poor nations have monetised upwards as a currency of street
trade.
Donors need to fnd a choke point to reduce corruption. One step towards making
recipient governments more transparent would be for donors to be open and explicit
GC2006 01 part1 110 8/11/05 17:55:11
6orrupIIon and hIVlkI8 111
about what they are giving, when and to whom. This requirement is included in
international recommendations, but the reality is far from ideal. Donors should ensure
that aid is used in line with good procurement guidelines, and work with pharmaceutical
companies to encourage and ensure responsible behaviour.
Ultimately, it is the responsibility of national governments to deal with corruption.
Given the associated sensitivities about international action, regional pressure may be
more appropriate; in Africa, the New Partnership for African Development (NEPAD)
peer review system could become an important tool. Finance and health ministers
control the foreign exchange that is used to purchase medicines and need to be aware
of the long-term effects of their misuse. When medicines are sub-standard or distributed
inadequately, the onset of drugs resistance is accelerated, leading to a growing burden
of chronically ill people. The cost of medical care to treat them will be far greater than
the price of the legitimate medicines in the frst instance.
HIV/AIDS is going to be a major problem for the next two decades at least. Experience
gained in other areas of development, and the need for transparency and strong domestic
accountability, should not be ignored if sustainable and effective approaches to tackling
the disease are developed.
hoIas
1. Liz Tayler is a UK public health physician, who worked for several years as the DFID health
adviser in Nigeria before joining the HLSP institute as an adviser. Clare Dickinson is an
HIV/AIDS specialist with HLSP and formerly worked in Indonesia on a health policy project
based in the Ministry of Health.
2. UNAIDS, 2004 situation report, www.unaids.org/wad2004/EPI_1204_pdf_en/Chapter3_
subsaharan_africa_en.pdf
3. Alex de Waal, HIV and the Security Threat to Africa. Evidence submitted to the high-level
forum panel on security threats and challenges, Justice Africa, May 2004.
4. Statement by CSO at the fourth ordinary African Union Summit of Heads of States, January
2005 Nigeria.
5. Malawi Network of People Living with HIV/AIDS (Manet), Voices for Equality and Dignity:
Qualitative Research on Stigma and Discrimination Issues as they Affect PLWHA in Malawi,
July 2003, www.synergyaids.com/documents/Malawi-MANET.pdf
6. The Nation (Kenya), 22 January 2004.
7. Fake and Counterfeit Drugs, WHO Fact Sheet 275, November 2003.
8. www.addistribune.com/Archives/2003/10/10-10-03/Black.htm
9. www.essentialdrugs.org/edrug/archive/200402/msg00028.php
10. www.essentialdrugs.org/edrug/archive/200401/msg00004.php
11. Financial Times (Britain), 23 May 2005.
12. Agence France-Presse (France), 22 April 2003.
13. Associated Press, 4 February 2004.
14. The Chronicle (Zimbabwe), 3 February 2004, 23 April 2004 and 19 July 2004.
15. In 2001, US $2.1 billion was spent on HIV and AIDS; within three years this almost tripled to
US $6.1 billion, with an expectation that needs will triple again by 2008. See Resource Needs
for an Expanded Response to HIV/AIDS in Lower and Middle Income Countries (UNAIDS,
2005).
16. Stephen Knack, Aid Dependence and the Quality of Governance: A Cross-Country Analysis
(Washington DC: World Bank, 2001).
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6orrupIIon and haaIIh 11Z
6orrupIIon In kanyas haIIonaI kI8 6onIroI 6ounoII
Kipkoech Tanui and Nixon Nganga
1
HIV/AIDS is one of the biggest challenges facing the health sector in Kenya, and was
declared a national disaster in 1999. The National AIDS Control Council (NACC) was
set up later that year to coordinate the prevention and control of HIV/AIDS. Its role
became even more critical when the current government placed at the centre of its
200307 development plan the goal of achieving 90 per cent awareness of the disease
and its effects across society.
The NACC was given control over funds pooled under the Kenya HIV/AIDS Disaster
Response Project (KHADREP), fnanced by the World Bank, the UNDP, and the UK
and US development agencies. In the 200405 fnancial year, the NACC was allocated
just under KSh4 billion (US $41 million). The most signifcant portion of its budget is
channelled into community-based organisations. It claims to have channelled KSh1.8
billion (US $24 million) to community-based organisations during 200003.
The NACC was set up under the Offce of the President (OP). However, a more natural
home for it is the health ministry, which is also a recipient of large amounts of bilateral
funding and runs the National AIDS and STD Control Programme (NASCOP). The
choice of the OP as home for the NACC was made ostensibly out of the governments
desire to control the sizeable budget it manages. The OPs record belies the wisdom of
this decision, however. It has been the focus of some of Kenyas most egregious acts
of corruption, often perpetrated by well-connected offcials who have proved almost
impossible for prosecutors to touch.
In April 2003, the OP was enveloped in scandal when it was revealed that the head of
the NACC, Margaret Gachara, had been receiving a salary seven times what she should
have been entitled to as a senior civil servant. She had negotiated the salary based on a
fraudulent letter from her previous employer that exaggerated her earnings there. Once
in offce, she raised her salary even higher than the already infated amount she had
been offered. In August 2003 she was ordered to refund US $340,000 to the NACC.
Fears that the corruption did not end with her high salary were confrmed in April
2005 when a report by the Effciency Monitoring Unit (EMU), also based in the OP,
revealed that for years high-level public servants had used the NACC as their personal
cash cow. There had been a number of early warning signals. An internal audit in June
2002 found irregularities in procurement procedures and in June 2003 the Global Fund
to Fight HIV/AIDS, Tuberculosis and Malaria withheld a US $15 million AIDS grant
until the government addressed corruption in the NACC.
The 300-page EMU report revealed that Kenya could not account for KSh3.64 billion
(US $48 million) donated by the United Kingdom over fve years since 2001. It put a fgure
of more than KSh37.3 million (US $490,000) on the amount used by NACC employees
to pay themselves infated salaries and fraudulent allowances, such as the payment of
private water, electricity, telephone and home security bills. The largest sum was the
money embezzled by Gachara, but others were also involved, including eight permanent
secretaries or their representatives, and NACC Chairman Mohammed Abdallah, who
was charged with embezzlement but later acquitted due to lack of evidence.
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6orrupIIon and hIVlkI8 118
Even where money did fnd its way out of NACC to the community organisations it
was intended to support, the report into its use was damning. The EMU found that on
a sample examination of the community-based organisations funded by the NACC, at
least half of the money allocated has been squandered.
Investigators probed three of the 10 national NGOs funded by NACC and several
provincial, district and constituency-level organisations. They found wanton theft of the
NACC money granted to noble-sounding projects that turned out to be sham. The worst
cases involved shell organisations purposely formed to cash in on the NACC windfall.
The NACC itself had cracked down on some of the so-called briefcase NGOs cited
in the report, including the Neema Childrens Centre in Nairobi. The NACC awarded
Neema US $14,000 out of a World Bank grant to fnance grassroots work on HIV/AIDS.
It was closed down in mid-2003 after inspectors could not fnd a single Neema worker
or a single orphan who had benefted from the childrens centre.
Money was squandered by almost all the AIDS Control Units (ACUs) formed in each
ministry to sensitise staff to the disease. Grants were spent on needless seminars, usually
involving the same participants. Of the US $205,000 given to the Ministry of Agriculture,
for example, more than 75 per cent was spent on staff accommodation, allowances and
participation fees at various awareness-raising shows, the EMU report noted. Almost
one-third of the amount spent was not accounted for and was presumed wasted.
Investigations into the three national NGOs revealed similar misdeeds. Par Aid, a
well-connected organisation based in Eldoret, received US $100,000 for a proposal to
study the effcacy of Par Aid herbal medicine in the treatment of HIV/AIDS infection.
The chairman of the Institutional Research and Ethics Committee at Moi Teaching
Referral Hospital, which is part of Moi University, withdrew a letter approving the
project because he was concerned that Par Aid was not serious about the study, but his
decision was quickly overturned with no explanation given by the hospitals director.
The study went ahead, and the EMU report found that most of the money was spent
on trips to collect the medicine, or on fuel. The medicine that should have been used
in free trials was sold to desperate patients, leading the EMU to conclude that Par Aid
was conducting a proftable business with NACC funds.
Corruption in the case of the AIDS Prevention Forum of Kenya (APFK) is even more
blatant. Also given US $100,000 in NACC funds, its directors appear to have gone on
a spending binge under the guise of organising seminars and workshops.
EMU noted a claim by the organisation that it spent US $16,000 hosting school pupils
at a seminar in the Chania Tourist Hotel. The schools said to have been involved denied
any knowledge of the activity and said some of the pupils alleged to have participated
did not even exist. Similarly, hotels refuted several account entries, saying they were
either paid considerably less, or did not host the seminars at all. For example, the Hotel
Big Five in Homa Bay, which was said to have hosted 150 students at a cost of US $6,200,
consists of just 12 rooms and denied ever accommodating the group.
A number of APFK directors were simultaneously directors of the third NGO
investigated, Technologies and Action for Integrated Development (Techno Aid), where
similar practices were uncovered. Techno Aid claimed to have organised seminars and
workshops for the same people as APFK, consulted academic experts who denied ever
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6orrupIIon and haaIIh 114
working for the NGO, and paid large bills to non-existent hotels. Both Techno Aid and
APFK presented receipts for stationery from the University of Nairobi bookshop, which
has disowned them as frauds.
The report points the fnger of blame at the lax implementation of the NACCs own
funding rules and, in the worst cases, outright collusion between crooked NGOs and
NACC staff. In some cases the NACC continued to fnance organisations even when its
own offcers had expressed concerns over the accounting for previous allocations.
As isolated cases, the funds may seem petty especially when juxtaposed with the
huge sums that HIV/AIDS attracts. But in their consolidated amounts, and if spent
on effective prevention programmes, life-prolonging anti-retroviral drugs (ARVs) or
income-generating activities for the affected and infected, the sums are signifcant.
The fght against HIV/AIDS in Kenya attracts massive funding. The Global Fund
has promised US $129 million over fve years while the United States has pledged US
$115 million. Other donors who have responded to Kenyas appeal for more funds
include UNAIDS (US $15 million) for disease mitigation initiatives and the World
Bank (around US $658,000 on top of a 2004 grant of US $4 million). The bulk of these
funds go to NASCOP, which has also fallen under suspicion for failing to deliver results
commensurate with its budget. If there were no leakage or ineffciencies in the use of
NASCOP funds, they should be enough to provide ARVs to 200,000 of the 1.4 million
Kenyans who are estimated to be infected with HIV. The real fgures are scandalously
small. By November 2004 only 24,000 people were reported to be on ARVs.
The EMU is based in the OP, and was created in response to donor pressure to
contain corruption in the institutions they support. Every state institution is liable to
be investigated by the unit, but given its scant resources staffed by just 50 people it
opts to probe those with sizeable budgets, often guided to them by rumours of sleaze.
The EMU is reputed to conduct thorough and impartial investigations. Its report,
Financial Management Audit of the National AIDS Control Council (NACC) in the
Offce of the President is the culmination of a two-year investigation.
The EMU has called on the Anti-Corruption Commission to investigate all the cases
of fraud and abuse of offce listed in the report. Gachara, the former NACC director,
was sentenced in August 2004 to one year in prison on three counts of fraud and
misuse of offce. She was granted a presidential pardon in December 2004, along with
7,000 petty offenders who had stolen from various government offces. Her release
was publicly decried.
In response to the report, the NACC claims to have hired auditors to probe the
accounts of the NGOs it funds. It says it will release funds in tranches, conditional on
proof that the previous allocation was properly utilised. It ordered 20 NGOs to refund
money that was misappropriated, or face prosecution. At the time of writing none had
refunded the money and none had been taken to court.
The role of constituency-based AIDS councils has also been bolstered in response
to the scandals. These had already been given a larger role in resolving the Global
Funds concerns and now have responsibility to scrutinise the expenditure of NACC
money. Many MPs who are the patrons of their respective constituency councils
have welcomed moves in this direction and some have called for the NACC to be
GC2006 01 part1 114 8/11/05 17:55:12
6orrupIIon and hIVlkI8 116
disbanded in favour of constituency-based AIDS management committees, citing bias
in NACC decisions over which NGOs to fund. Whether this will help curb corruption
is questionable, however. Civil society groups and the media have levelled accusations
of favouritism in appointments to the constituency councils and in their decisions over
the disbursements of funds.
hoIa
1. Kipkoech Tanui is deputy managing editor and Nixon Nganga is a journalist with The Standard,
Kenya.
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GC2006 01 part1 116 8/11/05 17:55:12
Part two
Country reports
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Lessons learned from anti-corruption campaigns 119
7 Lessons learned from anti-corruption campaigns
around the world
CobusdeSwardt
1
The past year saw the unfolding of several dramatic corruption scandals, including the
removal of the vice-president in South Africa after corruption allegations; investigations
of heads of state or former political leaders in Israel and Costa Rica; and major corruption
trials in France, Nepal and Venezuela. No country is immune to graft. As New Zealand
and Finland demonstrate in the Global CorruptionReport2006, even countries that
are consistently ranked in the top 10 in Transparency Internationals Corruption
Perceptions Index experience lapses in accountability. Corruption affects all sectors of
society, from construction (France and Malaysia in this book), education (Uganda) and
police (Malaysia, Nepal, Papua New Guinea), to parliament (Japan), the judiciary (Brazil,
Burkina Faso, Ecuador, Israel and Nepal) and even the church (Greece). As highlighted
by the Algeria report, corruption continues to be an obstacle to investment. It impedes
effective management of natural resource revenues (Cameroon and Venezuela) and can
lead to misappropriation of disaster relief funds (Sri Lanka).
But the news is not all bad. These scandals highlight the increasing role played by
civil society and the media in monitoring public funds and holding public offcials to
account. Corruption is no longer taboo in some countries, including Kuwait, and in
Morocco and Uganda the media has played a key role in exposing it. Civil society is
developing new ways to collaborate with reform-minded governments. South Korea
witnessed the signing of a nationwide, anti-corruption compact involving the private
sector, civil society and government.
Corruption and new governments
We have witnessed a dramatic turnaround in many countries, sparked by concerns
over corruption. After Georgias rose revolution in 2003, Ukraine followed suit with
the electoral victory of opposition leader Viktor Yushchenko in January 2005, and
then Kyrgyzstan with its tulip revolution in March 2005. The new governments were
quick to commit themselves to fghting corruption. A principal driving force behind
these changes was public outrage at the extreme methods used by previous regimes to
stay in power, and the realisation of the potential of civil society involvement. Across
the globe in Latin America, two presidents were forced to step down because of events
that were perceived to be related to corruption: the independence of the judiciary in
Ecuador and confict of interest in Bolivias oil and gas sector.
GC2006 02 part2 119 8/11/05 17:53:45
Country reports 120
New leaders face huge challenges in meeting the expectations of their electorates. The
example of Kenya shows how diffcult it can be for a leader to maintain the mantle of
an anti-corruption reformist. Prosecuting past and new cases of corruption has proved
daunting for governments in Kenya, Kyrgyzstan, Morocco and elsewhere.
International pressure is often a motor for change: efforts by Romania and Croatia
to pass anti-corruption measures are driven less by domestic demand than the pull of
becoming members of the EU. Peer pressure is also evident in Asia-Pacifc where the ADB-
OECD Anti-Corruption Initiative has brought 25 countries together to tackle corruption.
In Latin America, the OAS Anti-Corruption review mechanism is providing a valuable
opportunity for independent groups to assess corruption-related developments.
Reforms at country level
Reform of the judiciary is one of the most powerful anti-corruption measures. Georgia
passed a law to increase the independence of the courts in February 2005, strengthening
the governments capacity to prosecute corrupt judges. A series of high-profle corruption
scandals involving judges forced change in Greece and Kenya, while in Brazil, recent
reforms have focused on increasing transparency in what is already a very independent
institution. Other countries, including Burkina Faso, Ecuador and Venezuela, have
seen a reversal of this trend: the judiciarys capacity to tackle corruption cases has been
seriously called into question in these states.
Notable progress has been made in adopting reforms in other areas, including the
drafting, passing and implementation of laws that are at the heart of efforts to curb
corruption. Examples from the GlobalCorruptionReport2006include:
increasing transparency in public procurement (Cameroon, Finland, France, Guatemala,
Malaysia, South Korea and the United States)
reducing corruption in politics (Croatia and Slovakia)
increasing access to information (Slovakia, Switzerland and Panama)
ensuring the independence and transparency of the judiciary (Brazil, Georgia, Greece,
Poland and Romania)
enhancing public sector integrity through codes of conduct and confict of interest
rules (Croatia, New Zealand and Panama)
protecting whistleblowers (Japan, Papua New Guinea and Romania)
improving transparency in fnancial services (Ireland, Malaysia and South Africa)
Signing up to international conventions
Another positive trend is the increased attention governments give to ratifying anti-
corruption conventions. Every country report indicates which conventions a country
has signed and ratifed.
GC2006 02 part2 120 8/11/05 17:53:45
Lessons learned from anti-corruption campaigns 121
The UN Convention against Corruption, signed in Mexico in December 2003, has
now attained the minimum 30 ratifcations required and is expected to enter into
force in early 2006. All OECD countries have ratifed the 1997 OECD Anti-Bribery
Convention, which makes overseas bribery a criminal offence for companies in their
home countries, but its enforcement has been weak in many countries (including Japan
and the United Kingdom). A further problem, highlighted in the New Zealand report,
is the astonishingly low level of awareness of the Convention among the business
community.
Reducing poverty by tackling corruption
There is a growing consensus that progress on reaching the Millennium Development
Goal (MDG) of halving the number of people living in extreme poverty by 2015 is
dependent on tackling corruption. Poverty and corruption are clearly linked: corruption
leads to poverty when money to cover basic needs such as health and education ends up
in the pockets of corrupt offcials; when the private sector is harmed, leading to lower
investment; and when the environment is damaged through corrupt infrastructure
projects. Poverty can also exacerbate corruption because funds are not available to
properly fnance the institutions that keep corruption in check. The G8 summit of
leaders in July 2005 confrmed that anti-corruption measures in the poorest countries
of Africa must be a priority to reduce poverty. But it is not enough to combat corruption
at country level. Foreign companies are often the source of big-ticket bribes in the
developing world. It is just as important that wealthy governments publicise and enforce
their anti-corruption laws to ensure that companies no longer view bribery as an
acceptable way to win business. The multifaceted nature of corruption makes it diffcult
to tackle, and for this reason it is crucial that anti-corruption initiatives are initiated,
monitored and enforced at government, civil society and private sector levels.
About the country reports
As in previous editions of the GlobalCorruptionReport, the country reports refect
the unique combination of historical context, political, socio-economic, legal and
cultural climates that present a country with particular challenges in its efforts to
combat corruption. Mostly written by TIs national chapters, the reports are intended
to provide an overview of key developments in fghting corruption across the world.
The number of countries covered has expanded steadily over the years: from 34 in
2004, to 40 in 2005, and 45 this year. Special attention has been given to ensure a
balance of information from developed and developing countries of various sizes. The
absence of a particular country in this section does not refect a high or low level of
corruption in that country.
The country reports do not cover the same issues; topics of particular importance
to individual countries are presented instead. Nevertheless, the structure is consistent
across reports. Each begins with a list of which anti-corruption conventions the country
has signed or ratifed, followed by a list of key legal and institutional changes of July
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Country reports 122
2004April 2005. The reports then delve into an analysis of the main corruption-related
issues that arose during the period under review.
Note
1. Cobus de Swardt is director of global programmes at the Transparency International
Secretariat.
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Country reports ALGERIA 123
8 Country reports
Conventions:
AU Convention on Preventing and Combating Corruption (signed December 2003; not
yet ratifed)
UN Convention against Corruption (ratifed August 2004)
UN Convention against Transnational Organized Crime (ratifed October 2002)
Legal and institutional changes
A unit to process fnancial information, appointed by presidential decree in April
2004, became operational in the Ministry of Finance in December 2004. The unit is an
independent body with responsibility for receiving, analysing and dealing with suspicions
relating to banking or fnancial operations that may constitute money laundering or the
fnancing of terrorism.
A draft anti-corruption law that brings legislation into line with the UN Convention
against Corruption had its frst reading in January 2005 and was adopted by the Council
of Ministers in April 2005, pending presentation in parliament. The draft provides for
the creation of a national body vested with the widest powers in terms of preventing
and combating corruption. More particularly it will have responsibility for the drafting
and implementation of a national anti-corruption strategy. This body will have the
status of an independent administrative authority. Critics question the seriousness of
the governments will, given the recent crackdown on the media (see below). Similar
initiatives have been scuppered in the past: in 1996, the government set up a National
Anti-Corruption Observatory that was dissolved by President Abdelaziz Boutefika
in 2000.
Algeria
Crackdown on corruption or on
the press?
The state of emergency that has existed in
Algeria from 1992 to the present has had
many consequences, notably restrictions on
civil liberties, opposition parties and civil
society organisations. Public demonstrations
are frequently banned and the right to strike
has effectively disappeared. Journalists
often fnd themselves at the sharp end of
these restrictions. In June 2004, Mohamed
Benchicou, managing editor of the daily Le
Matin, was sentenced to two years in prison
for writing a book critical of the president. The
newspaper was forced to cease publication
in July 2004 when the state-owned printing
company suddenly demanded payment of
debts; its website suffered the same fate;
and its offces were sold at auction by the
tax authorities. Le Matin was noted for
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Country reports 124
publishing investigations into allegations
of corruption involving senior offcials.
1
In the past year the authorities issued
a stream of statements reiterating their
commitment to uprooting corruption in
response to increasing pressure for action
from international fnancial institutions,
foreign trading partners and the public.
While the government claims to be working
overtime on the problem, no concrete
actions have actually resulted. The rhetoric
strikes the right note, as did the ratifcation
of the UN Convention against Corruption
in August 2004, but there are fears they will
both be used as excuses for doing nothing.
To take one example, the auditor
generals department (Cour des comptes)
was created in 1980 and is required under
the constitution to publish annual reports,
but only two have been submitted in the
entire quarter century of its existence. In
spite of an order in July 1995 that set out its
mandate, the status of its investigators has
still not been clearly defned. Its association
of offcers has repeatedly protested against
the departments marginalisation, most
recently at a public meeting attended by
the press in August 2005, but the authorities
have never deigned to give an explanation
of their behaviour towards it.
Though s anct i oned under t he
constitution, access to information held
by the government is more likely to be
denied than granted. Despite the pledge
to eliminate corruption, no law facilitating
access to information has been promulgated
or included in any legislative programme.
On the contrary, departments are more
likely to restrict access to information,
whether for use by the public or by the
press. The latter fnds it diffcult to conduct
investigations, particularly into corruption,
when the authorities systematically refuse to
collaborate with information or sources. This
seriously inhibits media activity, as do the
numerous libel actions taken against them.
Public procurement is also tainted by
irregularities, including the excessive use
of private agreements. President Boutefika
referred to this in a televised speech in April
2005 when he said such agreements would
henceforth be prohibited in the public
procurement process. Algeria is set to invest
US $55 billion in infrastructure and other
public works over the next fve years, but the
IMF expressed reservations on how public
money is utilised in a report on Algerias
budgetary policy published in March. It
concluded that Algeria only partially observes
the norms on fscal transparency. It went on
to say that the distribution of data on the
execution of the budget is severely restricted
and sporadic and the transparency measures
laid down by law are not fully respected.
2
Capital fight is also a serious problem with
an estimated 500 million (around US $612
million) leaving the country annually,
according to government fgures.
3
Despite government efforts to the contrary,
the limited amount of foreign investment
Algeria receives can be principally explained
by the corruption prevailing among public
departments and officials. According to
the World Bank, which surveyed more
than 1,400 investors and companies in
2003, corruption is a major constraint for
investment in Algeria with 75 per cent of
frms reporting bribes are paid.
4
The World
Bank estimated that companies in Algeria
spend an average 6 per cent of their turnover
on corruption, while the OECD and the
African Development Bank called corruption
endemic in a recent joint report.
5
The state is the main shareholder in
Algerias wealthy oil and gas sector through
the company Sonatrach, which rarely
publishes details about its activities or the
payments it receives from foreign investment
partners. The only information it does
make available relates to export revenues.
It is a diffcult company for journalists to
investigate and any attempt to do so is
quickly halted. The procurement process is
also obscure. In April 2005, following the lead
of the president, energy and mines minister
Chakib Khelil expressed his own concerns
at the growing number of public contracts
being replaced by private agreement. He
observed that more and more procurement
contracts are being placed privately. This is a
GC2006 02 part2 124 8/11/05 17:53:46
Country reports ALGERIA 125
source of many abuses. The top priority is, in
consequence, to exclude private agreements
from public procurement processes.
6
This
same minister, however, filed a writ for
libel against four journalists at LeMatinfor
an article published in August 2003 that
questioned the legality of a sale of Sonatrach
buildings and denounced the business
interests of a number of politicians. Editor
Youcef Rezzoug and journalists Yasmine
Ferroukhi, Abla Cherif and Hassan Zerrouky
were sentenced to two- and three-month jail
terms, while Mohamed Benchicou, who had
already spent 10 months in jail, saw his two-
year sentence increased by five months.
The International Federation of Journalists
complained of a campaign of systematic
judicial harassment against reporters in
Algeria.
7
Since 2004, the government has
announced a number of initiatives to
combat corruption, particularly in the
wake of the Khalifa affair (see below). It
has also launched criminal proceedings
against elected representatives and senior
civil servants implicated in cases involving
the misappropriation of funds. One case
involved the former prefect of Oran, who
was sentenced to a prison term, and in May
2005 the spotlight fell on the prefect of Blida,
who was forced to resign. The latters son
was also charged with corruption in which
his father may have been involved.
8
The case
led to the arrest of, or charges against, several
magistrates and senior officials from the
justice ministry and the presidents offce. In
May, the minister for religious affairs sent a
note to imams asking them to stress the need
to fght corruption in their Friday sermons
through references to sharia law.
These gestures leave Algerians perplexed
as to whether, behind all the apparent
activity, there is any true commitment to
combating corruption. Past anti-corruption
campaigns rarely produced effective action
and were widely viewed as power struggles
in the higher reaches of government. It is
now up to the authorities to demonstrate
that their latest effort is more than another
empty exercise.
The Khalifa affair
Revelations continue to tumble out about
this enormous corruption case, reported in
detail in the GlobalCorruptionReport2004.
According to documents submitted to the
French courts in July 2004 by the liquidators
of El Khalifa Bank, the group owned
by Algerian businessman Rafik Khalifa
improperly transferred 689 million (US
$843 million) to other countries between
1998 and 2002.
9
Khalifa, who has refused
to comment on the collapse of his group,
was sentenced in absentia to five years
imprisonment and a fne of 6 billion dinars
(US $85 million) for banking violations in
March 2004.
Financed by local investors, El Khalifa
Bank provided cash for the groups subsidi-
aries in air transport and the media, which
subsequently failed. The bank received sums
from numerous companies because it offered
an interest rate of 17 per cent and a high
commission to new business providers. The
French courts are particularly interested in
Khalifa Airways purchase of real estate in
Paris for persons close to President Boutefika.
The police have drafted an investigative
memorandum referring to the acquisition
of two apartments. The frst was acquired
for someone close to the president and
the second was transferred to Abdelghani
Boutefika, the presidents brother, who also
worked as the Khalifa groups lawyer. The
authorities do not deny these allegations.
Candidates showed little interest in
the Khalifa affair during the presidential
campaign in April 2004 which returned
Boutefika for a second fve-year term, but
this hardly surprised analysts. Resolving
the affair risks opening a Pandoras box so
explosive that nobody could expect to derive
beneft. None of the subsequent inquiries
has reported on the generous facilities that
Algerias political, economic and fnancial
elites extended to Khalifa, nor examined the
factors that led the authorities to ignore the
warning signs until it was too late. Algerias
courts routinely say they are continuing their
investigations into this matter, but a trial
GC2006 02 part2 125 8/11/05 17:53:46
Country reports 126
DjilaliHadjadj(Associationalgriennedeluttecontrelacorruption)
Further reading
Lounis Aggoun and Jean-Baptiste Rivoire, Franalgrie:crimesetmensongesdEtats (French Algeria,
Crimes and Lies of States) (Paris: La Dcouverte, 2004)
Djilali Hadjadj, CorruptionetdmocratieenAlgrie (Corruption and Democracy in Algeria) (Paris:
La Dispute, 2001)
Reporters Sans Frontires, Algrie, livre noir (Algeria: The Black Book) (Paris: La Dcouverte,
2003)
Soir Corruption,a page devoted to news about corruption, has appeared in the evening newspaper
LeSoirdAlgrie every Monday since 2000. See www.lesoirdalgerie.com
Association algrienne de lutte contre la corruption (Algerian Anti-Corruption Association)
(AACC): www.chafafa.new.fr
Notes
1. Reporters Sans Frontires, press release, 2 February 2005, available at www.rsf.org/article.
php3?id_article=12443
2. Libert (Algeria), 3 March 2005.
3. ElWatan (Algeria), 12 March 2005.
4. World Bank, WorldDevelopmentReport2005 (Washington, DC: World Bank, 2004).
5. OECD and African Development Bank, AfricanEconomicOutlook, May 2005.
6. Libert (Algeria), 17 April 2005.
7. Agence France-Presse (France), 19 April 2005.
8. JeuneAfriqueLIntelligent (France), 5 June 2005, and ElWatan (Algeria), 22 May 2005.
9. LeMonde (France), 8 February 2005.
10. Libert (Algeria), 24 March 2005.
11. ElWatan (Algeria), 31 October 2004.
Conventions:
UN Convention against Corruption (not yet signed)
UN Convention against Transnational Organized Crime (not yet signed)
ADB-OECD Action Plan for Asia-Pacifc (endorsed November 2001)
originally set for March 2005 was postponed
without any new date being set. They have
issued an international arrest warrant for
Rafk Khalifa, who remains at large. French
investigations have focused on Khalifas
business dealings in France, including some
fnancial transactions and his generous gifts
to celebrities in the cinema and media.
According to the chief prosecutor in Blida,
the court dealing with the Khalifa affair, the
investigation is well under way. It is a case
which has caused considerable damage to the
national economy, he said. All those who
contributed to this fraud, from near or far,
will be severely punished.
10
His predecessor,
who died in December 2004, had expected
the trial to be held in March 2005, but judicial
sources said in late October the investigation
would only conclude in June 2005.
11
The
same source said more than 800 people were
involved in the Khalifa affair, of whom 600
had been interrogated and 20 charged.
Bangladesh
GC2006 02 part2 126 8/11/05 17:53:46
127
Legal and institutional changes
The long-awaited Anti-Corruption Commission was set up in November 2004, allowing
the government to claim credit for meeting its electoral commitments, as well as
responding to the demands of civil society and international donors (see GlobalCorruption
Report2005). But a troublesome takeoff, questionable staff policies and curbed fnancial
independence led TI Bangladesh and other NGOs to question the commissions potential
to curb graft (see below).
A cabinet meeting in December 2004 approved the appointment of a Tax Ombudsman
(passed into law in July 2005), whose main tasks will be to receive taxpayers complaints,
to call the National Board of Revenue (NBR) to account and to suggest measures to redress
injustices or malpractices. Widespread corruption in the NBR is partly responsible for the
extremely low level of internal revenue collection,
1
while many tax offcials are believed
to aid tax evaders upon receipt of a bribe. At the time of writing, the appointment of
the Tax Ombudsman was still awaiting approval from the Ministry of Law, Justice and
Parliamentary Affairs. Civil society and the business community have long called for
the foundation of such a post. In the absence of information about its independence,
investigative powers and resources, however, it is still questionable whether it will prove
an adequate response to corruption in the NBR (see below).
New anti-corruption commission
disappoints expectations
When the Anti-Corruption Commission
(ACC) was set up in November 2004, it was
viewed as a timely institutional reform, and
a strong signal that the government was
committed to fghting corruption. Hardly
a day has passed since then without the
publication of media reports highlighting
the scepticism that surrounds the ACCs
lofty goals.
2
Indeed, since the key stimulus
to set up the commission came from a
combination of civil society demands and
pressure from international donors, it could
be argued that the government made the
concession reluctantly, rather than out of
genuine political will.
3
The lack of impartiality in the procedures
used to select the ACCs three commissioners,
one of whom was appointed chairman,
drew fre from the outset. Under the Anti-
Corruption Commission Act of February
2004, commissioners were supposed to
be approved by the president following
recommendations by a selection panel of
judges. As soon as the appointments were
announced, however, critics cried foul saying
that political considerations had prevailed
over the panels recommendations. The
eligibility of the chairman was also queried
since he had formerly served as Chief Election
Commissioner (CEC) and Supreme Court
judge. Constitutional experts and some
former election commissioners claimed that
the new appointment was in violation of the
constitution, which does not allow former
CECs or judges to take up other public posts.
4
Public interest litigation challenging the
legal validity of the appointment was fled in
the High Court in March 2005. Irrespective
of the cases outcome and the constitutional
debate surrounding it, such events do not
bode well for the ACCs future.
Disputes over staffng ensued, with the
ACC following no clear rules of appointment.
More controversially, it decided to rehire the
former staff of the defunct Bureau of Anti-
Corruption, which was dissolved due to its
ineffectiveness and lack of independence.
5
The commission subsequently annulled
the hiring decision, but the damage to its
credibility had been done. Furthermore,
contrary to the provisions of the Anti-
Corruption Commission Act, decisions on
personnel appointments and transfers were
Country reports BANGLADESH
GC2006 02 part2 127 8/11/05 17:53:47
Country reports 128
taken without consultation between the three
commission members, leading to serious
doubts as to their capacity to provide the
leadership needed for the challenging tasks
ahead. Most problematic of all, however,
is the issue of the ACCs independence
since the government retains authority
over key policy issues, such as budget, staff
recruitment and organisational structure.
Indeed, the commission currently requires
cabinet approval before implementing any
of its decisions.
6
Despite the powers bestowed on it, the
commission has failed to take specific
policy measures in the past fve months,
or to convey to the public any sense of
its strategy for fghting corruption. Instead,
it has limited its mandate to a number of
ad hoc decisions that demonstrate lack of
vision and poor performance. For instance,
the ACC framed charges against a number
of transfer orders for government offcials,
but failed to follow them up.
7
Similarly,
it announced it was going to investigate
the unauthorised use of government
vehicles, the misappropriation of public
land (belonging to the railways) and the
importation of rotten rice.
8
No concrete
measures were taken apart from issuing
letters to the relevant departments.
Corruption in the customs
department
According to a study published by TI
Bangladesh in September 2004, corruption
is rife in the customs department, which
comes under the jurisdiction of the National
Board of Revenue. The study was conducted
in Chittagong port, which handles about
75 per cent of the countrys imports and
exports. Shipping companies have to submit
descriptions of their goods, either in an
Import General Manifesto (IGM) or Export
General Manifesto (EGM), in accordance
with regulations. The study found that
tipping for permissions went without
objection for so long that it had become
institutionalised, with bribes paid in 100 per
cent of cases for both the IGMs and EGMs.
Bribes were also demanded in 100 per cent
of cases to amend IGMs or EGMs for various
reasons.
9
Under the regulations, if a container with
imported goods has not been released within
45 days, it must be auctioned. Research-
ers found that importers bribed customs
offcials to delay the auctions in order to
take advantage of price fuctuations in the
market. To obtain release orders from the
customs authority for imported goods,
moreover, clearing and forwarding agents
have to pay bribes at a minimum of 16 and
up to 37 different customs personnel levels.
The study estimates the amount of bribes
paid by importers and exporters to offcials
at Chittagong port at around 8 billion takas
(US $130 million) annually.
10
In the wake of the TI Bangladesh report,
the Parliamentary Standing Committee
on the Ministry of Finance demanded in
October 2004 that customs reduce the
number of steps importers and exporters
have to pass through to release their goods.
The Chittagong Port Authority (CPA) formed
a fve-member inquiry team to investigate
the cases of corruption revealed in the
report. In January 2005, it launched a one-
stop service for importers and exporters in
a bid to minimise corruption. It is too soon
to evaluate the impact these initiatives may
have on curbing corruption, but the business
community has embraced them.
Other recommendations emerged,
including the privatisation of port
management, the restructuring of the CPA,
the introduction of more fexible clearance
procedures and the privatisation of goods
handling and labour management, to
facilitate a system of incentives to reduce
the undue influence of vested interests.
Steps could be taken, for example, to include
representatives of port users on the CPAs
board of directors, so beginning the process
of transforming it into a fully autonomous
organisation.
GC2006 02 part2 128 8/11/05 17:53:47
129
IftekharZaman,SydurRahmanandAbdulAlim(TIBangladesh)
Further reading
Asian Development Bank, ControllingCorruptioninAsiaandthePacifc(Manila: ADB, 2004)
Centre for Policy Dialogue, ReformingGovernanceinBangladesh (Dhaka: CPD, 2002)
Centre for Policy Dialogue, BusinessCompetitivenessEnvironmentReport (Dhaka: CPD, 2004)
Transparency International Bangladesh, CorruptionDatabase (Dhaka: TI Bangladesh, 2004)
Transparency International Bangladesh, ParliamentWatch (Dhaka: TI Bangladesh, 2005)
TI Bangladesh: www.ti-bangladesh.org
Notes
1. In a country of 140 million people, there are only around 1.5 million registered taxpayers,
of whom perhaps half actually pay any taxes. See DailyBanglabazar(Bangladesh), 17 January
2002.
2. NewNation(Bangladesh), 6 March 2005.
3. One sign of Bangladeshs lack of commitment to the anti-corruption drive was its failure to
send any representatives to the 6th Steering Group Meeting of the ADB-OECD Anti-Corruption
Initiative held in Hanoi, Vietnam, in April 2005, although it is one of 25 Asia-Pacifc countries
to have endorsed the initiative.
4. DailyStar (Bangladesh), 13 March 2005.
5. Independent (Bangladesh), 15 March 2005;DailyStar(Bangladesh), 18 February 2005; see also
GlobalCorruptionReport2005.
6. GlobalCorruptionReport 2005;DailyJugantor (Bangladesh),13 April 2005.
Professionalism in the police force
questioned
Concern has grown in recent years over the
role of the police force as a law enforcement
agency. Indeed, it has not only failed to
enforce the law, but violations have often
taken place with the passive connivance, if
not active participation of its members.
A survey by TI Bangladesh, conducted
in September/October 2004 and released
in April 2005, revealed that 92 per cent of
all respondents who fled complaints to the
police administration had to pay bribes,
while 80 per cent paid bribes to obtain police
clearance certifcates for various purposes.
The survey estimated the amount of bribes
paid by households to the police at 15.3
billion takas (US $260 million) a year.
11
Members of the police have been
implicated in cases of extortion, bribery,
arbitrary arrest and even custodial torture
and murder in some cases. In one case, an
offcer killed a man in Badda thana (police
station) after he refused to pay a bribe. A case
against the offcer has now been fled in the
magistrates court.
12
In July 2003, the government formed
the Rapid Action Battalion (RAB), a
mixed force of police, army, air force and
paramilitary personnel, with the special task
of curbing crime. Nine months later, the
government claimed the controversial unit
had succeeded in improving law and order.
Although it recovered a total of 718 arms,
over 200 people were killed in questionable
circumstances that were offcially described
as crossfire.
13
In May 2005 alone, police
killed 24 people and the RAB a further 21.
14
The deaths sparked a food of criticism from
civil society, human rights organisations,
opposition parties and donors. The RAB
was also reportedly engaged in extortion,
robbery and bribe-taking.
15
Given that professionalism in the police
force and in other law enforcement agencies
is crucial to the fght against corruption,
developments like these are scarcely
conducive to ensuring better governance in
Bangladesh.
Country reports BANGLADESH
GC2006 02 part2 129 8/11/05 17:53:47
Country reports 130
7. NewNation(Bangladesh), 7 April 2005.
8. NewNation(Bangladesh), 27 March 2005.
9. TI Bangladesh, ChittagongPort:ADiagnosticStudy (Dhaka: TI Bangladesh, 2004).
10. Ibid.
11. TI Bangladesh, HouseholdCorruptionSurvey (Dhaka: TI Bangladesh, 2005).
12. DailyProthomAlo(Bangladesh, in Bengali), 20 May 2005.
13. DailyStar (Bangladesh), 29 March 2005.
14. DailyJugantor (Bangladesh, in Bengali), 1 June 2005.
15. Asian Human Rights Commission, Urgent Appeals Programme, 25 July 2005, www.ahrchk.
net/ua/mainfle.php/2005/1182/
Conventions:
OAS Inter-American Convention against Corruption (ratifed February 1997)
UN Convention against Corruption (signed December 2003; not yet ratifed)
UN Convention against Transnational Organized Crime (signed December 2000; not yet
ratifed)
Legal and institutional changes
Members of the justice department and presidential anti-corruption delegation are
drafting a confict of interest law that is expected to be approved in 2005. The law is
aimed at bringing Bolivian legislation on the issue into line with the Inter-American
Anti-corruption Convention and is being drafted with the support of a US-funded anti-
corruption programme.
An amendment to the penal code is being drafted under the same process as above,
and is also expected to be approved in 2005 if the full congressional agenda allows for
the changes to be debated. The aim is to incorporate new corruption-related crimes into
the criminal code in order to make it easier to prosecute acts of corruption.
Bolivia
Conflicts of interest: relationships
between the public and private
sectors
The debate over the future role of multina-
tional companies in Bolivias large natural
resources sector has led to the uncovering
of a number of events that allowed foreign
natural resources companies to obtain very
favourable contracts, to the detriment of
the government. Questions have since
arisen about the need for confict of interest
mechanisms to safeguard decision-takers
against undue infuence from the private
sector or other interest groups.
A practice that has become commonplace
is for public offcials to cross over into private
sector positions or vice versa in the same
sphere of work. Employees in state-owned
companies, the energy minister or the state
regulator might cross the revolving door
to private sector companies, for example,
where they are required to negotiate with the
government on issues that were their direct
responsibility when public servants. This
means that they have an unfair advantage of
information and experience when it comes
to negotiating favourable contracts.
In April 2005, El Diario newspaper
reported that the civil society Committee
to Defend National Heritage (CODEPANAL)
had complained that Jaime Barrenechea, the
former president of the Bolivian state oil
company Yacimientos Petrolferos Fiscales
GC2006 02 part2 130 8/11/05 17:53:48
131
Bolivianos (YPFB), is now a manager for
Repsol-YPF Argentina, while former YPFB
executives Hugo Peredo and Arturo Castaos
have moved to Repsol-YPF and the Bolivian
branch of the Brazilian state-owned company
Petrobras, respectively.
1
Another recent
scandal involved Eduardo Baldivieso, a
former regulator of the industry, who moved
to GAS del Sur to become managing director.
He was able to negotiate a favourable
contract to export liquefed petroleum gas
for GAS del Sur.
2
Similar situations have arisen in the water
sector. Aguas del Illimani and Aguas del
Tunari, two companies with potable water
and sewage concessions, have profted from
staff that moved from public sector roles
directly connected to the contracts they
subsequently negotiated on behalf of their
private sector companies. The government,
in 2005 and 2000, respectively, rescinded
both contracts in response to protests.
These and other cases have highlighted
the need for a law regulating conficts of
interest. The use of privileged information
and contacts by people switching between
public and private sector posts in the same
area of work has undermined the credibility
of both sectors and led to protests.
President Gonzalo Snchez de Lozada
was forced to step down in October 2003
in response to protests demanding the
nationalisation of Bolivias natural gas
reserves, the second largest in Latin America.
His successor, Carlos Mesa, resigned in
June 2005. While protests centred on the
question of privatisation, the fact that
private companies were seen to be profting
unduly from contracts thanks to government
connections probably contributed to the
protest movements.
Unlawful enrichment at local
government level highlights need
for new law
Over the past few years, cases of unlawful
enrichment at municipal government level
have increased, highlighting the need for
greater powers to investigate acquisition of
wealth by public offce holders.
Cases of illicit enrichment by authori-
ties at national policy bodies and in central
government continue to arise, but offcial
records point to municipal authorities as the
perpetrators of corruption in a surprising
number of cases. Many cases against mayors
and local councillors are currently going
through the courts.
Examples are the mayor of Achocalla, a
small municipality near the cities of La Paz
and El Alto, who faces charges of misusing
public funds. Also implicated in cases of
abuse of public funds are representatives
of local authorities in Tiquina, Viacha,
Caranavi, Ayoayo, Yanacachi, Copacabana
and Uyuni.
3
Nepotism, infuence peddling and abuse
of authority all exist at local and central
government level, and there are laws
aimed at curbing some of these practices.
One missing piece of the legislative puzzle,
which makes it diffcult to tackle such forms
of corruption, is a law allowing authorities
to probe assets of public offcials. Draft laws
setting out the ways and means in which
authorities might be able to scrutinise the
assets and earnings of public offcials have
been presented to Congress, but have been
rejected.
There is, however, a Financial Investiga-
tions Unit within the bank regulator with
the capacity to probe transactions of people
within the banking system. This unit could
identify possible cases of illegal enrichment
for further investigation.
Reforms at the national highways
authority aimed at reducing corruption by
its staff proved successful in reducing cases
of unlawful enrichment by staff, and could
provide a useful model for possible reforms
at other government bodies. Among the
key pieces of reform were a move to more
competitive recruitment; decisive action
against employees accused of corruption;
and the introduction of transparent and
open contracting processes.
In the fnal analysis, the political will of
the authority is key to any successful reform
Country reports BoLIvIA
GC2006 02 part2 131 8/11/05 17:53:48
Country reports 132
GuillermoPouMuntSerrano
(CentrodeDesarrollodeticasAplicadasyPromocindeCapitalSocial)
Further reading
Andean Commission of Jurists, Informe anual sobre la regin Andina (Annual Report on the
Andean Region, January 2002)
Fundacin Etica y Democracia, Informe de evaluacin ciudadana de implementacin de la
Convencin Interamericana contra la corrupcin (Report of Citizen Evaluation of the
Implementation of the Inter-American Convention against Corruption, 2004)
Notes
1. ElDiario (Bolivia), 24 April 2005.
2. CA$H (Bolivia), 15 April 2005.
3. Presidential Anti-corruption Delegation, Registro de seguimiento de casos de corrupcin
(Register of follow-up of cases), 2005.
process, and pressure from civil society can
help keep the issue on their agenda. Over
the past few years a number of civil society
organisations have developed to monitor
public authorities, in particular local authori-
ties. The development is not positive a priori,
however, and needs to be monitored as well
to ensure that civil society organisations do
not participate in corrupt acts themselves, or
are not co-opted by private interest groups.
Public contracting processes still
provide opportunities for corruption
Public contracts are regulated by very
detailed legislation and mechanisms such
as Internet-based information systems
that allow contracts to be placed and bid
for on-line, in order to reduce the risk of
corruption. Nevertheless, while instances of
corruption in public procurement appear to
have decreased in the past few years, they
continue to arise.
In 2003 the government planned to
promote a law to regulate once and for
all problems associated with purchasing
processes. The draft law was rejected and
converted into a presidential decree, which
attempted to incorporate the main details of
the law, but lacked the weight and support
of a law. The decree also contained an ethics
code for public offcials responsible for pro-
curement.
There remains a need, therefore, for
a reform to streamline and simplify the
resulting morass of laws, norms and decrees.
There are several loopholes and areas of
corruption that fall between the gaps where
laws do not knit together well. It is still not
practice across the board, for example, for
contracting authorities to present transpar-
ent terms of reference to bidders.
While it is true that important steps still
have to be taken to increase the transparency
of contracts offered by government,
comparable steps by the private sector have
yet to be taken. There are too few good
examples of integrity mechanisms, such as
codes of conduct preventing attempts to exert
undue infuence over government decision-
makers, which could be disseminated across
private sector companies.
GC2006 02 part2 132 8/11/05 17:53:48
133
Conventions:
OAS Inter-American Convention against Corruption (ratifed July 2002)
OECD Anti-Bribery Convention (ratifed August 2000)
UN Convention against Corruption (ratifed June 2005)
UN Convention against Transnational Organized Crime (ratifed January 2004)
Legal and institutional changes
New legislation regulating publicprivate partnerships (PPPs) was approved in December
2004. The PPP is a relatively new method of fnancing and developing infrastructure in
Brazil. Mechanisms were introduced into the new law to curtail opportunities for private
sector companies to unduly infuence the terms of a PPP tender.
After 13 years of discussions and negotiations, congress passed a constitutional amendment
in December 2004 aimed at streamlining the judiciary and speeding up judicial process.
The amendment introduced the concept of binding precedent, conceived as a means of
guaranteeing uniformity of jurisprudence and restricting recurrent appeals, and established
a National Council of Justice as an external control mechanism over the judiciary (see
below).
A parliamentary front against corruption was created in the lower house of Congress
in July 2004 to address matters on corruption.
Brazil
The judiciary: who guards the
guardian?
In contrast to a number of other Latin
American countries, where strengthening
judicial independence against political
pressure is the main challenge to anti-
corruption campaigners, the calls for judicial
reform in Brazil paradoxically derive from
its excessive independence. Once defned
by President Lula da Silva as a black box,
1
the judiciary lacks transparency and is
often accused of being isolated, dedicated
to preserving corporate privileges and
unaccountable to society.
Understandably, there was concern
to strengthen the independence of the
judiciary when the current constitution
was drafted after two decades of military
rule, though it was granted extremely wide
latitude. The constitution gave the judiciary
broad functional and structural autonomy.
At the same time, in order to guarantee the
protection of a number of social rights, it
allowed for almost endless rights of appealat
different levels of the legal system besides
rejecting the binding nature of superior
court decisions on lower courts.
This constitutional architecture has
fatal results insofar as accountability and
performance are concerned. The judiciary
is slow and inaccessible to the poor. One
example of how these characteristics can
be abused was the decision by Jos Serra,
the new mayor of So Paulo, in early 2005
to suspend payments to suppliers even as
he acknowledged that R2 billion (US$ 851
million) was owing, since he knew a judicial
decision was likely to take 10 years or more
due to the sluggish pace of justice.
Inefficiencies in the judiciary lead to
impunity. According to a survey by Congresso
em Foco (Congress in Focus), an Internet site
specialising in legislative news, 102 out of
595 MPs currently face criminal, adminis-
trative or electoral accusations in protracted
Country reports BRAzIL
GC2006 02 part2 133 8/11/05 17:53:48
Country reports 134
lawsuits. Corruption, such as the Anaconda
scandal in 2003 that involved a judge selling
favourable sentences to criminals, completes
the picture of a dysfunctional judiciary.
2
These factors led to calls for change in
the judicial structure and procedures as a
way to broaden access to juridical services,
to make justice more expeditious, to simplify
the system of appeals, to allow for a faster
solution of conficts and to put an end to
self-interested practices by judges. Judicial
reform proved hard to push through, given
the resistance from judges themselves.
Finally, after 13 years of discussion, Congress
approved an amendment to the constitution
in December 2004.
A key measure is the provision of binding
precedent, conceived as a means of
guaranteeing uniformity of jurisprudence
and restricting the recurrent appeals in similar
cases. Another important development, the
National Council of Justice, was praised in
some quarters, including the government, as a
promising initiative to introduce an external
control mechanism over the judiciary.
Given that the council is part of the
judiciary and is composed largely of judges
(nine of its ffteen members are judges; two
are lawyers; two are public prosecutors; two
are citizens appointed by Congress), its
independence will be in question. Moreover,
it has been given only limited powers, since
its decisions can be contested and annulled
by the judiciary. Many see the council as a
cosmetic move, rather than one that will
make the institution more accountable and
effcient.
As approved, the reform does not tackle
the gravest problem afficting the Brazilian
judiciary: the absence of aggregated and
comparative information on its workings.
Although every judicial decision is public
(and is published on the Internet), the
judiciary does not collect or publish statistics
about its workings, making it impossible for
external observers to effectively monitor it.
The black box of the Brazilian judiciary
remains to be opened.
Lulas anti-graft platform is shaken
by corruption scandals
A series of corruption scandals in 2004 and
the frst half of 2005 has shaken the ruling
Workers Party (PT), and cast doubts over
its ability to make good on its campaign
pledge to tackle corruption. In its winning
campaign, the PT had championed fscal and
ethical probity.
The scandals date back to February 2004
when news broke that chief of staff Jose
Dirceus closest aide, Waldimiro Diniz, had
taken kickbacks from the operators of bingo
parlours (see GlobalCorruptionReport2005
for an analysis of corruption in Brazils
gambling industry). The government
blocked efforts to launch a congressional
inquiry into the case. Diniz was director of
the lottery sector of Rio de Janeiro at the
time and he had allegedly offered contract
privileges for on-line and over-the-phone
lotteries in exchange for campaign donations
to fund certain PT candidates campaigns
during the 2002 election. The report of a
congressional investigation into the fraud
was approved by the Rio de Janeiro State
Assembly in October 2004.
In June 2004, Operation Vampire was
launched into possible illegalities at the
Health Ministry and four other ministries
connecting officials to the illegal sale of
blood supplies worth more than US $660
million from 1990 to 2002.
3
Government
auditors launched an investigation into the
high prices paid for blood; the suspicion was
that public offcials were buying blood at
one price and invoicing the government at
a higher rate.
Later, in August 2004, the weekly magazine,
Isto, published that the Central Bank
president and a director hid overseas assets
from tax authorities. The article led to the
downfall of the director of monetary policy
at the Central Bank, Luiz Augusto de Oliveira
Candiota, and tarnished the reputation of the
Banks president, Henrique Meirelles. As soon
as the accusations were made public, a presi-
dential decree was issued giving Meirelles
(and all future central bank presidents) the
status of cabinet minister, so that he could
GC2006 02 part2 134 8/11/05 17:53:49
135
AnaLuizaFleckSaibro(TransparnciaBrasil)
Further reading
Rogrio Bastos Arantes, MinistriopblicoepolticanoBrasil (Public Prosecutions and Politics in
Brazil) (So Paulo: Sumar, 2002)
David V. Fleischer, CorruptioninBrazil:Defning,Measuring,andReducing (Washington DC: Center
for Strategic and International Studies, 2002)
Transparncia Brasil, Vote Buying in the 2004 Elections, www.transparencia.org.br
Transparncia Brasil: www.transparencia.org.br
Notes
1. www.brazzil.com/2004/html/articles/jul04/p135jul04.htm
2. www.congressoemfoco.com.br/arquivo_especiais/12fev2004_rochamattos/rocha_respostas.
aspx, and www.economist.com/world/la/displayStory.cfm?story_id=2542089
3. UPI (USA), 6 October 2004.
4. Veja (Brazil), 14 May 2005.
5. EstadodeSo Paulo (Brazil), 20 May 2005.
be better protected against accusations of
improbity. The Supreme Court is currently
investigating allegations that he evaded taxes
and foreign exchange regulations.
In May 2005, the weekly magazine Veja
uncovered a bribery scandal in the Brazilian
Postal Service.
4
Reporters revealed a secretly
flmed videotape showing the former chief
of the contracts and supplies department,
Maurcio Marinho, receiving a US $1,250
cash advance from private companies
seeking contracts. The opposition petitioned
for a parliamentary inquiry, which the
government consented to after initial
resistance. Roberto Jefferson, a member of
Congress and president of the Brazilian
Labour Party (PTB) which is allied with
the ruling party was allegedly implicated
in the scandal.
Jefferson was also involved in the next
scandal to break. In May 2005, the media
reported allegations by Ldio Duarte,
former president of the state-run Brazilian
Reinsurers Institute (IRB), that Jefferson had
tried to pressure him to hire a number of
his associates.
5
The scandal deepened after
Duarte accused Jefferson of also demanding
a monthly kickback to the PT of R400,000
(US $170,000) as a thank you for giving
him the IRB post.
In response, Jefferson accused the
governing PT of using undeclared funds to
pay campaign costs and bribe legislators.
Lacking a majority in Congress, the PT was
accused of paying a monthly allowance of
R30,000 (US $12,500) to congressmen from
two allied parties in return for their votes.
The two parties implicated are the Progres-
sive Party (PP), led by Severino Cavalcanti,
the low-profle ultra-conservative chairman
of the Chamber of Deputies; and the Liberal
Party (PL), whose president, Waldemar
Costa Neto, became the first lawmaker
to step down in the widening corruption
scandal.
Dirceu resigned as the presidents chief of
staff in June 2005 and returned to his seat in
the Chamber of Deputies where he is under
investigation by the Chamber of Deputies
Ethics Committee.
As the political crisis escalates and election
campaign fnancing irregularities are being
revealed, calls for political and campaign
financing reforms gain force. There is a
consensus that if anything positive can
result from Brazils worst political crisis in
a decade, it is the approval of comprehen-
sive political reforms that address problems
associated with private fnancing, inadequate
disclosure of campaign accounts and the
failure to impose proportionate sanctions
when breaches of political fnance rules are
found to have occurred.
Country reports BRAzIL
GC2006 02 part2 135 8/11/05 17:53:49
Country reports 136
Conventions:
AU Convention on Preventing and Combating Corruption (ratifed March 2005)
UN Convention against Corruption (signed December 2003; not yet ratifed)
UN Convention against Transnational Organized Crime (ratifed May 2002)
Legal and institutional changes
In March 2005, the National Ethics Committee submitted its report for 2003 to the
prime minister after a delay of one year. It highlighted the lack of professionalism, weak
governance and corruption in public service, and recommended the adoption of public
sector codes of conduct for the departments of public administration, health, education,
security and fnance. The nine-member committee also conducted ethics training with
parties, ministries, parliamentarians and civil society organisations throughout 2004. With
the publication of its second report, the committee has now gained a degree of public
confdence, but it remains to be seen if its recommendations will be implemented.
In December 2004, the government issued a decree on the conduct of the national police
force that sets standards for behaviour and provides disciplinary sanctions for breaches
of conduct. It is expected to increase public awareness of police offcers duties and the
rights of citizens to fle complaints about illegal acts committed by offcers, including
corruption.
Burkina Faso
Challenges faced by anti-corruption
bodies
Despite government promises to facilitate
anti-corruption efforts by creating
new institutions and ratifying several
international conventions, the continued
failure to disclose reports into official
corruption and a culture of relative impunity
cast doubts on these efforts in 200405.
A case in point was the 2004 report by
the High Commission for the Coordination
of Anti-Corruption Activities (HACLC) in
March 2005, which remained as confdential
as its predecessor in January 2004 in spite of
an agreement that HACLC fndings should
be publicly available.
1
Also in March, a
document setting out the priorities of a
national campaign against corruption,
initiated by the HACLC and validated
during a seminar attended by 200 people
in December 2004, was presented to the
government. Its two main recommendations
were the creation of a national anti-
corruption assembly, bringing together
delegates from the public and private sectors
and civil society, and the creation of a higher
authority to refer corruption-related matters
to the courts when necessary.
2
At the time of
writing, the government had not responded
to its recommendations.
The HACLC, which offcially began work
in 2003, faces a series of challenges to its
effective functioning and is viewed by some
as weaker than other anti-corruption bodies,
such as the National Ethics Committee and
the Public Accounts Court (see below).
Several ministers and project managers
were implicated in the misappropriation of
public funds amounting to FCFA3 billion
(US $5.5 million) in its frst report.
3
The
offcial response has been limited, although
three corruption-related cases were referred
to the courts on the instructions of the
prime minister. Critics saw the gesture as a
political move to gain popularity before the
presidential elections in November 2005 and
to wrong-foot the oppositions campaign
against corruption.
GC2006 02 part2 136 8/11/05 17:53:49
137
On submission of its second report, the
HACLCs president, Honor Tougouri, was
quoted as saying that the commission has
not received any tangible response to the
recommendations in the 2003 report, taken
as a whole, that would have enabled it to
direct, correct, amend, reorganise, energise
or even slow down its activities. Speaking
of the HACLCs operational difficulties,
Tougouri stressed that the main problem
was the governments slow reaction to its
requests. With respect to its budget of nearly
FCFA1 billion (US $1.8 million), he said:
Even if the HACLC budget has risen slightly,
it does not cover its essential activities, i.e.,
those that justify its creation.
4
The HACLCs problems are not limited to
the lack of fnancial and human resources;
it also suffers from a lack of direction. It is
not clear, for instance, whether it should
coordinate the fght against corruption, as
stipulated in its governing provisions, or
act in all areas related to anti-corruption,
such as raising awareness, investigation,
lobbying and interagency cooperation. Its
work should be much better coordinated
with the activities of the National Ethics
Committee, the Public Accounts Court (PAC)
and other courts, the General State Inspector-
ate (GSI) and the committee responsible for
monitoring the GSIs recommendations.
Despite these difficulties, the HACLC
deserves credit for producing activity reports
on a regular basis and for the professional-
ism of its nine members. Moreover, there
has been a significant increase in public
awareness of the importance of the fght
against corruption, and citizens now expect
greater integrity in public affairs.
The PAC, established in 2002, has played
a key role in the oversight of public fnance
management in the past few years. It has tried
to compensate for the failings of the former
Accounts Chamber by producing three draft
laws governing the state budgets for 1999
2001, 2002 and 2003. Although the
preparatory reports for these laws are
supposed to be public, when the court is
asked to produce them offcials reply that
they are not authorised to do so. Nevertheless,
every MP receives a copy and substantial
extracts can be found in the press.
The PACs investigations have led to the
discovery of irregularities that cost the public
purse dearly. According to an October 2004
report by the fnance and budget committee
of the National Assembly, routine checks
revealed that 151 retired civil servants in
various ministries were still receiving their
salaries.
5
Apparently unaware that the staff
concerned had retired, the fnance ministry
continued to pay the salaries, a blunder
that cost more than FCFA450 million (US
$860,000).
The PAC has planned to submit its frst
report to President Blaise Compaor in
the frst half of 2005. Preparations for its
publication have involved the inspection
of the budgets of a number of public
institutions, local authorities and public
companies, including many where the press
had already reported poor management,
embezzlement and fraud.
The judiciary comes under fire
A string of corruption scandals in 200405
raised expectations that prosecutions of
senior offcials would follow, but the courts
handed down only a limited number of
verdicts. From January 2004 to April 2005,
the Council of Ministers imposed sanctions
on offcials accused of corruption, dismissing
some and moving others to different posts.
Judicial proceedings were undertaken in
the most serious cases, involving nearly
20 state accountants, fnancial controllers,
collection agents and court registry offcials.
The steepest penalties were imposed on
the mayors of Ouahigouya and Zorgho,
both members of the ruling Congress for
Democracy and Progress (CDP). They were
removed from office and charged with
corruption in February 2005. This could be
interpreted as a settling of scores within the
CDP, given that other mayors suspected of
corruption were not charged. In February,
several cases of embezzlement of public
funds were also heard before the criminal
Country reports BURKINA FASo
GC2006 02 part2 137 8/11/05 17:53:49
Country reports 138
LucDamiba(REN-LAC)
Further reading
REN-LAC, Rapport2004surltatdelacorruptionauBurkinaFaso (2004 Report on the State of
Corruption in Burkina Faso) (Ouagadougou: Editions REN-LAC, 2005)
Mdiateur du Faso, Rapport fnal des confrences du mdiateur du Faso sur la gestion du patrimoine
public (Final Report on the Conferences of the Faso Mediator on the Management of Public
Assets) (Ouagadougou, 2004)
HACLC, Documentcadredelapolitiquenationaledelaluttecontrelacorruption (Framework Document
for the National Policy on Ways to Combat Corruption) (Ouagadougou: HACLC, 2004)
Conseil Suprieur de la Magistrature, Rapport de la commission dtude sur la corruption dans le
secteur de la justice, mars 2005 (Report of the Commission Charged with Studying Corruption
in the Judiciary, March 2005)
REN-LAC: www.renlac.org
courts. One involved the misappropriation
of some FCFA11 million (US $21,000) from
a public fund for health and nutrition by
state accountant, Jean Paul Balbogo. He
admitted the charges and was sentenced to
fve years in prison.
6
Nevertheless, the judiciary was widely
criticised for delaying alleged corruption
investigations involving senior offcials, such
as director generals, high commissioners,
MPs and ministers, even when there was
overwhelming evidence against them. The
sacrosanct rule of separation of powers
is not sufficiently observed: judges face
diffculties in opening such investigations
and corruption cases are rarely tried
before the courts. This has led to a public
perception that high-ranking offcials enjoy
impunity, and the fnger of blame points at
the judiciary.
Allegations of corruption have recently
been made against the judiciary, whose per-
formance has never been lower in the annual
corruption perception rating of REN-LAC, a
nationwide anti-corruption network of 30
civil society organisations. In December
2004, the magazine Evnement published the
fndings of an investigation into corruption
that accused judges of attempted extortion
from litigants; lawyers of robbing their
clients; court offcials of embezzling funds;
and other auxiliaries of tampering with court
fles and other documents.
7
The expos led
to a massive outcry. Professional lawyers
associations denounced their colleagues,
while others supported the justice ministry,
denying that corruption existed in their
ranks.
In the face of mounting public pressure,
the Higher Council of the Judiciary,
chaired by the president, created an ad hoc
commission of inquiry into corruption in the
judiciary in June 2004. Chaired by Kadiatou
Dakoure, who also chairs Council of State
meetings, it fled its fndings in March 2005
which confrmed that graft was widespread.
Corruption was found to be prevalent in the
courts of Bobo-Dioulasso and Ouagadougou,
which deal with the more serious cases. The
commission found more than 30 cases of
questionable practices and suspicious
behaviour implicating judges, lawyers,
police offcers, intermediaries or touts, and
other users of the judicial system, including
accounting frms and liquidators. The report
concluded that no strategy to combat
corruption would be effective without
genuine political will.
8
In the meantime, the bar association
imposed sanctions on two of its members in
April 2005. One, Matre Djibril Lankoand,
was suspended for extorting FCFA1 million
(US $2,000) from a client on the grounds
that the sum was needed to motivate the
judge in charge of the case.
9
The judiciary
was shaken by this and other cases, but no
offcial steps have been taken to address the
fndings of the commission of inquiry.
GC2006 02 part2 138 8/11/05 17:53:50
139
Notes
1. GlobalCorruptionReport2005.
2. National Seminar on the Proposed National Policy to Combat Corruption, Summary Report,
1315 December 2004.
3. HACLC Press Conference, 10 January 2004, published in LObservateurPaalga (Burkina Faso),
11 January 2004.
4. SanFinna (Burkina Faso), 4 April 2005.
5. National Assembly, Report No. 2004/030/AN/COMFIB, File No. 16; see also Bendr (Burkina
Faso), 17 October 2004.
6. www.aib.bf/siteaib/revuearch2.htm
7. Evnement (Burkina Faso), 10 January 2005, www.cnpress-zongo.net/evenementbf/pages/
dossier_1_59.htm
8. Conseil Suprieur de la Magistrature, Rapport de la commission dtude sur la corruption
dans le secteur de la justice, mars 2005 (Report of the Commission Charged with Studying
Corruption in the Judiciary, March 2005).
9. www.lefaso.net/article.php3?id_article=8270
Conventions:
AU Convention on Preventing and Combating Corruption (not yet signed)
UN Convention against Corruption (signed December 2003; not yet ratifed)
UN Convention against Transnational Organized Crime (signed December 2000; not yet
ratifed)
Legal and institutional changes
A law passed in September 2004 instituted a new procurement code (see below).
A decree in February 2005 laid down the rules for a new committee to coordinate the
fght against fraud, smuggling and forgery. Its remit is to review existing regulations
and propose changes; initiate administrative investigations; combat the import and sale
of products derived from fraud, smuggling or forgery; devise and monitor the imple-
mentation of prevention programmes; protect tax and customs receipts; and centralise
information about illegal commercial practices. The committee, chaired by the Minister of
Trade, includes representatives from other concerned ministries, the unions, the employers
federation, the security services and the department for external research. It will also have
inspectors at its disposal to carry out activities in the provinces.
A presidential decree in February 2005 established a special supervisory department
(Division spciale de contrle des services) in the national security service with
responsibility for investigating the confdentiality, state of mind, morale and loyalty of
members of the national and local police. If the new body were given real powers, it would
yield an immediate boost in public confdence since the police force is allegedly one the
most pernicious sources of everyday corruption.
1
It is doubtful the new department will
prove effective, however. A similar unit was created in the past but dismantled at short
notice, without proving its value.
In March 2005, the government promised to lift the secrecy surrounding its oil revenues
by signing up to the Extractive Industries Transparency Initiative and promising to
Cameroon
Country reports CAmERooN
GC2006 02 part2 139 8/11/05 17:53:50
Country reports 140
publish comprehensive, quarterly fgures about its production, sales prices and revenues
(see below).
Procurement: will independent
audits help?
Sixteen months after ratifying the UN
Convention against Corruption, the
government introduced a Procurement
Contracts Code in September 2004 to replace
the three decrees from 1995 and 2002 that
had regulated public tendering poorly. The
new code increases the responsibility of con-
tractors, establishes a mechanism to regulate
the system and strengthens supervision
before and after contracts are allocated by
submitting them to independent observers
and an independent auditor. Article 2
enshrines equality of access to public
orders, equality of treatment for bidders
and procedural transparency as the codes
guiding principles.
The code is intended to deal with a
multitude of procurement-related corrupt
practices, including: breaches of rules
regarding publication of offers, limiting
competition; failure to respect confdentiality
when bids are examined; lack of precise
criteria by which candidates and offers
are chosen; acquisition of interests by the
supervisory authorities through the creation
of fictitious companies; skewing of the
selection procedure; abuse of the purpose of
contracts; fctitious deliveries; payment for
contracts not performed; and the splitting
of orders to circumvent procedures by
remaining below the minimum required
threshold. Such practices make regular
appearances in the courts, most notably
in the Mounchipou case in 2003 when a
former minister of telecommunications was
found to have colluded in the fraudulent
award of a public works contract that
involved order splitting, fctitious delivery
of contracts and overpricing.
2
To combat these practices, the government
proposed two measures to improve the
performance of the Procurement Contracts
Commission (CPM), which is responsible
for providing contractors with technical
support and supervision in all departments,
including state-owned companies and
diplomatic missions. The frst is a new sub-
commission within the CPM to analyse and
classify bids in purely technical and fnancial
terms. It will be supported by four specialist
bodies with supervisory responsibility for
monitoring procurement procedures in roads
and infrastructure, buildings and collective
facilities, general supplies, and intellectual
services.
The codes other innovation is the
recruitment of an independent observer
through an international call for bids by the
Agency for the Regulation of Procurement
Contracts (ARMP), whose role is to ensure
that all regulations, transparency rules
and principles of fairness are respected in
procurement processes. The ARMP will
also recruit an independent auditor of
untarnished reputation to conduct annual
audits of all procurement contracts above
FCFA500 million (US $940,000) and a 25 per
cent sampling of contracts worth FCFA30
500 million. While the recruitment method
provides some assurance that the independent
observer will be truly independent, the weight
of administrative practice and pressure from
senior politicians (such as that exerted on the
NGO Global Witness when it was appointed
independent observer in the forestry sector)
could jeopardise the posts impartiality.
Cameroon should be congratulated on
the new procurement code, but it remains
to be seen how effective it will prove in the
absence of an independent judiciary, the
body ultimately responsible for enforcing
the law and sanctioning illegalities. Lack
of human and fnancial resources, and the
complexity of procedures invariably lead to
judicial delays while eroding the integrity
of staff. Successful implementation requires
that the commissions created by the new law
should be staffed by people of integrity, as
required by article 8 of the UN Convention
against Corruption.
GC2006 02 part2 140 8/11/05 17:53:50
141
Jean-BoscoTallaandMauriceNgufack(TICameroon)
Further reading
Cameroon National Governance Programme, Cameroun:leschantiersdelagouvernance (Cameroon:
The Workshops of Governance) (Yaound: PNG, 2004)
Lucien Ayissi, Corruptionetgouvernance(Corruption and Governance) (Yaound: PUA, 2003)
Arguably, the weakest link in the moni-
toring chain is the ARMP, which oversees its
application, recruits external observers and
auditors, and appoints chairmen to the four
supervisory bodies. As a state agency, it has
close ties with the political elite, and thus does
not have the independence necessary to carry
out the delicate tasks entrusted to it. There is
also the danger of operational drift by the
regulatory authority. At the time of writing,
a frst generation of observers appointed in
2001 to oversee procurement had not been
paid for nearly two years, a state of affairs that
clearly exposes them to temptation.
3
Finally, with respect to contracts,
departmental price lists cannot be used as a
reliable basis for assessing suppliers invoices.
State agents are well accustomed to corrupt
practices and the offcial list for offce supplies,
to take one small example, constitutes prima
facie evidence of overpricing, because it
contains prices four times higher than normal
market rates. External audits and reviews are
imperative if the hidden commissions that
litter price lists are to be weeded out before
the new code becomes operational.
Cameroon signs up to EITI
In a month that saw 500 civil servants
referred to a disciplinary council on charges
of fraud or misappropriation
4
and news that
3,000 fctitious offcials had been stripped
from the payroll,
5
the government gave
further evidence it was taking corruption
seriously by signing up to the Extractive
Industries Transparency Initiative (EITI) on
17 March 2005. In a letter to the IMF on
30 March, Prime Minister Ephram Inoni
reiterated that commitment and promised
to post quarterly data on oil production,
sales prices and revenue since 2000 on the
website of the state-owned Socit Nationale
des Hydrocarbures by the end of June 2005,
and to update it regularly.
In the light of these undertakings, civil
society organisations are in the process of
setting up a contact group to monitor the
publication of oil revenues. It comprises the
Centre for the Environment and Develop-
ment (CED), the Cameroonian Womens
Foundation for Rational Environmental
Action (FOCARFE), Transparency Interna-
tional Cameroon (TIC), the Catholic Relief
Service (CRS) and the Commission for Justice
and Peace of the Episcopal Conference of
Cameroon (CJPCEC). The EITI initiative
provides potential for civil society to play
the role of objective observer.
Breaking the secrecy surrounding oil
revenues will have a direct impact on
the recently completed ChadCameroon
pipeline, providing communities in the
regions that it crosses with vital information
against which to measure the governments
performance in developing the country.
The pipeline is expected to have a major
economic effect. By one account, the salaries
and income derived from the supply of
goods and equipment during the three-
year construction phase increased national
GDP by 2 per cent, and an annual 1 per cent
increase is anticipated during the 2530
years of its lifespan.
6
In 2004, the Cameroon
Oil Transportation Company (COTCO) paid
Cameroon some FCFA23 billion (US $43
million) in transit fees, a fgure included
in the budgetary framework as required by
international lenders, particularly the IMF
and the World Bank.
For many observers, while sustained
efforts are required to reduce the extent of
corruption, the EITI initiative forms part
of a raft of measures recently introduced
to clean up public sector management and
promote professional ethics. The test will be
in implementing them.
Country reports CAmERooN
GC2006 02 part2 141 8/11/05 17:53:51
Country reports 142
Charles Manga Fombad, The Dynamics of Record-Breaking Endemic Corruption and Political
Opportunism in Cameroon, in John Mbaku and Joseph Takougang (eds), TheLeadership
ChallengeinAfrica:CameroonunderPaulBiya (Trenton, NJ: Africa World Press, 2004)
Friedrich Ebert Stiftung, Luttecontrelacorruption:Impossiblenestpascamerounais (Combating
Corruption: Everything is Possible in Cameroon) (Yaound: PUA, 2002)
Pierre Titi Nwel (ed.), DelacorruptionauCameroun (Corruption in Cameroon) (Yaound: Gerddes-
Cameroun and Friedrich Ebert Stiftung, 2001)
Babikassana and Abissama Onana, LesdbatsconomiquesduCamerounetdAfrique (Economic
Debates about Cameroon and Africa) (Yaound: Prescriptor, 2003)
Notes
1. See GlobalCorruptionReport2005.
2. Ibid.
3. Mutations (Cameroon), 28 April 2005.
4. CameroonTribune (Cameroon), 1 March 2005.
5. LeMessager (Cameroon), 1 April 2005.
6. Roger Tsafack (ed.), LepipelineTchadCamerounetlemploi.Quellesleons? (The ChadCameroon
Pipeline and Employment. What Lessons Can Be Learned?) (Yaound: PUA/FES, 2003).
Conventions:
UN Convention against Corruption (signed December 2003; not yet ratifed)
UN Convention against Transnational Organized Crime (ratifed September 2003)
ADB-OECD Action Plan for Asia-Pacifc (endorsed April 2005)
Legal and institutional changes
On 19 September 2004, the Fourth Plenary Session of the 16th Central Committee of the
Communist Party of China (CPC) adopted a resolution on governance capacity building
that called for more accountability of members through broader citizen participation,
greater separation of government from the management of businesses and the creation of
more democratic evaluation systems. The resolution included a call for whistleblowers
protection, a right offcially enshrined in an ordinance that came into effect on 24
October (see below).
In January 2005, the CPC Central Committee released guidelines for a national system
of corruption prevention that entails a three-pronged approach of ethics education,
institutional accountability and civil monitoring. The system is due to be in place by
2010. This is the frst time Chinese leaders have laid out a comprehensive blueprint for
a national anti-corruption campaign (see below).
Given that more and more corrupt offcials settle their families abroad before joining them
with their ill-gotten gains, the Central Commission of Disciplinary Inspection (CCDI) began
a scheme in July 2004 under which senior offcials must declare in advance any overseas
visits by spouses and children. A pilot project is currently operational in Xiangfan, Hubei
province, Suzhou in Shanxi and in a factory and power station belonging to the Shenhua
Group. Offcials who do not declare such visits will be denied promotion.
China
GC2006 02 part2 142 8/11/05 17:53:51
143
In April 2005 the standing committee of the 10th National Peoples Congress (NPC)
approved the countrys frst civil servant law to defne offcials rights and responsibilities.
The law covers such areas as duties, posts and ranks; recruitment, training, salaries and
assessments; and punishments and related issues. The law stipulates that all public servants
should be recruited through just, open and fair examinations. At present, some people
become civil servants by directly engaging or transferring from civilian organisations.
In addition, the law provides for a more stable rewards system by ensuring that salaries
are raised in line with economic growth.
Planned improvements to the
strategic system against corruption
Shenzen, the site of Chinas first special
economic zone, is to be the test-bed for
the CPCs blueprint for checking internal
corruption before it is rolled out to the rest of
the country by 2010. The implementation
guideline for the establishment of a national
system of punishing and preventing
corruption, unveiled in January 2005, calls
for further development of democracy and
legal institutions with the goal of bringing
power to closer public account. Among the
guidelines targets are more dynamic anti-
corruption tactics; broader channels for
public oversight and civil society monitoring;
protection of whistleblowers and citizens
rights to criticise; and increased transparency
of public policy. Five ordinances were
introduced in 2004 with the aim of increasing
the accountability of high-ranking offcials,
including two designed to promote greater
meritocracy in the selection and promotion
of party and government officials, and
another that specifes complaints procedures
for party members.
The guideline calls for improved
responsibility systems for the administrative
and judicial sectors, and a three-pronged
programme of ethics education, institutional
accountability and civil monitoring. Ethics
education will be incorporated into general
school curricula; the Central Commission
of Disciplinary Inspection (CCDI) will be
responsible for accountability capacity
building; and the Party Congress will
encourage whistleblowing by party members,
accountability in the public administration
and a code of conduct for the judicial
sector.
In particular, it prioritises enhanced
auditing in targeted sectors and ministries,
and introduces effciency auditing for high-
ranking offcials. All audits will be published,
building on an existing trend towards more
active and open auditing processes. Notably,
in June 2004, the state audit offce publicly
released a report on central government
spending that disclosed that 41 out of 55
central departments audited were suspected
of embezzlement and appropriation of
public funds, including funds earmarked for
the China Olympic Committee and disaster
relief fund. The report led to disciplinary
action against 545 people and more than
80 judicial hearings, including cases against
the former director of the Beijing Municipal
Power Supply bureau and against two vice-
presidents of the Agricultural Development
Bank. In July 2004, the state audit offce
announced plans to audit all CPC central
committee departments and all central
government ministries, commissions and
departments that receive funds from central
government.
The guideline foresees the creation of a
checks-and-balances institution to ensure
the accountability of investment decisions
by state companies and agencies, and to
monitor their projects. Those responsible for
investment policies will be held accountable.
In a similar vein, it proposes introducing a
real name bank accounts system to limit
cash transactions, a warning system for
high-volume cash movements and improved
information sharing to contain money
laundering.
Country reports CHINA
GC2006 02 part2 143 8/11/05 17:53:51
Country reports 144
Whether the guidelines grand designs will
translate into action is debatable. Beijing has
tended to advocate mostly administrative
measures to combat corruption. Moreover,
party investigators will fnd it diffcult to
investigate their own bosses.
Corruption amongst party cadres
Ever since the late 1990s, when the party
chief in Zhanjiang, Guangdong province
and two mayors in the autonomous
region of Anyang, Henan province were
convicted of corruption, the practice of
selling promotions for cash has been on the
rise. Despite passing a series of regulations
to streamline its system of selection and
appointments in 2000 and 2002, the CPC
has failed to stamp out power trading,
as it is known, though the detection rate
may have slightly improved. In 2000, Ding
Yangning was convicted of trading posts for
money during his three-year term as party
chief in Zhenghe, Fujian province, a case
that incriminated 246 offcials on charges
of bribery. This record was soon beaten
by Wang Hulin of Changzhi City, Shanxi
province, who allegedly sold 278 government
or party posts in a single month.
In 2004, five more ordinances aimed
at closing institutional loopholes in the
accountability of officials were issued,
among them interim regulations on open
selection of party and government offcials,
interim provisions on promotion via open
competition and another on party or
government offcials who take occasional
jobs in enterprises. At the same time, the
Central Committee sent out five teams
on inspection tours to monitor senior
leaders at provincial and ministerial level.
In a sign that power trading still thrives,
Ma De, former party chief in Suihua city,
Heilongjiang province, was charged in
March 2005 with taking bribes worth US
$726,000 from 260 officials over his six-
year tenure of offce. The conviction of Ma
known as the 10,000 yuan chief for his
daily income from bribes sent shock waves
through political circles and later ensnared
the provincial heads of the high court and
prosecutors offce, a deputy governor, the
chair of the provincial congress and the head
of the local party secretariat. Tian Fengshan,
a former minister of land and resources, was
also implicated.
The inspection teams exposed the extent
of corruption at all levels of administration.
Xinhua and ChinaDaily reported almost daily
on offcials scamming the system, ranging
from the Xintian education offcials who
owned luxury cars in an impoverished county
in Hunan province, or accusations that
offcials in Fuzhoudisplaced impoverished
land owners without compensation and sold
their plots to developers at prices lower than
market value. Examples of this are legion.
The NPC publicised the arrest of crooked
party cadres and offcials at banks and other
state-owned enterprises, claiming more
than 150,000 corrupt members had been
disciplined and the misuse of public funds
of over US $300 million had been uncovered
in 2004.
Further substantiation that lack of
accountability is endemic among offcials
is provided in a survey released in January
2005 by Wang Jianxin, an expert at the Law
School of the JiangxiUniversity of Finance
and Economics in eastern China.
1
Wangs
survey of village officials demonstrated
that there has been an increase in offcials
abuse of power and related economic crimes,
with cases of corruption by high-ranking
and grassroots officials cropping up in
quantity. Such cases involved bribes valued
at thousands, tens and even hundreds of
thousands of yuan (from US $240 to US
$1.2 million).
massive graft plagues some of
Chinas banks
Chinas banking system suffered a string of
graft allegations involving senior executives
at major state banks in 200405, and was
weakened by high levels of bad debt and
GC2006 02 part2 144 8/11/05 17:53:51
145
GuoYong(TsinghuaUniversity,China)andLiaoRan(TransparencyInternational)
Further reading
Wang Chaunli, FeelthePulseofCorruptionStudiesoftheCorrelationbetweenFrequencyofCorruption
andControlIntensity (Beijing: Qunzhong Publishing House, 2004)
Li Junjie, The Current Status, Development Perspectives and Monitoring of Chinas Banking
System, InternationalEconomicReview 34, 2004
Chi Lo, Bank Reform: How Much Time does China Have?, ChinaBusinessReview, MarchApril
2004
Xie Ping and Lu Lei, The Economics of Corruption in Chinas Financial Institutions: Behaviour
and Mechanism Design (Beijing: Peoples Bank of China, 2003)
Yan Sun, Corruption and Market in Contemporary China (New York: Cornell University Press,
2004)
low rates of capitalisation. In January,
investigators found 1 billion yuan (US $120
million), missing from deposits at a local
branch in Haerbin city after the branchs
director fled abroad. In March, a staff
member in the Dalian branch of the Bank
of China was found to have misappropriated
US $6 million and staff at the Baotou branch
of Chinas Industrial and Commercial Bank
were accused of a conspiring to loan illegally
300 million yuan (US $37 million). On 16
March, the chairman of China Construction
Bank, Zhang Enzhao, resigned amid reports
that he had allegedly received a US $1
million kickback and other monetary
favours from US companies in return for
granting loans. Zhang is under investigation.
His predecessor, Wang Xuebing, was jailed
for corruption in 2002. China Construction
Bank, the countrys top property lender, had
been the shop window of Chinas efforts
to reform its debt-ridden banking sector,
having received US $22.5 billion late in 2003
to recapitalise its balance sheet following
aggressive bad-loan write-downs. According
to a survey by the Research Bureau of the
Peoples Bank of China, 81.5 per cent of
people think corrupt dealing is a common
feature of Chinas banking system.
In April 2004, the media exposed another
fraudulent loan scandal. Two years earlier,
an internal investigator at the Beijing branch
of the Bank of China had found a loan case
in which Real Estate Ltd used its employees
names, forged purchase contracts and
proof of income declarations to apply for
199 separate loans from the bank worth
645 million yuan (US $78 million). The
fraud resulted in the abandonment of
273 unfinished luxury apartments. This
scandal highlighted the vulnerability of
Chinas banking system, which is groaning
under a mountain of bad loans. In 2004,
credit risk was increasing because bank
lending continues to tilt towards large real
estate and capital construction projects,
favouring medium- and long-term loans,
and monopolistic industries, such as
highways, railways, airports, power and
communications. The capital adequacy rate
of most banks in China is well below the 8
per cent Basel Standard. These two factors
are severe impediments to further reform of
the banking sector.
The Chi na Banki ng Regul at or y
Commission (CBRC) announced a new
crackdown on corruption following the
resignation of Zhang Enzhao. The CBRC says
it will enact a range of investigative checks,
including the monitoring of mortgage,
consumer and infrastructure project loans
to help address the problems. Meanwhile, it
warns banks to tighten their own checks to
prevent new cases of corruption emerging.
Between 2001 and 2005, courts sentenced
27,000 bank employees for fnance-related
crimes, over 4,000 of them to more than fve
years imprisonment, life imprisonment or
death. Attempts to solve the bad debt issue
by improving monitoring and internal
controls have failed because of political
leverage on credit decisions.
Country reports CHINA
GC2006 02 part2 145 8/11/05 17:53:52
Country reports 146
Zhong Wei, Ba Shusong, Gao Qinghui and Zhao Xiao, Evaluation Report of Chinas Financial
Risks, ChinaReform 3, 2004
Li Yifan, Strategic Shift of Chinas Fight against Corruption, ChinaOutlook 2, 2004
Guo Yong, Strengthening International Cooperation to Deal Heavy Blows against Trans-Border
Corruption, StudiesofInternationalIssues 5, 2004
Note
1. Unpan1.un.org/intradoc/groups/public/documents/apcity/unpan020124.htm
Conventions:
OAS Inter-American Convention against Corruption (ratifed June 1997)
UN Convention against Corruption (signed December 2003; not yet ratifed)
UN Convention against Transnational Organized Crime (ratifed July 2003)
Legal and institutional changes
A law against corruption and illicit enrichment in the public services was approved
in October 2004. The law defnes and provides sanctions for crimes including infuence
peddling, international bribery and appropriation of gifts to the state, which formerly
were not defned and therefore rarely prosecuted. The new law also provides detailed
requirements for public offcials to declare their assets.
The Offce of the Special Attorney for Ethics and Public Services, established by
law in 2002, became operational when the post was flled in 2004. The budget for the
offce was increased following a series of high-profle scandals in 2004 (see below), and
its remit expanded to include supervising implementation of the OAS Convention
against Corruption, and helping the public prosecutor with ongoing investigations into
allegations of corruption against four former heads of state.
Costa Rica
Trust in political institutions wanes
as the cover is pulled off corruption
Costa Rica, hitherto the most stable
democracy in Latin America, had been able
to boast low levels of corruption until a
recent spate of scandals drew the publics
attention to decades of shady financing
of politicians and parties. It now faces the
challenge of rebuilding public trust in its
political institutions.
The first scandal erupted in October
2004 when former president Miguel Angel
Rodrguez was forced to resign as Secretary-
General of the Organization of American
States less than three weeks after he had taken
up offce. He stepped down after allegations
implicated him in a bribery scheme
involving the French telecommunications
company, Alcatel. In mid-2004, details
emerged that Alcatel had been awarded a
contract to improve the countrys cellular
phone system allegedly after its officials
successfully bribed Jos Antonio Lobo,
Rodrguezs protg and a former director
of the state electrical company, Instituto
Costarricense de Electricidad (ICE), with a US
$2.4 million prize. Lobo said he had been
advised to accept the sum by Rodrguez,
who is reported to have then demanded 60
per cent of it.
Digging deeper into Alcatels dealings,
allegations emerged that it had attempted to
GC2006 02 part2 146 8/11/05 17:53:52
147
infuence previous Costa Rican politicians as
well. Jos Mara Figueres, a former president,
was forced to step down from his senior
position at the World Economic Forum in
Geneva in October 2004 following allegations
that he had received a US $900,000 bribe
from Alcatel during his years of public service.
And current President Abel Pacheco has been
asked to explain an undeclared US $100,000
donation to his presidential campaign, also
by Alcatel. In total, the authorities believe
that Alcatel, which enjoys a near monopoly of
telecommunications services in the country,
has paid more than US $4.4 million to Costa
Rican politicians and offcials.
Money fowed to party coffers from foreign
governments as well. Rodrguezs Panama-
based investment company, Inversiones
Denisse, allegedly received two payments of
US $500,000 from the Friendship Company,
which has strong ties to the Taiwan
government. When he was president, he is
alleged to have received US $200,000 from
Taiwan on two separate occasions and his
party, the Social Christian Unity Party, has
been questioned over donations worth US
$500,000 from companies with connections
to Taiwan.
A separate scandal embarrassed another
former president, Rafael Angel Caldern, who
is accused of receiving nearly US $450,000
from a US $40 million loan from the Finnish
government to subsidise the state-run social
security system (see Grand corruption in
Costa Rica, Chapter 2, page 26).
These scandals along with evidence
produced through monitoring campaign
spending suggest that the sums of off the
record money fowing to campaign chests
dwarf the amounts legally declared and
scrutinised by the electoral authorities.
Current legislation requires parties to
report donations received and campaign
spending, sets limits on both and forbids
parties from accepting money from foreign
sources. Most of these regulations were
violated in the recent elections in April
2002, according to TI Costa Rica, but the
authorities failed to sanction the abuses.
Civil society groups found it difficult to
obtain information about party fnancing
that should be made public.
The legislature responded by setting
up special commissions to investigate
irregularities in the fnancing of the recent
campaign and to draft reform bills to
tighten up the legal framework. This is a
start, but more is needed if the public is to
regain confdence in the countrys political
institutions, especially given the gravity of
the allegations against former presidents.
Levels of abstention are expected to
increase in the next elections. A poll taken
in the first quarter of 2005 showed that
one in two people does not support any of
the potential candidates one year ahead of
elections, compared with one in three people
in 2001 and one in fve in 1997.
1
According
to a second poll in January 2005, corruption
is the biggest public concern (37 per cent
of people polled put it frst), while violence
and crime were the primary concern of just
5 per cent. In July 2004 the opposite was
the case, with 26 per cent placing violence
and crime at the top of their worries, and
only 5 per cent expressing concern about
corruption.
2
Two positive developments have been
increased public involvement a massive
march against corruption took place in
October 2004 and the increased credibility
of the judiciary. The public prosecutor has
shown a great deal of independence from
political pressure in his investigations, and
polls by the University of Costa Rica show
increased confdence in the judiciary.
3
Access to information: the citizens
tool against corruption
Access to information has been confrmed as
a critical tool in the fght against corruption,
thanks to a series of rulings by the Consti-
tutional Court rejecting attempts to limit
access to public information. Prior to the
rulings, access was limited to what offcials
permitted.
One major advance was lifting bank
secrecy provisions. This was effected through
Country reports CoSTA RICA
GC2006 02 part2 147 8/11/05 17:53:52
Country reports 148
RoxanaSalazar(TransparenciaCostaRica)
Further reading
Casals and Associates, ElfnanciamientodelospartidospolticosenArgentina,Chile,CostaRicay
Mxico:LeccionesparaAmricaLatina (Financing of Political Parties in Argentina, Chile, Costa
Rica and Mexico: Lessons for Latin America), 2004, www.respondanet.com/spanish/boletines/
pdf/issue41.pdf
Carlos Eduardo Serrano Rodrguez, LacorrupcincomofenmenosocialenCostaRica (Corruption as
a Social Phenomenon in Costa Rica) (San Jos: Escuela de Administracin Pblica, 2004)
Roxana Salazar (ed.), Corrupcin:unavisindesdelasociedadcivil (Corruption: A View from Civil
Society) (San Jos: Editorial Fundacin Ambio, 2004)
Roxana Salazar, Mapasderiesgodecorrupcinenelsectorforestal (Corruption Risk Maps in the
Forestry Sector) (San Jos: Editorial Fundacin Ambio, 2004)
Jorge Vargas and Luis Rosero-Bixby, LaculturapolticadelademocraciaenCostaRica(The Political
Culture of Democracy in Costa Rica) (Nashville: Vanderbilt University, 2004), www.dec.org/
pdf_docs/PNADB407.pdf
Transparencia Costa Rica (TI Costa Rica): www.transparenciacr.org
Notes
1. ElFinanciero(Costa Rica), 28 March 2005.
2. Ojo (Costa Rica), 12 and 30 January 2005.
3. University of Costa Rica, Sondeo sobre corrupcin de las lites polticas costarricenses: la
ciudadana valora positivamente las acciones contra la corrupcin (Survey on Corruption by
Costa Rican Political Elites: Citizens React Positively to Actions against Corruption), Instituto
Investigaciones Sociales, Proyecto Investigacin en Opinin Pblica, November 2004.
a writ against public and private banks that
appealed to bank secrecy rules to prevent
access to information. The Constitutional
Court ruled that where the funds of political
parties or candidates were concerned,
banking secrecy did not apply. The ruling
made reference to a constitutional reform
in 2000 stating that public institutions
must be accountable and held up to public
scrutiny.
The newspaper La Nacin requested
information about non-contributory
pensions to the board of directors of the
social service agency, Caja Costarricense
de Seguro Social. The reporters wanted an
electronic copy of the database, including
the names of benefciaries and details about
their pension entitlement. The request was
denied in September 2002 on the grounds
that it was information about third parties
whose confdentiality should be respected.
The reporters filed a writ of habeas
data requesting the information, which
they argued is public. The court agreed in
March 2003, asserting that transparency
is a constitutional requirement for public
administration, and only limited exceptions
apply. The journalists were granted the infor-
mation as a result.
Not only should information be made
publicly available when requested, the court
ruled, but the government should actively
disseminate information that is in the public
interest.
While the courts attitude is important
in prising open public records, obstacles
continue to be put in the way of accessing
information and a law clearly delineating
the right to access information is necessary.
Several access to information bills exist in
draft form but have yet to be adopted.
GC2006 02 part2 148 8/11/05 17:53:52
149
Conventions:
Council of Europe Civil Law Convention on Corruption (ratifed June 2003)
Council of Europe Criminal Law Convention on Corruption (ratifed November 2000;
Additional Protocol ratifed May 2005)
UN Convention against Corruption (ratifed April 2005)
UN Convention against Transnational Organized Crime (ratifed January 2003)
Legal and institutional changes
In September 2004, parliament passed a law on the fnancing of the presidential
campaign that prohibits campaign donations from foreign powers, state-owned and
public companies, unions, employers associations, civic organisations, public institutions
and companies partly or entirely owned by local governments. A signifcant innovation is
article 6, which requires candidates to declare the amount and sources of their campaign
funding. Although the law represents some progress towards a more transparent election
process, it sets no upper limit on campaign costs (see below).
The Prevention of Conficts of Interest in the Exercise of Public Offce Act (PCIA), passed
in October 2003, underwent two alterations in July 2004 and April 2005. The frst reduces
the amount of base capital a serving public offcial may retain in a company from 25
per cent to 0.5 per cent. Fines for violating the law were raised, and the list of liable
offcials expanded to include the Croatian president, the secretaries of the supreme and
constitutional courts, the deputies of secretaries of parliament and the government. The
second amendment closed a loophole on the declaration of gifts by including presents
of less than 500 kunas (US $80), presents to relatives, and national and international
awards. Since April, offcials are also obliged to report in their personal declaration forms
on how they acquired their assets and the sources of the funds with which they purchased
properties (see below).
In August 2004, the Ministry of Justice and the State Geodetic Administration launched
a 62 million (US $74 million) project to digitalise the countrys land register with the
twin aims of resolving hundreds of thousands of disputes over ownership, and drawing
up an accurate and more accessible land registry database. Assisted by EU grants and
a credit from the World Bank, the Ministry established 107 land registry departments
to work with 105 land registry courts with a view to settling the 351,046 cases then in
progress. The old system of registering property was cumbersome and offered a platform
for corruption by public offcials in land offces and the judiciary. By February 2005, the
new system had successfully resolved 62,000 property registry claims. The frst electronic
land register was expected to be published in June 2005.
1
An amendment to the law on the Offce for Prevention of Corruption and Organised
Crime (USKOK) in February 2005 gives the agency complete jurisdiction in all felonies
involving corruption and organised crime. County attorney offces and police will
conduct preliminary investigations into cases bearing the hallmarks of these offences. If
they establish reasonable suspicion, they will pass the case up to USKOK. It is hoped that
the amendment, which was sponsored by an USKOK working party set up in March 2004,
will make the offce more effcient by eliminating cases that are not under its jurisdiction.
Croatia
Country reports CRoATIA
GC2006 02 part2 149 8/11/05 17:53:53
Country reports 150
In 2004, USKOK investigated 117 cases of corruption of which 65 went to court, but only
20 ended in prison sentences.
2
Progress in implementing the 2003 Right of Access to Information Act was ftful
with high numbers of requests on one hand, but slipped deadlines and non-existent
reporting on the other. While the Central Offce for State Administration (COSA) did
issue regulations concerning the organisation of offcial records, which was a prerequisite
for implementation of the law, the government published a list of the bodies to which
the act applies six months late. The report on implementation of the law, published by
COSA in May 2005, showed that ministries had received a combined 4,302 requests in
2004, of which 16 were refused; other government offces received 1,174; and COSA itself
redressed 13 requests it had previously rejected.
3
The opposition criticised the reports
brevity, saying it did not provide adequate information on why requests were being
refused. One opposition member claimed that 180 municipalities had not handed in
their reports on the act and some had not even appointed information offcers to deal
with requests.
Political financing: a free-for-all
The presidential elections of January 2005
threw a spotlight on Croatias less than
transparent system of fnancing political
parties and their electoral campaigns.
Financing of the election process is based
on two laws: the Law on Political Parties,
which came into force in 1993; and the Law
on Financing of the Presidential Campaign,
adopted in September 2004 in preparation
for the presidential election of January 2005.
Given the lack of will by politicians to disclose
details of their own fnancial arrangements,
neither provides very satisfactory regulation,
although the more recent of them was
undoubtedly an improvement.
The Law on Political Parties disposes of
the entire topic in a few curt clauses. Article
19 describes the methods of processing
fnancial transfers that parties receive from
the national budget and article 20 obliges
parties to declare their sources of funds,
and their designated uses, within one
year. But the law does not prohibit specifc
types of fnancing (foreign governments,
corporations, unions, and so on), nor
determine a fgure above which a party is
obliged to make the donors identity known.
Nor are there limits on expenditure during
electoral campaigns.
The new Law on Financing of the Presiden-
tial Campaign regulates some of these issues.
It makes donations from foreign sources,
state-owned companies, unions and public
institutions illegal, while article 6 requires
candidates to publicly declare the amount of
funds used in campaigns, and their sources.
The law is an undoubted improvement on
the 1993 political party law, but it still fails
to set a ceiling on electoral expenditure.
Another major faw and one with which
the public is very familiar is that there is no
independent offce responsible for verifying
whether a partys declaration of funding
and sources is true, and no provisions for
sanctions in the event it proves false.
Consider the presidential campaign
of January 2005 when there was much
speculation in the media about the
expenditure of Jadranka Kosor, the HDZ
(Croatian Democratic Union) candidate.
4
Civil society, led by local NGOs GONG
(an election monitoring watchdog) and TI
Croatia, applied in January and February
2005 to Croatian National Television
(HRT) to publish the cost of promotional
videos and electoral advertising purchased
by all candidates. HRT refused, claiming
the information was protected by rules
of commercial confdentiality. This was
implausible, given that HRT is a state-owned
institution with a duty to make information
of public interest available under the Right
of Access to Information Act. HRT refused
to provide the same information to its own
Council, creating the impression that its
executives were trying to shield a candidate
GC2006 02 part2 150 8/11/05 17:53:53
151
from public scrutiny. HDZ later claimed
that Kosor had spent 6 million kunas (US
$979,000) on her campaign, but a market
research agency reportedly estimated her
expenditures to be twice as high,
5
although
this fgure in turn has been contested. Due
to public pressure, information on the
costs of television advertisement of the
campaigns of Kosor and other candidates
was offcially issued by Croatian National
Television in May 2005. But there is still
no independent regulator with powers to
investigate and verify the fnancial reports
of electoral campaign expenditure, and
to apply sanctions on those who violate
regulations.
Other anomalies exist in the auditing of
the states contributions to party fnances.
Though required to deliver budget
reports to a parliamentary committee
(Standing Orders and Political System), the
information is not published in the offcial
gazette. A number of specialist observers
claim that several parties do not meet even
this minimal legal requirement, but were
not sanctioned. Parties who fle on time
do so in the knowledge that their reports
will not be subject to an independent audit.
There is a clear need for root-and-branch
reform of the legal framework of party
and election fnance. The Law on Political
Parties needs revision, with particular
focus on the source and size of donations,
public accounting of the use of state and
private contributions and the creation of
an independent oversight body. Only then
will transparency be improved in what is
currently a murky electoral process.
6
The Imostroj affair
Since it was passed into law in October
2003, not a single high ranking public
offcial has been brought to book under
the Prevention of Conficts of Interest Act
(PCIA), although the public has become
increasingly concerned about corruption
and abuse of power by those in high
offce. This is only partly explained by the
resignation of the commission responsible
for implementing the PCIA in late 2004
due to internal political disputes, with the
result that it did not start work properly
until February 2005.
The most controversial confict of interest
allegation in 200405 was the Imostroj
affair, whose chief protagonist was the then
minister of foreign affairs, Miomir uul. The
local media alleged that uul took a bribe
from a friend and businessman in return
for pushing the cabinet to cancel the debts
of Imostroj, a company the man planned
to buy.
7
Although the State Attorney and
Audit Offces did not identify any confict of
interest, the public remained sceptical.
In parliament, the opposition Social
Democrat Party (SDP) and Croatian Peoples
Party (HNS) demanded the ministers
resignation. The majority Croatian
Democratic Union (HDZ) turned the tables
by appointing a committee to inquire
into conficts of interest by senior offcials
during the 200003 coalition government,
naming Zlatko Tomci, leader of the
Croatian Peasant Party (HSS) and former
parliamentary speaker, and Radimir Caci,
a former minister of public works and
member of HNS, as ripe for investigation.
Miomir uul, considered Prime Minister
Ivo Sanaders right-hand man and head of
the team negotiating Croatias entry to the
EU, resisted calls to step down for two more
months, but fnally resigned in January
2005, several days before the presidential
election. In his letter of resignation, he
defended his innocence but recognised
that the allegations had inficted some
political damage on the government. His
resignation was a demonstration of the
power that public pressure can exert when
conficts of interest arise real or perceived.
Nevertheless, he remained in charge of
coordinating negotiations with the EU for
some time after.
While the allegations against uul fell in
the fallow period before the commission for
investigating conficts of interest resumed
work, the case demonstrated Croatias bare-
knuckle approach to allegations of political
impropriety: when accused of corruption,
Country reports CRoATIA
GC2006 02 part2 151 8/11/05 17:53:53
Country reports 152
AnaFirst(TICroatia)
Further reading
Davor Derencinovi, CommentsonUNConventionagainstCorruption(Zagreb: University of Zagreb
Law Faculty, 2005)
Viktor Gotovac and ord
jan
Dinki said in March 2005 there were insuf-
fcient funds to pay the increase.
Few would claim that higher salaries
will eliminate corruption or even ensure
better work by MPs, but there are other
reasons to take the issue seriously. Under
a Constitutional Court ruling in May
2003, MPs are ultimately masters of their
mandate even when elected from a partys
list, rather than directly. When MPs cross
the foor to join other parties, they remain
the representatives of their constituencies.
In 2003, the defection of MPs to parties
defeated in the elections led Dr Vladimir
Goati, a political analyst at the University of
Belgrade, to refer to Serbia as an example of
non-elective parliamentarism. Even if they
accept bribes to vote for a law or join another
party, MPs are not liable for corruption since,
under Serbian law, there is nothing that
representatives should or should not do in
the scope of their authorisation.
Doubtful effects of conflict of
interest legislation
Confict of interest legislation was adopted
in April 2004 and dealt with duties in the
public and private sector, gifts, and the
declaration of assets and incomes.
11
Public
offcials, including some 1,000 people in the
central government and at least 10,000 in
lower levels of administration, were obliged
to comply with two deadlines. The frst, due
in July 2004, was to cancel all consultancy
arrangements, to resign from management
jobs and to transfer any managerial roles in
private enterprises. The second was to fle
property and income declarations for them-
selves and their immediate family after the
launch of the Board for Resolving Confict
of Interest.
The board was envi saged as an
independent, autonomous body, but in
reality it suffered a number of hindrances.
The procedure for nominating members was
long-drawn-out, the government did not
provide enough resources for it to function
by the deadline of May 2004, and nor
did it beneft from the 2005 budget. Such
oversights obstructed the laws intent since
the deadline for submission of disclosures
was set to coincide with the boards creation,
and no other agency existed to verify and
punish violations. By the first deadline,
the government announced on its offcial
website, www.srbija.sr.gov.yu, that all
offcials appointed by the government have
complied with their prescribed duties, but
there was no agency in place to check. The
media quickly detected two prominent cases
of non-compliance.
Bogoljub Lazi, then deputy minister of
capital investment, came to his job from the
Mobtel telephone company which he was
also investigating as part of a commission
responsible for determining the extent of the
states holding in it. When appointed, Lazi
froze his position in Mobtel in line with
the legislation valid at the time, but failed
to terminate his contract as required under
the new law. The government removed him
from his post in September 2005. A weightier
confict of interest issue concerned Lazis
manager, the Minister of Capital Investment,
Velimir Ili. The media pointed out that Ili,
who is president of the New Serbia party,
which also has close relations with the Force
of Serbia Movement (FoSM), is inevitably
linked with Bogoljub Kari, who is both head
of the FoSM and effective owner of Mobtel.
Since Ilis ministry is partly responsible
for regulating Serbias telecoms industry,
this posed a serious confict of interest. The
second victim was Oliver Bogavac, former
head of the money-laundering prevention
unit in the Ministry of Finance. The media
reported that Bogavac had agreed to act as
a consultant for the state-owned enterprise
Belgrade Airport in 2004 and had not
cancelled his contract.
12
The government
dismissed him from the post in February
2005.
Events passed more smoothly with regard
to the second deadline but its overall success
Country reports SERBIA
GC2006 02 part2 237 8/11/05 17:54:16
Country reports 238
NemanjaNenadic(TISerbia)
Further reading
Ivana Aleksi and Sreko Mihajlovi, KorupcijauNovimUslovima (Corruption in a New Environment)
(Belgrade: Centre for Policy Studies, 2002)
Boris Begovi, CorruptioninCustoms:CombatingCorruptionattheCustomsAdministration (Belgrade:
Centre for Liberal-Democratic Studies, 2002)
Vladimir Goati, Nemanja Nenadi and Predrag Jovanovi: FinancingthePresidentialElectoral
CampaigninSerbia2004ABlowtoPoliticalCorruptionorPreservationofStatusQuo? (Belgrade:
TI Serbia, October 2004), www.transparentnost.org.yu/english/PUBLICATIONS/index.
html#fnancing
TI Serbia: www.transparentnost.org.yu
Notes
1. A nearly identical version of the bill was submitted to parliament in 2003 but was soon
withdrawn by the former government (see GlobalCorruptionReport2005).
2. These include fve ministries, including the Ministry of Defence and Ministry of Foreign
Affairs.
3. Article 39. Among other information, the directory will include: description of powers, duties
and in-house organisation; data on budget; procedures for submitting requests for access to
information or complaints against decisions made; overview of requests, complaints and
other measures undertaken by interested parties; data on the manner, medium and place of
storing information; and type of information held.
4. See www.transparentnost.org.yu/english/ACTIVITIES/ACCOUNTABILITY/2001-e05.html
5. See www.srbija.sr.gov.yu/vesti/vest.php?id=13926
6. The coalition, headed by Prime Minister Vojislav Kostunica, is comprised of the Democratic
Party of Serbia, G17 Plus, the Serbian Renewal Movement and New Serbia, supported by the
Socialist Party of Serbia.
7. The basis for calculating salaries in the executive branch was changed through a conclusion
of the government, which is not published in the offcial gazette and therefore not public,
contrary to new laws on access to information and confict of interest. Moreover, the ruling
establishes a different basic wage for various categories of offcials, although their level of
responsibility is already mirrored in the different coeffcients assigned to different posts.
8. www.beta.co.yu/korupcija/default.asp?st=a&str=1&p=1&lis=1&pi=1164523
9. See, for example, the statement of Zoran Andjelkovic, chair of the Socialist Party group, at
www.beta.co.yu/korupcija/default.asp?st=a&str=&p=1&lis=1&pi=1114390
10. www.nspm.org.yu/PrenetiTekstovi/2005_evropa_dinkic_feb.htm
11. See also GlobalCorruptionReport 2005.
12. Blic (Serbia), 9 February 2005.
was limited. Most central and provincial post
holders submitted disclosures by 1 April, but
offcials in local governments and public
enterprises largely ignored the requirement.
The boards next task is to follow up the
names and assets of those who failed to
respond. But members of the public, who
might have more precise information about
the wealth of individual offcials, are denied
access to the contents of the disclosure fles,
cutting off a huge resource of information
for the board.
GC2006 02 part2 238 8/11/05 17:54:16
239
Conventions:
Council of Europe Civil Law Convention on Corruption (ratifed May 2003)
Council of Europe Criminal Law Convention on Corruption (ratifed June 2000; Additional
Protocol ratifed April 2005)
OECD Anti-Bribery Convention (ratifed September 1999)
UN Convention against Corruption (signed December 2003; not yet ratifed)
UN Convention against Transnational Organized Crime (ratifed December 2003)
Legal and institutional changes
In February 2005, parliament approved an act regulating the fnancing of political parties
and electoral campaigns. From the viewpoint of corruption, it contains several principles
that improve regulation and increase transparency of party fnancing, but weaknesses
remain, most notably the monitoring of the laws implementation (see below).
An amendment to the act on administrative proceedings, effective since November 2004,
strengthens citizens right of access to information by requiring all authorities to post
details of their decisions on the Internet or an accessible notice board. The amendment
requires authorities to inform the public clearly and in good time about all meetings, their
conduct and the decisions reached that could constitute a subject for public interest.
A law on the property of the municipality, effective since September 2004, amended
the previous act and offers further potential to fght corruption at the local level. The
frst of two amendments stipulates that no municipality may transfer ownership of its
property to any employee mayor, deputy, budget directors, or any persons or companies
close to them other than by public tender under the commercial code. The second
amendment allows for a reasonable exception by stating that an apartment, a plot of
land or a movable asset worth less than SK50,000 (US $1,600) may be transferred to an
employee of the municipality without a public tender.
The law on the establishment of a special court and prosecutor to fght corruption
and organised crime entered into force in September 2004.
1
By December 2004, the
prosecutors offce had investigated 416 cases, 12 per cent of them involving corruption.
The establishment of the special court, meanwhile, was delayed. Following the failure of
the Judicial Council (the body responsible for nominating judges) to elect the requisite
number of special judges, its powers were temporarily delegated to the Bansk Bystrica
regional court. By June 2005 the special court had fnally reached the number of judges
required for it to begin work.
Slovakia
New party law plagued by loopholes
Since 1991, Slovakia has fnanced political
party activity partly from the national budget,
due to the poor economic situation and
the lack of a culture of private donations.
2
However, the transparency of management
has remained low and the monitoring mech-
anisms created have been far from adequate.
The tendency to increase state support
continued until 2004 and politicians, irre-
spective of the parties they belonged to, were
the systems main advocates. In that year,
civil society NGOs warned that citizens no
longer felt adequately represented by their
parties, and harboured suspicions that their
political leaders were mired in corruption,
cronyism and conficts of interest.
Country reports SLovAKIA
GC2006 02 part2 239 8/11/05 17:54:16
Country reports 240
The legislation regulating party fnances
has changed several times. Amendments in
2000 and 2001 improved monitoring by
imposing obligations on parties to publish
annual accounts, lists of donors and to submit
statements to an independent auditor, but
the act contained defects that enabled it to
be circumvented. It did not limit the amount
members could contribute; it emphasised
transparency in only one form of income
(gifts from persons and legal entities); and
it placed the onus of monitoring on a par-
liamentary committee, thereby effectively
licensing parties to monitor themselves.
3
2
0
0
4
O
b
s
e
r
v
a
t
i
o
n
s
1
9
9
5
1
9
9
6
1
9
9
7
1
9
9
8
1
9
9
9
2
0
0
0
2
0
0
1
2
0
0
2
2
0
0
3
2
0
0
4
A
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S
t
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a
r
d
e
r
r
o
r
t
-
s
t
a
t
i
s
t
i
c
s
Argentina 28 0.7 0.6 0.6 0.4 0.4 0.4 0.1 0.6 0.4 0.0 0.16 0.03 4.6
Australia 28 0.7 0.8 1.0 0.6 0.7 0.6 0.5 1.1 0.1 0.0 0.05 0.02 2.4
Austria 27 0.4 0.5 0.6 0.5 0.3 0.8 0.7 0.4 0.2 0.0 0.08 0.05 1.8
Belgium 28 0.1 0.1 1.4 1.3 1.5 0.4 0.0 0.1 0.0 0.0 0.08 0.06 1.4
Brazil 28 0.2 0.2 0.2 0.2 0.0 0.1 0.1 0.3 0.3 0.0 0.02 0.03 0.7
Bulgaria 15 1.4 2.4 2.4 1.0 1.0 1.0 0.6 0.0 0.4 0.0 0.15 0.05 3.3
Canada 28 0.6 0.6 0.4 0.5 0.5 0.3 0.4 0.3 0.1 0.0 0.07 0.03 2.3
Chile 28 0.3 0.4 0.5 0.5 0.2 0.1 0.2 0.2 0.5 0.0 0.01 0.03 0.3
China 27 0.5 0.8 0.2 1.2 0.1 0.3 0.4 0.5 0.1 0.0 0.02 0.03 0.5
Colombia 27 0.2 0.0 1.3 0.9 0.4 0.2 0.3 0.0 0.1 0.0 0.11 0.04 2.9
Costa Rica 15 0.7 0.9 0.8 0.7 0.5 0.5 0.7 0.4 0.0 0.05 0.02 2.4
Czech
Republic
28 0.3 0.6 1.1 0.2 0.1 0.0 0.3 0.0 0.2 0.0 0.10 0.03 3.2
Denmark 28 0.1 0.0 0.2 0.1 0.1 0.2 0.2 0.2 0.0 0.0 0.01 0.01 0.8
Ecuador 15 1.5 0.5 0.5 0.5 0.5 0.2 0.2 0.2 0.2 0.0 0.08 0.03 2.7
Estonia 16 2.2 1.0 0.9 0.8 0.8 0.8 0.9 0.7 0.0 0.15 0.03 4.3
Finland 28 0.4 0.3 0.1 0.1 0.1 0.0 0.1 0.0 0.0 0.0 0.03 0.01 3.1
France 28 0.3 0.3 0.3 0.2 0.2 0.4 0.8 0.8 0.1 0.0 0.01 0.03 0.2
Germany 28 0.7 0.6 0.7 0.2 0.1 0.8 0.7 0.6 0.2 0.0 0.06 0.04 1.5
Greece 28 0.3 0.1 0.7 0.8 1.0 0.1 0.3 0.1 0.1 0.0 0.04 0.05 0.7
Hong Kong 28 1.4 1.4 0.3 0.1 0.2 0.7 0.3 0.6 0.6 0.0 0.12 0.04 3.2
Hungary 28 0.9 0.9 0.4 0.4 0.2 0.2 0.0 0.3 0.0 0.0 0.03 0.04 0.8
Iceland 19 0.8 0.8 2.9 1.4 1.5 0.7 0.0 0.3 0.1 0.0 0.22 0.10 2.3
India 28 0.5 1.1 0.0 0.9 0.3 0.1 0.3 0.2 0.0 0.0 0.00 0.02 0.2
Indonesia 28 1.0 1.5 0.1 0.1 0.2 0.1 0.6 0.4 0.2 0.0 0.07 0.03 2.7
Ireland 28 0.7 0.7 0.4 0.2 0.4 0.4 1.3 0.3 0.6 0.0 0.17 0.04 3.9
Israel 28 1.5 1.8 1.2 0.0 0.6 1.2 1.4 0.5 0.9 0.0 0.10 0.06 1.6
Italy 28 0.9 0.8 0.7 0.5 0.5 0.2 0.2 0.1 0.3 0.0 0.09 0.03 3.5
Japan 28 0.3 0.3 1.5 1.9 1.4 0.3 0.8 1.0 1.3 0.0 0.02 0.03 0.5
Jordan 19 0.1 1.4 1.1 0.7 0.8 1.0 1.1 0.1 0.0 0.03 0.07 0.5
Luxembourg 16 0.8 0.7 0.5 1.0 1.2 1.0 0.6 0.0 0.0 0.02 0.06 0.3
GC2006 03 part3 294 9/11/05 10:41:34
Ten years of the CPI 295
T
r
e
n
d
s
1
9
9
5
2
0
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4
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s
1
9
9
5
1
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1
9
9
8
1
9
9
9
2
0
0
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A
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s
t
i
c
s
Malaysia 28 1.2 2.4 2.2 1.9 0.3 1.8 1.5 2.2 1.5 0.0 0.07 0.04 1.9
Mexico 28 0.2 0.2 0.3 0.1 0.3 0.3 0.3 0.4 0.5 0.0 0.06 0.02 3.3
Netherlands 28 0.3 0.6 0.6 0.4 0.7 0.7 0.7 0.6 0.4 0.0 0.02 0.02 1.0
New
Zealand
27 0.2 0.4 0.3 0.1 0.3 0.1 0.2 0.1 0.1 0.0 0.02 0.01 1.5
Norway 28 0.4 0.2 0.4 0.1 0.1 1.1 0.8 0.0 0.9 0.0 0.02 0.05 0.3
Peru 18 0.9 0.7 0.7 0.6 0.4 0.3 0.6 0.1 0.0 0.0 0.05 0.06 0.9
Philippines 28 1.1 1.0 1.7 1.3 3.2 1.2 0.7 0.7 1.0 0.0 0.06 0.03 2.2
Poland 27 1.3 1.5 1.4 1.1 1.3 1.7 1.1 0.9 0.5 0.0 0.12 0.03 3.4
Portugal 28 0.2 0.1 0.9 0.8 0.6 0.6 0.1 0.6 0.1 0.0 0.01 0.06 0.2
Romania 15 0.3 0.6 0.7 0.7 0.8 0.7 0.6 0.3 0.1 0.0 0.03 0.06 0.6
Russia 28 0.4 0.3 0.2 0.4 0.0 0.1 0.2 0.6 0.0 0.0 0.06 0.03 2.1
Singapore 27 0.1 0.1 0.2 0.3 0.1 0.2 0.3 0.1 0.1 0.0 0.00 0.01 0.4
Slovakia 21 0.7 0.7 0.5 0.1 1.2 0.8 0.3 0.8 0.2 0.0 0.03 0.05 0.6
Slovenia 18 0.4 0.2 0.4 0.3 0.5 0.8 0.4 0.3 0.0 0.14 0.07 2.0
South Africa 28 0.7 0.2 0.6 0.4 0.9 0.8 0.8 0.8 0.7 0.0 0.04 0.03 1.2
South Korea 28 1.0 0.3 1.9 1.5 1.8 1.5 1.1 0.1 0.9 0.0 0.01 0.04 0.3
Spain 28 2.4 2.2 0.3 0.4 0.4 0.7 0.1 0.3 0.8 0.0 0.25 0.06 3.9
Sweden 28 0.1 0.1 0.1 0.0 0.5 0.0 0.1 0.1 0.1 0.0 0.01 0.02 0.6
Switzerland 28 0.1 0.3 0.2 0.0 0.3 0.2 0.7 0.2 0.0 0.0 0.02 0.03 0.6
Taiwan 28 1.5 2.5 1.1 0.0 0.7 0.8 0.3 1.7 1.0 0.0 0.07 0.03 2.4
Thailand 27 0.1 0.2 0.5 1.3 0.3 0.2 0.3 1.3 0.9 0.0 0.02 0.03 0.7
Turkey 28 0.7 0.4 0.4 0.4 0.6 0.7 0.2 0.2 0.1 0.0 0.07 0.03 2.5
Ukraine 17 0.7 0.8 0.8 0.0 0.1 0.2 0.0 0.4 0.2 0.0 0.02 0.03 0.6
United
Kingdom
28 0.4 0.4 0.3 0.2 0.1 0.3 0.2 0.1 0.2 0.0 0.05 0.02 2.9
USA 27 0.5 0.5 0.4 0.5 0.8 0.3 0.2 0.4 0.3 0.0 0.00 0.02 0.2
Venezuela 28 0.6 0.1 0.4 0.2 0.5 0.4 0.1 0.3 0.2 0.0 0.03 0.02 1.5
Vietnam 17 0.9 0.6 1.3 0.9 1.3 1.1 0.1 1.2 1.0 0.0 0.03 0.04 0.7
Zimbabwe 16 1.6 0.2 0.2 0.2 0.3 0.8 0.4 0.8 0.0 0.17 0.06 3.0
GC2006 03 part3 295 9/11/05 10:41:35
Research on corruption 296
the t-statistics reported are emphasised in bold in the case of decreasing corruption, or
italics in the case of increasing corruption.
The values for the annual change range between 0.25 and 0.17, which suggests
that lowering perceived levels of corruption achieving improvements in the CPI is
a long-term undertaking. A decade of substantial effort might improve the score by
1 point on a scale from 0 to 10. Only in rare instances will improvements be more
pronounced.
Overall, our fndings indicate that signifcant improvements between 1995 and
2004 occurred (in descending order of signifcance) in Estonia, Spain, Italy, Bulgaria,
Mexico, Hong Kong, Colombia, Costa Rica, Taiwan, Australia, Iceland and Russia. A
deterioration, on the other hand, was signifcant in Argentina, Ireland, Poland, Czech
Republic, Zimbabwe, United Kingdom, Ecuador, Indonesia, Turkey, Canada and the
Philippines.
This data mark a frst approach to determining composite time-series information
for a sample of 58 countries. Due to the short time horizon, the level of signifcance
is still limited. As data on levels of corruption become available for future periods, the
precision of the underlying measurement is likely to increase. The data presented here
may prove useful in determining the causes and consequences of corruption, where
research has until now been limited to cross-section analysis.
Notes
1. Johann Graf Lambsdorff is chair in economic theory at the University of Passau and a research
consultant to Transparency International, for whom he has coordinated and carried out the
CPI since 1995.
Figure 10.1: Levels of corruption, Argentina, individual data as reported by EIU, IMD and WEF
1.50
2.00
2.50
3.00
3.50
4.00
4.50
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
L
e
v
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l
s
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I
GC2006 03 part3 296 9/11/05 10:41:35
Ten years of the CPI 297
2. Bjrnskov and Paldam determine time series by processing only the ordinal changes in the
data over time, that is, whether a country improves its rank relative to others. With this
approach, one-shot changes of a purely methodological nature play a minor role as compared
to actual trend information. They conclude that generalised trust is about the only explanatory
variable with signifcant impact. See C. Bjrnskov and M. Paldam, Corruption Trends in J.
Graf Lambsdorff, M. Schramm and M. Taube (eds) TheNewInstitutionalEconomicsofCorruption
Norms,Trust,andReciprocity (London: Routledge, 2004), pp 5975.
3. Minor variations in the phrasing of questions have taken place over time, however. For instance,
in 200204, IMD asked respondents to assess whether bribing and corruption prevail or do
not prevail in the economy. Previously, respondents had been asked whether bribing and
corruption prevail or do not prevail in the public sphere. This change seemed to have little
impact on the data, however, allowing inferences to be made over time.
4. Separately for each country, k, I seek to determine the coeffcient a
k
, which depicts the infuence
of a simple time trend (Trend
1995
= 1, Trend
1996
= 2 ) on the dependent variables, which are
our sources values for country k. The coeffcient a
k
thus resembles an estimate for the annual
change in the CPI. All four subsequent regressions were run simultaneously.
IMD
ik
= a
k
.
Trend
i
+ b
k,IMD
.
d
IMD
+ e
i
WEF
ik
= a
k
.
Trend
i
+b
k,WEF
.
d
WEF
+ e
i
PERC
ik
= a
k
.
Trend
i
+b
k,PERC
.
d
PERC
+ e
i
EIU
i+1,k
= a
k
.
Trend
i
+ b
k,EIU
.
d
EIU
+ e
i.
We allow for our sources to differ systematically and capture this difference with the help of
a dummy variable for each source, for example d
IMD
. Thus, if IMD is more favourable in its
assessment of country kas compared to WEF, this is captured by the dummy and its associated
coeffcient, b
k,IMD
. A random error term is added, e
i
.