03/28/2021

Ben Margolis, PhD, MPH

Office of the Assistant Secretary for Health
Program Office
240-453-2821
RE: PROPOSAL FOR RESEARCH STUDY GRANT
Dear Ben Margolis, PhD, MPH:

I am grateful for the opportunity to present my grant proposal to the Office of the Assistant
Secretary for Health. The aim of this application is to obtain the Announcement of Anticipated
Availability of Funds for Research on Research Integrity Conferences Grant.
If this exploratory research project is selected for funding, I would aim to fill the holes in
evidence on the impacts of corruption on the health system in the United States. The short-term
objective of this study is to collect, compute and publish data in medical journals, which will offer
me power in disseminating results to news outlets and the government. Ultimately, the long-
term objective of this study is to provide other scholars with proof of wrongdoing in order to
design the strongest techniques equipped for anti-corruption reform. Additionally, this can lead
to greater awareness of the issue, education, further research, and pushing good governance
for transparency, accountability and elimination of systemic health sector corruption.
This experimental research study would provide detailed evidence of the misconduct in the
pharmaceutical industry, thus spurring further research into the key strategies of anti-corruption
programs, and eventually relying on the federal government to uphold the United States
Constitution's commitment to support the general well-being of ourselves and our posterity.
To begin this vital and comprehensive study, I respectfully request a $700,000 grant that will be
awarded at $233,333.33 every fiscal year for a three-year term. This grant would cover the
expense of contract services for the National Opinion Research Center (NORC) at Chicago
University, as well as the salaries of a statistician, a director, and a project manager. In addition
to the expense of the required data recording equipment, transport, and cash rewards for
participants.
Thank you in advance for reviewing my proposal; I look forward to collaborating with your
organization by taking this critical first step towards improving the health and wellbeing of all
Americans. If you have any inquiries, please do not hesitate to contact me at the phone number
or email address below.

Sincerely,
Miranda Duckworth
Bachelors of Science in Chemical Engineering Candidate
University of North Dakota
(813) 836-4616
Abstract
There is an abundance of commentary and articles establishing and outlining the problem of
pharmaceutical corruption and its negative effects. Although there is a lack of empirical evidence to
support this notion in the United States, the problem of health sector misconduct continues to run
rampant. As a result, legislation and policy reform does not move in a forward direction to initiate anti-
corruption measures. Gaining an understanding of the entirety of this wicked problem through careful
analysis, the need for empirical evidence and documentation on misconduct in the health sector is
required to initiate change. I am embarking upon an extensive research study to explore and document
the dimensions of corruption entangled in the complex web of the pharmaceutical sector. This data will be
gathered in conjunction with the National Opinion Research Center (NORC) at Chicago University and will
be compiled over a three-year period beginning in March 2023. Consequently, after this study is done,
there will be compelling and persuasive evidence that pharmaceutical industry abuse and its harmful
implications are a public health problem that needs urgent action.
 Impacts of Health Sector Corruption
Submitted to: Office of the Assistant Secretary for Health
Announcement of Anticipated Availability of Funds for Research on Research Integrity
Conferences
Proposed by: Miranda Duckworth
March 28, 2021
 Introduction and Background
Being economically disadvantaged can allow you to experience the greatest impacts of
health sector misconduct. Should the United States practice good governance that pushes for
pharmaceutical system transparency and accountability? The United States ranks the 25 th
country in the Corruption Perceptions Index by Transparency International with a score of 67
out of 100. Annually across the globe, there are 140,000 child deaths that can be attributed to
corruption. The U.N. has established Sustainable Development Goals (SDGs) that support
abolishing corruption, reducing bribes in all ways, promote healthy lives and wellbeing for all,
and support fair and civil societies. There is notably a lack of research on health sector
corruption to initiate reform to reach the SDGs. To meet the needs of the public, we must
gather more documentation on corruption, the effects of corruption in all dimensions,
techniques identified that show results, and push good governance to provide transparency
and accountability.
The communities in the United States rely on good governance to end health sector
corruption and fulfill their duties of office to protect the public. They are relying on the health
sector to provide medicine and perform services in an efficient, purposeful, and ethical manner.
The impacts on health, wellbeing, and communities in the United States need reform and
eroding trust in the sector cannot be ignored. The Sustainable Development Goals from the
United Nations require effective anti-corruption techniques that uphold the SDGs in the United
States.
Significance of the Study
Without empirical evidence on pharmaceutical system misconduct, the outlined
Sustainability Development Goals by the United Nations cannot be achieved. The complexity of
the system has become a wicked problem that seems unsolvable, but the initial step is data
collection. After the data is collected and published, awareness on the issue will gain
momentum that could pave the way for further research and education throughout the United
States. Ultimately, efficient anti-corruption techniques will become established and
implemented through policy reform to achieve results.
Research Aim
To document and gather evidence on health sector misconduct within the United States. The
following research objectives will facilitate this achievement of this aim:
1. Complete nationwide participant interviews and collect “Release of
Information’s” by March 2023.
2. Request documents from all medical and financial facilities by April 2023.
3. Analyze and categorize each participant’s statements on corruption by June
2024.
 4. Compute findings and submit report for peer review by November 2024.
5. Submit peer reviewed report for publishing in a medical journal by February
2025.

Literature Review
Corruption in the health sector can be viewed as something that either does not exist or
should not be discussed. Unfortunately, the impact of pharmaceutical corruption should not be
overlooked or hidden any longer. This corruption takes place on a national and global scale,
ranging from minor instances to grand state-level schemes. The consequences can be short-
term financial burdens to long-term with grave health and economic outcomes. As citizens, we
expect our duly public officials to represent the best interest of the public, particularly when it
impacts the health, wellbeing, and community of society. The widespread corruption of the
health sector is a complexity that has become a wicked problem but can still be solvable.
Corruption is well known on a global scale in various industries but hidden beneath the
commonly researched topics is an industry ripe with corruption. This type of corruption can be
deeply entrenched all across the globe; yet, the information is not readily available and can be
perceived to be an emotionally charged subject. Given that public officials often purchase
services, goods and work in the health sector for the public procurement, this system should be
sound and free of corruption for public interests (Kohler, 2020). Corruption can be hard to
define and even harder to document. Corruption can be defined as “the abuse of entrusted
power for private gain” (Paschke, 2018). Although the definition of corruption does not include
illegality, the act of misaligning from an official’s purpose to provide protection to the public
should be included (Fotaki, 2020). Even then, humanity has inalienable rights to receive health
care in a time of need. My own perspective is that the health system should have minimal
corruption and unethical behavior, despite capitalism, given the nature of the sector. The core
purpose of the health field is to care for others. With the existence of corruption in the
pharmaceutical sector, the core purpose becomes diminished, and consequences will arise.
Without proper empirical research, evidence of corruption, greater awareness, anti-corruption
measures and education, and good governance, the problem of corruption in the health sector
can grow.
What is Corruption?
The corruption found in the health sector is systemic corruption. Systemic corruption
can be well hidden, complex, hard to capture evidence, and can even be legal. The examples of
corruption can be misconduct and fraud involving payments for healthcare goods and services
that are not rendered; bribery, kickbacks, and unauthorized bribes to health workers and
officials; conspiracy and competition rigging in pharmaceutical procurement and contracts;
evasion, misappropriation, and stealing of different health resources; harmful or skewed
decisions due to conflicts of interest in pharmaceutical transactions/relationships; and
misconduct in medical practice, education, and research (Mackey, 2016). It is thought that
corruption may be small or grand, acceptable or bad, and it can even be determined to be part
of life (Fotaki, 2019). Even though corruption can be entirely legal, the definition of corruption
should involve the perversion of core purposes that become misconstrued or damaged through
the guise of personal gain. Although the definitions of corruption may not all be the same, the
six core dimensions of corruption can be defined universally with these key factors: (Gaitonde,
2016).
• The misconduct infringes on civil liberties of people or groups.
• The misconduct can reward the abuser, their family or friends, and an organization.
• Can be committed by individuals in the public or private positions of influence.
• A role of power or authority can be delegated either to traditional government
structures or to social/cultural systems.
• The misconduct can be directly or indirectly committed.
• The rewards can be monetary, material, or favors.
Factors for Corruption
The health sector can generate big business since everyone will rely on the health sector
at some point in their lives. According to the World Bank, “the healthcare sector is one of the
fastest and largest segments of the global economy, accounting for nearly 10% of the
worldwide gross domestic product (GDP)” (Mackey, 2016). Foreshadowing conditions can take
place prior to corruption as these observations have been made. These factors are inclinations
to make a profit, a general lack of obligation, and people with discretionary powers (Kohler,
2020). The health sector is complex, requires various levels of expertise, with large amounts of
money involved, making it a “honey pot” for corruption (Kohler, 2019).
Health Impacts
Health sector corruption can have vast consequences to U.S. citizens and people across
the globe. These consequences can negatively affect the health, social, and economical
outcomes of individuals, families, communities, nations, and the globe. Health system
corruption leads to reduced performance, capability, and integrity of healthcare which impacts
individual health and developments (Gaitonde, 2016). In contrast with other types of corruption
in conventional economic sectors such as power, extractive manufacturing, banking and
construction, pharmaceutical sector corruption is highly problematic in that it poses a "dual
burden" of reducing both economic and human growth while at the same time jeopardizing
patients and the welfare of the public (Mackey, 2016). It has been documented that when a
country has better control over corruption, “longer life expectancy, a lower infant mortality
rate, and a lower under-five mortality rate for citizens” can be anticipated (Gaitonde, 2016).
The plague of corruption prevents access to universal global health care due to costing over
US$500 billion annually (Transparency, 2019). It is estimated by the Federal Bureau of
Investigation (FBI) that 35 to 117 billion is lost every year to overpayments from Medicaid and
Medicare budgets (Gaitonde, 2016). Lives are also lost due to corruption. “A 2011 study
estimating that about 140,000 child deaths annually could be attributed to corruption”
(Hutchinson, 2019). Additionally, health sector corruption causes financial losses leading to
unequal distributions of money, preventing innovations and improvement in health services,
and increases the bill to receive care which impacts the economically challenged the hardest
(Gaitonde, 2016). A patient that is in a compromised state in a hospital setting or doctor’s office
can be taken advantage or not fully aware of their rights. This is another vulnerability in the
system that allows corruption to take place in the health sector that should be immediately
reformed for a civil society.
Lack of Trust
Social media, conspiracy or lack of trust, and global outbreaks are hot topics with full
current awareness. The current outbreak with declination of the public following health orders
warrants the analyzation of the weakening of trust in public officials, healthcare professionals,
and CDC recommendations. Corruption in the health sector leads to “weakening either the
public’s trust in that institution or the institution’s inherent trustworthiness” (Fotaki, 2020).
Society begins to take notice of the negative outcomes from health sector corruption and
begins to ask questions, lose trust, and seek reform. This can take place on social media with
online communities seeking guidance for health questions that were not resolved or ignored
with medical professionals. Other instances of public distrust in the pharmaceutical industry
can be observed on social media outlets as the public discusses confusion on health orders
from officials, corruption of the health sector, and financial gain for the health industry. The
pharmaceutical industry and public officials should consider that corruption “undermines the
trust that underpins effective, equitable, and responsive healthcare” (Hutchinson, 2019) and
that any backlash during the outbreak could be a consequence to lack of accountability and
transparency.
Anti-Corruption, Transparency, and Accountability
The United Nations has established Sustainable Development Goals (SDG) that include
abolishing corruption. SDG 3 is to “ensure healthy lives and promote well-being for all at all
ages” (United Nations, 2018). SDG 16 to “promote just, peaceful, and inclusive societies” with a
sub-target to “substantially reduce corruption and bribery in all their forms” (United Nations,
2018). An undeniable solution to combat corruption in the health sector is for good governance
to uphold transparency and accountability in its framework. To have a civil society that upholds
human rights for good health, well-being and community would require good governance to
provide accountability to the health industry. Transparency would illuminate areas for concern
and would fulfill trust into the system that it is being conducted as designed and core purposes
are fulfilled. Transparency involves the public to receive information and understand it so that
the entire pharmaceutical system can be held accountable. With the public holding the health
industry accountable, greater awareness to stakeholders on the importance of accountability,
beneficial change to the health system in the functionality of disclosing information to the
public, and more efficient pharmaceutical access would improve society for the better (Paschke,
2018). In a United States report on corruption in the health sector, it was found that an
independent agency worked to investigate corruption, and where it led to convictions, vast
sums of money were obtained, and the government’s money was potentially saved in the
process (Gaitonde, 2016). There is a need for more evidence on anti-corruption measures and
the impact on reducing corruption in the health sector.
Methodology
Survey Instruments
A selection of 500 American born citizens between the ages of eighteen and seventy-five
will be chosen based on their role in pharmaceutical sector corruption through a contract
partnership with the National Opinion Research Center (NORC) at Chicago University. To
reduce the impact of regional burdens, we will pick one hundred people from each of the five
regions of the United States. Based on the parameters mentioned below, the sample size will
be further subdivided.

1.) Fifty individuals that were patients who experienced corruption in the health sector.
2.) Fifty Individuals in the medical field who witnessed or participated in corruption in the
health sector.

Using this selection criteria, the NORC will allocate auditors to communities that meet the
requirements and search out interested candidates by using a pre-selected list of interview
questions that include the following questions.

For patients:
1.) Were the victim’s civil liberties infringed upon?
2.) Did the victim have negative impacts on their health, wellbeing or community?
3.) Has the victim's emotional and physical health been bad, average, or excellent in the
last year?
4.) Did the corruption take place within the past year?
5.) Would the participant sign a Release of Information granting us access to HIPPA-
protected medical records? (Assuring, by informed consent forms, that all material is
kept secret and deleted until computed.)
6.) If the participant can share their income tax returns. (Assuring, by informed consent
forms, that all details will be kept secret and deleted until it has been computed.)
For medical field workers:
1.) Did the abuser infringe on civil liberties of people or groups?
2.) Did the abuser receive a reward or for their family, friends, and organization?
3.) Was the reward monetary, material, or favors?
4.) Did the corruption take place within the past year?
5.) Would the participant sign a Release of Information granting us access to HIPPA-
protected medical records? (Assuring, by informed consent forms, that all material is
kept secret and deleted until computed.)
6.) If the participant can share their income tax returns. (Assuring, by informed consent
forms, that all details will be kept secret and deleted until it has been computed.)
Individuals will be chosen to proceed with the sample based on their responses, or they
will be discarded from the survey. Individuals must meet the following requirements in order to
be chosen:

1.) Fit within one of the categories listed above.

2.) Have witnessed, experienced, or participated in health sector corruption within the
past year.
3.) Be willing to disclose medical and financial information.

Selected Candidates
Selected candidates will be given informed consent forms, which will be reviewed by the
University of North Dakota's Institutional Review Board, through which they will be informed
of their rights, the study's purpose, the procedures to be followed, and the benefits and
drawbacks of participating. Participants will be informed in the consent form that all details
will be concealed and deleted until the process is completed. If participation is limited, a
cash reward of $250.00 per participant could be available.

Ethical Concerns
To maintain anonymity, each individual will be allocated a participant ID, and their
medical and financial details will be ciphered to that ID number as an identifier, with any
sensitive identifying information redacted from further study. Both objectives, plans, quality
management, project budget, and communication will be monitored by Marc D. Basson,
M.D., Ph.D., M.B.A., F.A.C.S. Senior Associate Dean of Medicine and Research at the
University of North Dakota.

Data Analysis and Presentation of Findings

When the data has been obtained, it will be assembled into a graph and evaluated and
recorded by the principal investigator and a statistician.
 1.) Types of corruption.
2.) Health impacts, lack of trust, and other negative consequences.
3.) Similarities in types of corruption experienced, witnessed, or participated in among
participants.
4.) Incentives received from corruption.
5.) Loopholes, lack of transparency, and accountability identified.
6.) Socioeconomic status of victims and abusers.
7.) Reduction in performance, capabilities, and integrity of health organization identified.
8.) Factors for the misconduct.
9.) Direct or indirect misconduct.

Following completion of the data analysis, all results will be compiled into a research
study, which will be submitted for peer review. If the peer review is favorable, the study will
be submitted for release in one or more medical journals.

Schedule
Deliverables: Mar Apr Jun Nov Feb
2023 2023 2024 2024 2025
Complete nationwide participant interviews and
collect “Release of Information’s”
Request documents from all medical and financial
facilities
Analyze and categorize each participant’s health
impacts
Compute findings and submit report for peer
review
Submit peer reviewed report for publishing in
medical journal

Budget
Expenditures Quantity Cost Total
Expense
Cost
“RedCap” Data tracking Software One-time fee for a $5000.00 $5000.00
three-year program.
 National Opinion Research Center One Contract $100,000 $100,000.00
Contract spanning 1.5 years

Project Director Salary Yearly X 3 $60,000 $180,000.00

Project Manager Salary Yearly X 3 $45,000 $135,000.00

Statistician Salary Yearly X 2 $52,500 $105,000.00

Fringe Benefits 3 years X 3 $10,000 $30,000.00

Participant Incentives X 500 participants $250.00 $125,000.00

Supplies (Paper, envelopes, ink, As needed $10,000 $10,000.00

Postage)
Travel (Flights, Hotels, Rental Cars, per As needed $10,000 $10,000.00
diem)
Total: $700.000.00

Communication Plan
Participants will also receive a personalized letter from the Principal Investigator detailing why I
am undertaking this research, the relevance of the study, and thanking them for their involvement, in
addition to the consent forms. Participants will then be notified that they will be receiving an online
questionnaire created and sent by survey monkey, in which they will be asked for their views on health
sector corruption in the United States and what improvements they would like to see.
 References

Fotaki M. Why We Must Talk About Institutional Corruption to Understand Wrongdoing

in the Health Sector Comment on "We Need to Talk About Corruption in Health
Systems". Int J Health Policy Manag. 2020;9(5):206-208. Published 2020 May 1.
doi:10.15171/ijhpm.2019.103
Gaitonde R, Oxman AD, Okebukola PO, Rada G. Interventions to reduce corruption in
the health sector.Cochrane Database Syst Rev. 2016;(8):CD008856. Published 2016 Aug
16. doi:10.1002/14651858.CD008856.pub2
Hutchinson E, Balabanova D, McKee M. We need to talk about corruption in health
systems. Int J Health Policy Manag. 2019;8(4):191–194.
doi:10.15171/ijhpm.2018.123
The Ignored Pandemic. Transparency International. 2019.
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health systems: Comment on “We need to talk about corruption in health systems.” Int
J Health Policy Manag. 2019;8(9):563–569.
doi:10.15171/ijhpm.2019.48
Kohler JC, Dimancesco D. The risk of corruption in public pharmaceutical
procurement: how anti-corruption, transparency and accountability measures may
reduce this risk. Glob Health Action. 2020;13(sup1):1694745.
doi:10.1080/16549716.2019.1694745
Mackey, T.K., Kohler, J.C., Savedoff, W.D. et al. The disease of corruption: views on
how to fight corruption to advance 21st century global health goals. BMC Med 14, 149
(2016). https://doi.org/10.1186/s12916-016-0696-1

Paschke A, Dimancesco D, Vian T, Kohler JC, Forte G. Increasing transparency and

accountability in national pharmaceutical systems. Bull World Health Organ.
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doi:10.2471/BLT.17.20651
 References
Sustainable Development Knowledge Platform Sustainable Development Goal 3.
United Nations. 2018.
https://sustainabledevelopment.un.org/sdg3
Sustainable Development Knowledge Platform Sustainable Development Goal 16.
United Nations. 2018.
https://sdgs.un.org/goals/goal16