July 2018

Nahitun Naher1, Muhammad Shaikh Hassan2 Roksana Hoque3, Nadia Alamgir4

Syed Masud Ahmed5

1 nahitun.naher@bracu.ac.bd2 shaikh.fuad@bracu.ac.bd

3 roksana.hoque@bracu.ac.bd4 nishrat@bracu.ac.bd

5 ahmed.sm@bracu.ac.bd

Centre of Excellence for Health Systems & Universal Health CoverageBRAC James P. Grant School of Public Health, BRAC University

Irregularities, informal practices, and the motivation of frontline healthcare

providers in Bangladesh: current scenario and future perspectives towards achieving

universal health coverage by 2030

Working Paper 004

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ContentsAcknowledgments 3

ExecutiveSummary 4 Background 4 Keyfindings 4 Recommendations 5

Acronyms 6

1. Introduction 7 1.1. Background 7 1.2. Relevanceandscopeofthereview 8 1.3. Methodology 8

2. Context 10 2.1. Adefinitionofcorruption 10 2.2. Formsandpracticesofcorruptionwithinthehealthsector 10 2.3. Whythehealthsectorispronetocorruption 11 2.4. Conditionsthatincentivisecorruption 11 2.5. Theimpactofcorruption 13

3. Health-sectorcorruptioninBangladesh 14 3.1. Anti-corruptionpolicyandlegislationinBangladesh 17 3.2. Anti-corruptioninitiativesbytheGovernmentofBangladesh 17 3.3. Organisationsthatfacilitateanti-corruptionactivitiesinBangladesh 22

4. Conclusionandrecommendations 23 Recommendationsfortheshortterm(one-twoyears): 23 Recommendationsforthelongterm(beyondtwoyears): 24

5. References 25

FiguresFigure1:PRISMAflowdiagramforselectionofarticles 9 Figure2:ReasonsforpayingbribesinBangladesh'shealthsector 14 Figure3:Servicesforwhichbribeswerepaid 15

TablesTable1:Commoncorruptpracticesinthehealthsector 11 Table2:Factorscontributingtohealth-sectorcorruption 11 Table3:Organisationstaskedwithfacilitatinganti-corruptionactivitiesinBangladesh 22

BoxesBox1:Commonconditionsthatincentivisecorruption 11 Box2:Impactsofcorruption 13 Box3:CausesofcorruptioninBangladesh 14 Box4:Existinglegislationandpoliciesthataddresshealth-systemcorruptioninBangladesh 17

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AcknowledgmentsThisreviewentitled“Corruption,ProviderPractice,Motivation&HealthsystemPerformanceinBangladesh,”formspartofalargerstudyfundedbyUKaidfromtheUKGovernment,andisconductedbytheCentreofExcellenceforHealthSystemsandUniversalHealthCoverage(CoE-UHC),BRACJamesPGrantSchoolofPublicHealth(BRACJPGSPH),BRACUniversityinpartnershipwithSOASUniversityofLondonandtheLondonSchoolofHygiene&TropicalMedicine(LSHTM),UK.

TheCoE-UHCacknowledgesthefollowingpersonsfortheirvaluablesupportandinsightinpreparingthereport:Dr.SabinaFaizRashid,Dean&Professor,BRACJamesPGrantSchoolofPublicHealth,BRACUniversity,ProfMushtaqKhan,SOASUniversityofLondon,DrDinaBalabanova&DrEleanorHutchinson,LSHTM.

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ExecutiveSummaryBackground

Globally,thehealthsectorfacesrelativelyhighrisksofcorruptionforvariousreasons,includingtheuncertaintyofillness,amultiplicityofactors,thebroadrangeofservicesthatitencompassesandasymmetryofinformation.Corruptioninthehealthsectoroftenendsupcostinglives,orresultsinimpoverishmentwhichimpactsdisproportionatelyonpoorandmarginalisedpopulations.Italsoleadstoerosionoftrustinthehealthsystem,whichisaprerequisiteforitseffectiveandefficientfunctioning.

Arisingtrendincorruptionisnoticeableinthelow-andmiddle-incomecountriesofsouthandsouth-eastAsia,includingBangladesh.Irregularpracticesincludeabsenteeism,informalpaymentsandbribes,embezzlement,andpoorservicedeliveryandregulatorypractices.Thepluralistic,largelyinformalnatureofthehealthsystemservestomakethescenarioworse.Forthemostpart,conventional,top-down‘carrot-and-stick’methodshavebeenfoundtobelargelyineffectiveincurbingsuchcorruptioninthesecountries.

Thereisthusaneedtore-thinkandre-visitthediscoursearoundcorruptioninthehealthsector,withcallsforabottom-upapproach.However,inordertodesignaneffectivestrategy,detailedinformationisfirstneededregardingthedifferentformsofhealth-sectorcorruption,alongsideevidenceonwhathasworkedpreviouslytocombatirregularpracticesandhow.ThissystematicreviewattemptstofillthisknowledgegapwithrespecttoBangladesh,bydescribingtheliteratureonthenature,extentandeffectofcorruptioninhealthserviceprovision,aswellasrelevantnationalpoliciesandremedialefforts.

Keyfindings• Therehasbeenarisingtrendinirregularitiesandinformalpracticesinthehealth

sectorinBangladesh,bothinthepublicandprivatesectors,whichisevidentfromtheCorruptionPerceptionIndex(CPI).

• Commontypesofcorruptioninclude:taking‘donations’duringadmissiontoprivatemedicalcolleges;theforcedpaymentofinformalfeesbyhealthworkerstosecurepublic-sectorjobs;non-merit-basedhiringpractices;stock-outofdrugs;theuseofpublic-sectormedicalequipmentinprivatepractices;preferentialcontractswithpharmaceuticalcompaniesandlaboratories;tradingofhumanorgans;absenteeismandprivatepracticeduringofficehours;andpaymentofbribesforlicensing,registrationandcertification.

• Divisionswithinthesectorthataresusceptibletocorruptioninclude:constructionofhealthinfrastructure,especiallyhospitalsandclinics;procurementofmedicines,medicalproductsandinstruments;licensingofpharmacies(medicineshops)andapprovalofprivatehealthcarefacilities.Peoplealsoexperiencecorruptionwhileseekingandreceivinghealthcareservicesduetolackofinformation,andpoorresponsivenessofthesystem.

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• Theprocessofcorruptionstartsfromtherecruitmentofprospectivestudentsineducationalinstitutions,andcontinuesthroughoutprofessionalpostings,transfers,trainingandpromotion.

• Theimpactofcorruptionislarge,particularlyonaccesstohealthcareforpoorandvulnerablegroups.Itnegativelyaffectsresourceuse;thecostsoftreatment,medicinesandequipment;qualityofcareandtreatmentoutcomes;andtrustinthehealthsystemandserviceproviders.

• Certainconditionsincentivisecorruption,includingthehighcostofmedicaleducation,poorsalariesandcareerprospects,lackoftransparencyandaccountabilityinhealth-sectorexpenditure,absenceofperformanceincentives,poorworkenvironmentswithgenderinequalitiesandpoliticalclientelism.

• Theinfluenceoftherulinggovernmentandpoliticalpowermakeslawenforcementandanti-corruptionagenciesweakintheregionwithanti-corruptionagenciesunabletoactinmostofthesecountriesduetopoliticalpressure,includinginBangladesh.

• Micro-level,novelinitiativesarecontributingtoeffortstocombathealth-sectorirregularitiesinBangladesh,particularlyatfacilitylevel.Theseincludecommunity-basedmonitoring;publicdialogue,campaignsandtheatre;communitymobilisationaroundcomplaintsandthereportingofcomplaintsinthemedia;patientwelfarecommittees;schoolprogrammes;andcommunityscorecardsandhealthcommittees.Someexamplesincludethemobilisationandactiveinvolvementofcommunityvolunteers;adviceandinformation(AI)deskstoprovideinformationandadviceonkeypublicservices;demand-sidefinancing(‘voucherschemes’);andimprovedservicedeliverythroughthemobilisationoflocalcommunitiesandresources,andpublichearingsforcomplaints.

Recommendations

Basedupontheabovefindings,thispaperputsforwardrecommendationsfortheshortterm(aroundonetotwoyears)forawareness-buildingandhealthliteracyofpatientsandcare-givers,andholdingserviceprovidersandfacilitiesaccountabletolocalcommunitiesthroughcitizenengagement.Inthelongterm,recommendationsaremadeforinstitutionalisingtheprocessofcitizenengagementinthesupervisionandmonitoringofservicedeliveryatvariouslevels,facilitatingtheexchangeofmanagementinformationbetweenlocalandcentralauthoritiestoimproveservicedelivery,andincludingthesubjectofirregularpracticesandrelevantethicalcodesinthemedicalcurriculumsothathealthcareprofessionalsareawareof–andabletoavoidandreport–corruptionwithinthesector.Regulatoryapparatusalsoneedtobestrengthened,bothintermsofhumanresourcesandlogistics,toeffectivelyimprovetheimplementationofexistinglegislation.

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AcronymsACE Anti-CorruptionEvidence

AI Adviceandinformation

BDT BangladeshiTaka

BMDC BangladeshMedicalandDentalCouncil

BRACJPGSPH BRACJamesP.GrantSchoolofPublicHealth

BMA BangladeshMedicalAssociation

CCC CommitteeofConcernedCitizens

CoE-UHC CenterofExcellenceforUniversalHealthCoverage

CPI CorruptionPerceptionsIndex

CSO CivilSocietyOrganisation

HMC HospitalManagementCommittee

LMIC Low-andmiddle-incomecountry

LSHTM LondonSchoolofHygieneandTropicalMedicine

MoHFW MinistryofHealthandFamilyWelfare

NGO Non-governmentalorganisation

NIS NationalIntegrityStrategy

PRISMA PreferredReportingItemsforSystematicReviewsandMeta-Analysis

SHO Self-helporganisation

SOAS SchoolofOrientalandAfricanStudies

TI TransparencyInternational

TIB TransparencyInternationalBangladesh

UNCAC UnitedNationsConventionAgainstCorruption

WHO WorldHealthOrganization

WHRAP Women’sHealthandRightsAdvocacyPartnership

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1. Introduction1.1. Background

Corruptionwithinthehealthsectorcanhavesevereconsequencesforaccessto,andthequality,effectivenessandequityof,healthcareservices(Muhondwaetal.,2010).Italsohampersthesuccessfulimplementationofinterventionstoimprovehealthservices.Health-sectorspendingoftenrepresentsalargeshareofgovernmentexpenditure,howeverthehealthsectorissusceptibletocorruptionbecauseofasymmetriesofinformation,uncertaintyastowhenandhowresourcesneedtobeused,andcomplexitiesaroundaccountabilitymechanisms(AzfarandGurgur,2008).Thiscanbeparticularlyevidentatthemicro-orfacilityandpatientlevelswhereprovidersoftenhavethefreedomtoshapewhatcareisavailabletothepopulation.Thebehaviourofserviceprovidersiscentraltothisdebate,astheyoperateatthefrontlineofservicedelivery.Understandingthedecision-makingprocessandmotivationstoengageincorruptactivitiesisessentialtocombatcorruption,butasignificantknowledgegapexiststhatlimitsprogress.

In2012,TransparencyInternational(TI)rankedBangladeshasthe13thmostcorruptcountrygloballyusingtheCorruptionPerceptionsIndex(CPI)(TI,2012).In2015,theNationalHouseholdSurveyonCorruptioninServiceSectorsofBangladeshestimatedtheannualcostofbribery(unauthorised/informalpayments)tobeBangladeshiTaka(BDT)8,822crore1(US$1.1+billion),equalto0.6%ofgrossdomesticproduct(GDP)and3.7%ofthenationalbudget(TIB,2016).Ofthis,health-sectorbribesaccountedforBDT57crore(US$7+million).Ofthehouseholdsseekinghealthcareservices,37.5%facedirregularitiesandcorruptioninoneformoranother,withtheaveragecostofinformalpaymentsamountingtoBDT196(ibid.).Thetopthreeservicesforwhichinformalpaymentsweremadeincludetrolley/wheelchairservices(54%),wound-dressingservices(26%),andsurgery(16.5%).Thereasonsgivenformakinginformalpaymentsinclude:wouldn’treceiveservicewithoutextrapayment(44%),didn’tknowthefeeamount(40%),toreceiveservicesontime(24%),toreceiveproperservices(23%),andtoavoid‘hassle’(11%).Thesamesurveyalsorevealedthataround14%ofthehouseholdsfacedirregularitiesinobtainingmedicines(ibid.).

Fortherecruitment,transferandpromotionofthehealthworkforceunderBangladesh’sMinistryofHealthandFamilyWelfare,thefollowingannualcoststothecountrywerereportedinasurveybyTransparencyInternationalBangladesh(TIB,2014a):appointmentofadoctoronanadhocbasis,BDT3-5lakh;2transferofhealthadministrativeofficialstoDhakaorareasnearby,BDT5-10lakh;transferofdoctors,BDT1-2lakh;promotionofdoctors,BDT5-10lakh.

11crore=10millionBDT.21lakh=100,000BDT.

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Thereasonsprovidersengageincorruptionandpoorpracticesaremultifaceted.Onemotivationistomaximiseprivategaininsettingscharacterisedbypoorsalaries,scarceresourcesandlimitedcareerchoices(SavedoffandHussmann,2006).Otherreasonsrelatetoineffectivemanagement,poorgovernance,andmistrustbetweenprovidersandmanagers.Insuchsituations,providerbehaviourisa(oftenrational)responsetoregulatoryfailuresandagenerallackoflawandorderinthebroaderhealthsystem(ECORYSandEHFCN,2013).Inaddition,socialnorms,traditionsandculturallydeterminedbehaviourshapetheroleoftheproviderswhoareveryofteninreciprocalrelationshipswithothermembersofthecommunity(SavedoffandHussmann,2006).

Thefocusofthissystematicreviewisonthetypesandforms,andtheinstitutional,organisationalandpoliticalcausesofcorruptioninordertoidentifyknowledgegapsthatarehamperinganti-corruptioneffortsinthehealthsectorinBangladesh.

1.2. Relevanceandscopeofthereview

Irregularitiesandinformalpractices(‘corruption’)inthehealthsectorunderminetheequitabledeliveryofqualityhealthcareservices.Therefore,itisimportanttoidentifyandclosepotentialloopholeswithinhealthsystemstoimproveperformance.ThisreviewidentifiescommonconcernsinBangladesh’shealthsector,andcriticallyanalysesevidenceforthecategoriesoffrontlinehealthcareprovidersandfacilitieswheremostdetrimentalirregularitiesoccur.

1.3. Methodology

Weusedasystematicapproachtoreviewtheliteratureonhealth-sectorcorruptionandrelevantnationalpolicies.Adetailedprotocoloutliningtheobjectives,keyquestions,datasources,keysearchterms,andinclusioncriteriawasdeveloped.

Inbrief,allarticlespublishedinEnglishfromJanuary2007toAugust2017onhealth-sectorcorruptioninthelow-andmiddle-incomecountries(LMICs)ofsouthandsouth-eastAsiawereincludedforinitialscrutinyusingPubMed,SCOPUSandGoogleScholar,inadditiontorelevantgreymaterialsonpolicies,transparencyandaccountabilityfromgovernmentwebsitesandhandsearchesofsomerelevantjournals.WefollowedthePreferredReportingItemsforSystematicReviewsandMeta-Analysis(PRISMA)methodforscreeningarticles(seeFigure1).Searchtermsweredevelopedcollaborativelybetweenthestudypartners,andincludedthefollowingkeywords:corruption,informalpayment,rent-seekingbehaviours,bribery,anti-corruptionstrategyand/orbehaviour,governance/goodgovernanceand/oraccountabilityinfrontlinehealthworkers/managers,serviceprovidersofhealthfacilities/system,hospitals.Theliteraturesearchwasconductedbetween14Septemberand15October2017,andcitationsforthejournalarticlesweremanagedusingEndNoteX7.7.1software.Tworeviewersidentifiedarticlesindependentlyfromelectronicdatabasesandgreyliterature.

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Afterremovingduplicatearticlesandreviewingthesearchresultsforcertainexclusioncriteria,wescreened5,970articlesbytitleandabstract.Fourreviewers(includingtheprincipalinvestigator)discussedandcheckedarticlesforeligibility.Intotal,30papersoncorruptionand40papersongovernance/accountabilitycloselyrelatedtothestudyobjectiveswereselectedfordataextractionandsynthesis.

Figure1:PRISMAflowdiagramforselectionofarticles

Includ

ed

Eligibility

Screen

ing

Iden

tification

Duplicatecitationsremoved(n=8,242)

Eligiblearticlesoncorruptionandgovernance(n=83)

Recordsafterduplicatesremoved(n=21,873)

Recordsexcluded,(n=15,903)• Timeframe:BeforeJanuary2007• Subject:Notrelevanttohealthsector• Notpeerreviewedjournal• Fulltextnotavailable• Language:notinEnglish

Full-textarticlesscreenedbytitleandabstract(n=5,970)

Full-textarticlesexcludedthatarenotfocusedoncorruptionandgovernance(n=4,498)ArticlesexcludedthatarepublishedregardingcountriesotherthanLMICinSouth/South-EastAsia(n=1,389)

CitationidentifiedthroughPubMed,ScopusandGoogle

Scholar(n=30,115)

IncludedarticlesforGovernance&accountability(n=40)

IncludedarticlesforCorruption(n=30)

Notenoughdata(n=13)

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2. Context2.1. Adefinitionofcorruption

Corruptionisdefinedastheuseofpublicpropertyandpowerinagivenpositionforpersonalgainandbenefit(Vian,2008),andthemisuseorabuseofpublicofficeorpropertyforprivategain(FactorandKang,2015;Hussetal.,2011).TIexplainsthatprivategainmaybeeitheractualorpotential(toberealisedinthefuture),andfinancialorevenpolitical(TI,2015).Inthehealthsector,corruptbehaviourincludesmisinformationtopatients,unlawfulactivities,excessivemedicaltestsandcosts,etc.Corruptioncanalsobedefinedasabuseoftrustandintentionalviolationofduty(Mostertetal.,2012).Corruptionwithinthehealthsectorcanthreatenpeople’slives(TI,2015),andpredominantlyaffectsmarginalisedpeople.

2.2. Formsandpracticesofcorruptionwithinthehealthsector

Therearemanyformsofcorruptioninthehealthsector,frominformalpaymentsforconsultations,‘jumpingthequeue’fortreatmentandbribestoobtainmedicine.Whilenegligencehappenswhenamedicalpractitionerfailstoprovideanexpectedlevelofcarewhichresultsininjuryordeathofapatient(Mahajan,2010),nepotismistheunfairuseofpowertofavoursomeonefinanciallyorintheprovisionoftreatmentorotherservices.DescriptionsofnegligenceandnepotismarecommonintheliteratureonthehealthsectorinBangladesh(Chattopdhyay,2013;Knox,2009).

Corruptioncanoccuracrossdifferenttiersofthehealthsystem,throughoutprocurement,thepharmaceuticalsandmedicalsupplychain,andhealthsystemdelivery.Worldwide,17%ofpeoplepayabribewhenseekingmedicalcareinhospitals(Mackeyetal.,2016).Pettybribes,absenteeism,theembezzlementoffundsand‘kickbacks’(informalcommission)arethemostcommonformsofcorruptionglobally.Otherexamplesincludetheforcedpaymentoffeesfromhealthworkerstosecurethemselvespublic-sectorjobs,useofghostworkerstoobtainwagesandotherbenefits,frequent'stock-outs'ofdrugsandsupplies,andpatientspaying'underthetable'directlytoindividualserviceproviders(FactorandKang,2015).Theftanddiversionofresourcesarealsocommon(Demming,2017).Nepotism,non-merit-basedhiringpracticesandnon-compliancewithregulationsresultinpoorgovernance,whichoftenleadstocorruption.

Thepharmaceuticalindustrycompoundstheproblembybribingdoctorstoprescribetheirbrands,whilesomephysicianshavesetuptheirownfoundationswithdonationsfrompharmaceuticalcompaniesandhaveacceptedgiftsforthemselvesandtheirfamilies(Sachan,2013).Somepracticesarestraightforwardlycorrupt,suchassellingofficialpositions,kickbacksandtheft.However,otherpracticesoperateonthemarginsbetweenprivategainandmismanagementandinefficiency(Lewis,2006).Whilesomeoftheseinformalpaymentsareconsidered'fair'wherepublic-sectorwagesarelow,sociallythisis'corrupt'behaviour.Insuchcasesitisdifficulttodelineatebetweentheuseofregulatorypowerforthepublicgoodandrent-seekingbehaviour(Bloometal.,2011).

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Table1:Commoncorruptpracticesinthehealthsector

Area Practices

Administration,includingpayment,procurementanddrugs

• Nepotismandpatronage• Taking‘donations’duringmedicalcollegeadmission• Healthworkersforcedtopaytosecurepublic-sectorjobsandnon-merit-based

hiringpractices• Kickbacksintheconstructionofmedicalinfrastructureandtheprocurementof

medicalapparatus• ‘Stock-outs’ofdrugs• Useofpublicequipmentforprivateservicedelivery

Pharmaceuticalsanddiagnostics • Preferentialcontractswithpharmaceuticalcompaniesandlaboratories

Servicedelivery • Poorinteractionbetweenpatientsandproviders• ‘Underthetable’payments• Tradingofhumanorgans• Absenteeismandprivatepractice

Regulation • Bribesforlicensing,registrationandcertification

2.3. Whythehealthsectorispronetocorruption

Manyunderlyingfactorsmakethehealthsystempronetocorruption(seeTable2).

Table2:Factorscontributingtohealth-sectorcorruption

Factors Examples

Uncertaintyofillness Whowillfallillandwhen,treatmentoptionsandtheallocationofresources

Multiplicityofactors Providers,patients,suppliers,regulators

Multiplicityofservices Curative,preventive,immunisation,familyplanning

Informationasymmetry Amongdifferentstakeholdersofthesystem

Monopolyandauthority Autonomousauthoritytomakedecisionsversusmonopolieswithinservicesandsupplies

2.4. Conditionsthatincentivisecorruption

Box1:Commonconditionsthatincentivisecorruption

• Highcostsofmedicaleducation

• Poorsalaries,facilitiesandcareerprospects

• Lackofaccountability

• Absenceofperformanceincentivesintheworkplace

• Politicalpatronageandhighpayments(bribes)forrecruitment,promotionandtransfers

• Lackofcommunityownership

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Lackofeffectivepluralismandpoliticalwillaretheleadingfactorsinhealth-systemcorruption(Holvoetetal.,2013).IndevelopingcountrieslikeBangladesh,healthproviders’behavioursarenotlikethoseof'Weberianbureaucrats'withgoodsalariesandcareerprospects.Mostly,theirperformanceisinfluencedbyfinancialincentivesandpoliticalpatronage,whichleadstogovernmentsystemfailure(Bloometal.,2011).Lackofaccountabilityisoneofthemajorcausesofcorruption,whichisaggravatedbyinadequatemanagement,lackofoversight,poortrainingandabsenceofperformanceincentives(Mackeyetal.,2016).Typesofcorruptioncanbepredictedbyindicatorssuchastotalhouseholdincomepermonth,whereapatientlives,gender,andwhetherpaymentshavebeenmadeforprescriptionsorreferralstoprivateclinics(Knox,2009).Communitiesoftenperceiveoversightofhealthservicesasbeingtheresponsibilityofhealthmanagersorthegovernment,ratherthantheirownresponsibility(Lodensteinetal.,2016).Communitiesdon’tfeeltheownershiptoquestionorchallengeirregularitieswithinthesystemandtheyacceptirregularitiesasnaturalphenomena,andperceiveoversightofhealthservicesasbeingtheresponsibilityofhealthmanagersorthegovernment.

Corruptionisincentivisedatthebeginningofamedicalcareer.Whenstudentsareadmittedtoprivatemedicalcolleges,theyoftenhavetopaylarge‘donations’totheirundergraduateandpostgraduatecourses.Manyfamilieshavetosellland,mortgagetheirpropertyorseekcredittoaffordthesepayments.Moreover,itisexpensivetostudyingovernment-runmedicalcolleges,thereforehealthprofessionalshavelittlechoicebuttoearnextramoneythroughinformalmeans.Indeed,healthcareprovidersinpublichospitalsinLMICsreceivelowsalariescomparedwithotherpublic-sectorworkers(Berger,2014)–sometimesanaverageof10%less–whichisamajorincentiveforpeopletostartprivatepracticesandacceptinformalpayments(Mahajan,2010).

Manyyounghealthprofessionalsarepostedtoruralhealthcentres,butpost-graduateorhigherdegreespullthembacktocities.Staffshortagesinruralcentresnegativelyaffectthemotivationofremainingstaff,generatestressandincreasetheriskofmorestaffleaving(Hope,2015).Addedtothis,manygovernment-runhospitalslackfacilitiesforhealthworkers(especiallytransportation,accommodationandpropereducationfacilitiesfortheirchildren)aswellasadequatesecurity,particularlyforfemaleprofessionalsonnightduty,whichacttoincreaseabsenteeisminruralhealthcentresalso.

Directorsofdistricthospitalsaregivengreatautonomywithregardstotherecruitmentandpromotionofhealthcarestaff,whichcanincentivisethemtoacceptbribesforthetransferandpromotionofstaff.Weakornon-existentregulations,lackofaccountability,lowsalaries,limitedopportunitiesforpromotionandinadequatetrainingalsoincentivisecorruptbehaviour(ibid.).

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2.5. Theimpactofcorruption

Box2:Impactsofcorruption

• Pooruseofavailableresources

• Inequitableaccesstoandutilisationofhealthcareservices

• Increasedcostsoftreatmentandmedicines

• Lossoftrustbetweenproviders,patientsandotherstakeholders

• Inefficiencyamongstthelabourforce

Corruptioncancausenegativeoutcomeswithregardstodevelopmentalassistanceandtheachievementofglobalhealthobjectives(Demming,2017).Corruptionresultsinpoorresourceuseandlabour-forceinefficiencies,lossoftrustinpublicservicesandorganisationallegitimacy,reducedcompetition,andlackofmotivationamongsthealthworkers(seeTable4)(Hechanovaetal.,2014;Hussetal.,2011).Informalpayments,unnecessarytreatment,pricehikesandpooravailabilityofmedicinesultimatelyaffectbothpoorandwealthiercitizensandcreatebarrierstohealthservices(Demming,2017).

Corruptioncanincreasethecostoftreatmentifbribesarepaidinadditiontoofficialfees,whichactstoreducedemandforservicesandmaythereforeworsenhealthoutcomes(AzfarandGurgur,2008).Indeed,countriesthathaveahighincidenceofcorruptionhavebeenfoundtohavehigherinfantmortalityrates(Hope,2015).AccordingtoTI’sGlobalCorruptionBarometer2013,incountrieswherethepercentageofthepopulationwhopaidabribeinthepastyearwas60%ormore,theaveragematernalmortalityrateper100,000livebirthswas482–ninetimeshigherthanincountrieswherelessthan30%ofthepopulationpaidabribe.

Poorpeoplearedisproportionatelyharmedbycorruption,becausetheycannotaffordbribesorprivatealternatives.Furthermore,inadequateinformationservicescanbolstercorruptpracticessuchasunofficialpaymentsforhealthservices(Paredes-Solísetal.,2011)aswellastheexploitationofpatientswhoaremadetoundergounnecessarytestsonlytomakemoneyfortheprivatehealthsector.

Widespreadcorruptionandnepotismarepersistentchallengestogoodgovernancealso.Doctor-patientrelationshipsareerodedsothatpatientsnolongertrusttheirphysicians(ThappaandGupta,2014),andinsteadrelyonpharmacists,someofwhomalsodemonstratealackofethicsthroughthesaleofinappropriatedrugsandexcessivepricing(Berger,2014).Similarly,corruptioncancreatedistrustbetweengovernmentandhealthserviceusers(Demming,2017).Forexample,thepeopleofLiberiaperceivedtheirgovernmentascorrupt,andasaresulttheydisbelievedhealth-relatedinformationandearlywarningsofEbola(ibid.).

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3. Health-sectorcorruptioninBangladeshBox3:CausesofcorruptioninBangladesh

• Poorworkandlivingconditions

• Localpoliticalpressureandthreatstopersonalsafety

• Limitstohigherstudy,promotionandtransfersduetopoliticalpatronage

• Lackofsupervisionandmonitoringindifferenttiersofthehealthsystem

• Poorpatientdocumentation

• Lackofawarenessamongstcommunitiesaboutservicesavailable

TherateofcorruptioninBangladesh’shealthsectorwas40.2%in2012and37.5%in2015(TIB,2016).3Reasonsforthepaymentofbribesincludethatservicesareinaccessiblewithoutbribes(90.9%),lackofinformation(33.3%),theavoidanceofharassment(26.5%)andattemptstoinfluenceserviceproviders(4.4%)(seeFigure2).

Figure2:ReasonsforpayingbribesinBangladesh’shealthsector

Source:TIB(2016)

Amongallhealthserviceuserswhorespondedtothe2015nationalhouseholdsurvey,37.5%facedcorruptivebehaviour(includingbribery(16.7%),irregularitiesregardingmedicine(13.8%),andabsenteeismofdoctorsandnurses(4.8%)amongstotherpractices(TIB,2016)).AccordingtoTIB(2014a)andAndaleebetal.(2007),absenteeism,poorqualityservices,

3Measuredby%respondentstonationalhouseholdsurveyreportingthattheywerevictimsofcorruption.

90.90%

33.30%26.50%

4.40%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

Serviceinaccessible Unavailableinformaron Avoidingharrassement Influenceproviders

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irregularitiesingettingbedsandmedicines,thepresenceofmiddlemenluringpatientstoprivatehealthfacilities,andfinancialcorruptionamongstpatientsandhealthprofessionalsarepervasiveinBangladesh’shealthsystem.

HealthserviceprovisioninBangladeshisinfluencedbypartypolitics,corruptionwithintheMinistryofHealthandFamilyWelfare(MoHFW)andtheDirectorateofHealth,conditionsimposedbytheMinistryofEstablishmentandMinistryofFinance,andpurportedinterferencebydevelopmentpartners(Andaleebetal.,2007)–allofwhichhasanimpactonrecruitmentandpromotions,budgetaryplanningandprocurement.

Ithasbeenreportedthatthesalariesof379newlyrecruitedstaffnursesweredelayedduetofailurestopaybribesofBDT700eachtotheHospitalDiplomaNurseAssociation(TheKalerKantho,2017).Eventhen,thenurseshadtopaybribestoadministrativestafffortheirreleaseandtransferletters.Suchscenariosaffecthospitalstructureandsystemsofserviceprovision.FeniSadarHospitalhas250beds,andpositionsfor46doctorsandnineconsultants(TheDailyIttefaq,2016).Atpresent,24positionsarevacantandof21doctorsonlyfiveorsixofthemareworking.Thereare40positionsformedicaltechnologistswith33ofthemvacant,57positionsforcleanerswith41vacant,and15positionsforsecurityguardswithninevacant.Undersuchcircumstances,thehospitalisabouttoclose.Appointeddoctorsdonotcometothehospitalontime,andmostrecordtheirattendanceonlyandthenreturntotheirprivateclinics(ibid.).

AccordingtoBangladesh’snationalhouseholdsurveyfor2015(TIB,2016),acrossallsectors,58.1%ofhouseholdshavefacedcorruptionintheformofbribery.Onaverage,peoplepaidBDT196forhealthcareservices,withthehighestshareofhouseholds(38%)facingcorruptioninUpazilaHealthComplex,followedbymedicalcolleges(35.1%)anddistrictsadarhospitals(33.6%).

Figure3:Servicesforwhichbribeswerepaid

Source:TIB(2016)

53.70%

26%

14.90%11.90% 10.90%

7.40%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

Wheelchairservice Dressingservice MaternityService TicketPurchase DiagnosrcService BedAvailability

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AsourcefromChittagongMedicalCollegeHospitalreportedthatpregnantwomenwillnotbedischargediftheyareunabletopaya‘Baksheesh’(gratuity)(TheDailyJugantor,2017).Thispracticeiscompoundedbytheabsenceofpatientrecordsandinappropriatesystemsofdischarge(Andaleebetal.,2007),andresultsin41%ofpatientspayinganaverageofUS$2.11asanextra(illegal)consultationfeeforconsultingadoctorinapublicclinic.

Sometimes‘brokers’forcecaregiversandpatientstoadmitthemselvestoprivateclinicsfromgovernment-runhospitals.Forthis,brokersusedtoreceiveacommissionofBDT2,000perpatientadmitted,andBDT200forinvestigations/diagnostics(TheDailyKalerKanthoandDailyJugantor,2017).This‘commissionbusiness’isanothersignificantformofcorruptioninBangladesh’shealthsector,wherebydiagnosticcentresalsoreceivehugeamountsofmoneyfrompatients,ofwhich30-60%isgiventodoctors(TheBangladeshPratidin,2017).Ithasevenbeenreportedthatdoctorshaveprescribedmedicinewithoutanyclinicalreason,haveadmittedpatientstointensivecareunitsforlifesupportandhaveprescribedsurgeryinordertoearnmoneythroughunnecessaryout-of-pocketexpendituresbypatients(ibid.).Suchpracticesunderminetheethicsandmoralityofthemedicalprofessionandresultinmistrustbypatientsandserviceusers.DuetothehighcostsandpoorservicesinBangladesh,wealthierpatientsprefertogotohospitalsoverseasfortreatment,andconsiderthetravelandvisaprocessingcostsasinvestmentsinreturnforhigherqualityyetlessexpensivetreatment(Andaleebetal.,2007).

Asanotherformofcorruption,discriminationhasbeenobservedinthepromotionandopportunitiesforcontinuedstudiesbydoctorswithinpublicandprivatemedicalcollegehospitals.Doctorsarenotpromotedorpermittedtostudyunlesstheyarecommittedtoanypoliticalparty(TheDailyIttefaq,2017).Indeed,thesafetyofdoctorsissometimesthreatenedbylocalpoliticalinfluenceandpressure,andtheymaybeforcedtoissuefalsecertificatesfollowingharassmentbylocalpeople(ibid.).

Poorsupervisionandmonitoringacrossdifferenttiersofthehealthsystem,includinglackofaccountabilitytolocalauthorities,canpromotecorruptioninBangladesh.InRajnagarUpazilaHealthComplex,healthcareprovidersarenotsupervisedappropriatelybydistrictsupervisors,andaredisconnectedfromdistrict-levelmanagersintermsofdecision-makingandinformation-sharing(FaguetandAli,2009).TheyarealsodisconnectedfromelectedUnionParishadrepresentatives.Asaresult,thereisalackofawarenessabouthealthservices,highprevalenceofdisease,facilitiesthatareinpoorrepair,personnelwholacktraining,andabsenteeismratesof10%.

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3.1. Anti-corruptionpolicyandlegislationinBangladesh

Box4:Existinglegislationandpoliciesthataddresshealth-systemcorruptioninBangladesh

• TheMedicalandDentalCouncilAct1980

• TheMedicalPracticeandPrivateClinicsandLaboratories(Regulation)Ordinance1982

• BangladeshMedicalandDentalCouncil,CodeofMedicalEthics

• ThePublicProcurementAct2006

• WhistleBlowerProtectionAct2007

• TheRighttoInformationAct2009

• TheConsumerRightsProtectionAct,2009

Forfulldetailsofthesepolicies,seeappendix1.

TheUnitedNationsConventionAgainstCorruption(UNCAC)isaglobalinstrumentandlandmarkanti-corruptiontreatythatwasadoptedby181countriesin2003tocombatcorruptionandsetguidelinesforaction(Hechler,2010).Bangladesh’scaretakergovernmentadoptedthetreatyinFebruary2007,andcommittedtodevelopguidelinestodealwithcorruptionatdifferentlevelswithinthecountry(TI,2015).Followingthis,Bangladeshreportedgapsindifferentsectorsandthenewparliamentissuedguidancein2008oncompliancewiththetreaty(Mostafa,2009).

TheGovernmentofBangladeshhasalsoratifiedtheAnti-CorruptionAct2004,theNationalHumanRightsCommissionAct2009,theCharteredSecretariesAct2010,theWhistleBlowers’ProtectionAct2011,thePreventionofMoneyLaunderingAct2012,andtheCompetitionAct2012topromotegoodgovernanceandcombatcorruption(TIB,2014b).WealsoreviewedotherrelatedlegislationsinBangladesh,includingtheMutualLegalAssistanceAct2012,theConsumerProtectionAct2009,thePublicProcurementAct2006,andtheNationalHealthProtectionAct2014(seeTable6).Despitetheseinitiatives,implementationoftheUNCAChasprovenchallenginginBangladeshandprogressacrossdifferentsectorsisuneven.Generallyspeaking,wefoundthelegislationstobeweakinnatureandpoorlyimplemented.

3.2. Anti-corruptioninitiativesbytheGovernmentofBangladesh

Inadditiontothelegislationdetailedabove,theGovernmentofBangladeshhastakenstrategicstepssince2007tocombatcorruption,someofwhichaddressirregularitiesinthehealthsector(TIB,2014b).

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InformationCommission

TheInformationCommissionwasestablishedin2009toensureimplementationoftheRighttoInformationAct.ThisCommissionoverseestheactivitiesofthe‘InformationProvisionUnit’ofservice-provisionorganisations,andinvestigatescomplaintsrelatedtorightstoinformation(ibid.).

PerformanceAuditSystem

TheGovernmentofBangladeshintroducedaPerformanceAuditSystemtoevaluatetheroleandperformanceofpublic-sectoremployeesbasedonmutuallyagreedindicators(ibid.).

StrengtheningPublicExpenditureManagementprogram(SEMP)

TheSEMPseekstoimprovebudget-managementprocessesinthepublicsectorandstrengthenfinancialaccountabilitythroughouttheexpendituremanagementcycle(ibid.).

CitizenCharter

ACitizenCharterwasintroducedin2000followingrecommendationbythePublicAdministrationReformCommission(ibid.).Sincethen,thegovernmenthasstartedasecond-generationChartertocreateaplatformforcivilservantsandcitizenstointeractdemocraticallyandsolvetheirproblemsrelatedtoserviceprovision(ibid.).

NationalIntegrityStrategy(NIS)2012

AsapartoftheratificationofUNCACin2007,theGovernmentofBangladeshdevelopeditsNIStocombatcorruptionandensuretransparency,accountability,efficiencyandeffectivenessofstateandnon-stateorganisations.Theintentionwastogivetheseactorsfreedomoverdecision-makingandtopreventinfluencefromtherulingparty.ThevisionofNISis‘aBangladeshfreefromcorruption’,anditsmissionis‘Peopleandinstitutionsembracevaluesandprinciplesofintegrity,andincreasinglypracticethemaspartoftheirindividualandinstitutionalactivities’.In2013theCabinetDivision–thechiefexecutivebodyofthegovernment–conductedanindependentreviewofNISandsetguidanceforfutureaction(GoBCabinetDivision,2013).Theseguidelinescovercoordination,monitoringandreporting,andincludeanactionwhichwillbeupdatedonanongoingbasisaccordingtodemand.

ComprehensiveSocialandBehaviouralChangeCommunicationStrategy2016

Bangladesh’sMoHFWintroducedastrategyin2016tosupporttherequiredsocialchangetoimprovehealthoutcomes(MoHFW,2016).Thisstrategyparticularlyfocusesoncommunicatingbehaviourchangetopatientsacrossdifferenttiersofsocietyandthehealthsystem(ibid).

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Innovationstocurbcorruptionwithinnon-statesectors

CommitteeofConcernedCitizens(CCC)

TIBsetupaninterventioninselectedareasofBangladeshtoinvolvecommunitiesinanti-corruptioneffortsandcreateaparticipatorysocialmovementtoencourageaccountability.CCCswereestablishedwithvolunteersfromyouthgroupsandlocalcommunitypeople.TIBpreparedoperationalmanualsandfactsheets,setupadviceandinformationdesks(AIs),andorganisedstreettheatretoraiseawarenessaboutcorruptionandhowitcanbeaddressed.TrainingwasprovidedtoCCCmembersonsocialmobilisation,tacklingcorruption,goodgovernance,networking,marketing,gender,financialsustainabilityandadvocacy.Followingthisintervention,access,qualitylevelsanddemandforhealthservicesincreasedinallcatchmentareas(TIB,2018a).

Activeengagementofcommunitiesandlocalgovernment

InSaturiaUpazilaHealthComplexinBangladesh,therateofstaffabsenteeismis1%andthefacilityisclean,organisedandresponsivetopatients(Mahmud,2004).Thereasonbehindthissuccessispropertop-downmonitoringofstafffromthedistrictlevel,regularinteractionbetweenthecommunityandhealthworkers,andactiveinvolvementoftheUnionParishadChairmanandofficialsinvolvedinhealthservicedelivery.Asaresult,thepopulationofSaturiasufferslessfromdisease,isawareaboutexistinghealthcareprovisionandactivelyseeksservicesfromthefacility.

In1998,theGoBdecidedtoestablishcommunityclinicstoimproveutilisationofhealthservices.Boththecommunityandlocalgovernmentcontributedfinanciallytotheconstructionandoperationoftheclinics.Communitygroupsconsistingoflocalgovernmentrepresentatives,localserviceprovidersandlocalresidentswereestablishedtoensureanaffordable,accessible,reliableandresponsivehealthservicecapableofmeetingtheneedsofthecommunity.Subsequently,serviceutilisationincreasedto60%,andwomenwereabletoaccessserviceswithoutfacingbarriers.Still,thesuccessoftheprogrammewashinderedbyissuesofpoverty,inequalitiesinpowerandpartypolitics(ibid.).

Communityvolunteers

Aprojecthasbeencompletedbetweenicddr,bandself-helporganisations(SHO)ofChakariatoencourageindividualandcollectiveeffortsbythecommunitytoseekhealthcareservicesandcontributetowardsparticipatoryplanning,monitoringandservicedelivery.Communitymembershavebeentrainedashealthvolunteerstoproduceanddisseminatecommunicationmaterialstoraiseawarenessaboutavailablehealthservices.TheseSHOshavealsoraisedfundsforpoorpeoplewithinthecommunitytoensuretheirpropertreatmentwhenneeded–schemeswhichhavesincebeenconvertedintomicro-healthinsurance(BhuyianandRibaux,1997).

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Adviceandinformationdesks(AIdesks)

AIdesksprovidebasicinformation(e.g.thecostofdrugs;surgeryhours;examinationfees)andadviceonkeypublichealthservices.Theyalsoreceivereportsofcorruption,educatethepublicatthelocallevelontheirrightsanddutiesinchallengingcorruption,provideeffectivechannelsfordialogueandfeedbackoncorruptioncases,andestablishworkingpartnershipswithrelevantgovernmentinstitutionsinvolvedincurbingirregularpractices.AIdesksarelocatedatCCCoffices,with‘satellite’desksplacedatschools,hospitalsandlocalgovernmentoffices(TIB,2018b).

NariDal(women’sgroup)initiatives

Naripokkho,awomen'sorganisationinBangladesh,workedwith16localnon-governmentalorganisations(NGOs)thataremembersoftheWomen’sHealthandRightsAdvocacyPartnership(WHRAP)in14upazila(districtsub-unit,equivalenttoacounty)toimproveservicedeliverysystemsinhealthcarefacilities(CentreforHealthandSocialJustice,2015).Theyformed'NariDals'(women’sgroups)with640activemembersamongstthepoorestandmostmarginalisedwomenwhohadgoodcommunicationskills.Trainingwasprovidedtoenablethewomentoadvocatefortheirrightsandraiseawarenessthroughcommunitymeetingsaboutavailableservicesandpaymentstructuresatexistingfacilities.Asaresult,womenstartedtoseekservicesathealthfacilitiesinsteadofpayinginformalfees.Atthesame,WHRAPcommitteemembersvisitedhealthcentresfortnightlytomonitorcleanliness,andthepresenceandbehaviorofproviders.Thecommitteemembersthensharedtheirfindingsinzila(districts)andupazilacoordinationmeetings.AlthoughtheNariDalinitiativesawpositiveresults,theyfacedchallengesinobtainingpermissiontoobservewithinhealthcentres,andanunwillingnessbyhighergovernmentofficialstodiscussbottlenecksintheirfacilities(ibid.).

HospitalManagementCommittees(HMCs)

EveryhealthfacilityinBangladeshhasaHMC,whichconsistsofhealthdepartmentofficials,NGOrepresentatives,localmembersofparliament,hospitalemployees,mediarepresentativesandwell-knowncitizens.Naripokkhoworkedwiththesecommitteestoimprovetheservicedeliverysystemforwomenspecifically(ibid.).HMCshavebeenfoundtoreduceabsenteeismandthepracticeofinformalpayments,andtoimprovepatient-doctorinteraction.However,themainchallengesofHMCsarethatmemberslackknowledgeregardingtheirmembershipandresponsibilities,poorattendanceatmeetings,fundingshortagesandalackofformalauthority(ibid.).

Demand-sidefinancingandvoucherschemes

Pilotsofdemand-sidefinancingprogrammesimplementedin33disadvantageddistrictsinBangladeshhaveshownpromisingresultsforpoorhouseholds,withmaternalhealthvoucherscreatingsignificantpurchasingpowerforpatients.Whileadequateadministrativeandfinancialresourceshavebeenmobilisedforthetimelyprocessinganddisbursementofvouchersandincentivepayments,theinitiativehasbeenlimitedbylackofcapacitytodeliverlocalhealthservices(AhmedandKhan,2010).

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TheChowgachamodel

DrEmdadulHaque,seniorconsultantofChowgachaHealthComplexofJessoreinBangladesh,focusedhiseffortsonminimisinginequalitythroughlocalparticipation.Duringhisleadershipofthecomplexfrom1996to2012hehelpedtodevelopstandardhealthservicesinthedistrictandmobilised46additionalworkersfromthecommunitytoimprovetheservicedeliverysystem.Byprovidinghealthcardstopregnantwomen,monitoringservicesandencouraginguptake,thehealthcomplexmanagedtodeliver52%ofbabiesborninthedistrictwithinahealthfacilityasopposedtoathome,comparedto anationalaverageofonly15%.Asaresult,itwasawardedforbestperformanceinemergencyobstetriccareintheadministrativedivisioneveryyearfrom2005to2014(GlobalHealthInsights,2016).TheChowgachamodelhasshownhowimprovedservicedeliverycanbeachievedthroughfinancialcollaborationbetweenpoliticalactorsandthecommunity(ibid.)

DrHaquealsoinitiatedcommunityparticipationinSadarHospitalofJhenaidahinBangladeshtoimproveserviceprovisionthere(.Inresponsetohisefforts,membersofparliament,doctorsandtownspeopleareprovidingsubstantialmanpowertosupporttheinitiative.TheMayorofJhenaidahisalsoplayinganimportantroleinensuringhospitalcleanliness,securityandwastemanagement.ThissupportfromdifferentsegmentsofsocietyhasprovensuccessfulandhascontributedtoJhenaidahSadarHospitalbecomingthehighestrevenue-generatinghospitalinKhulnaDivisionin2014(ibid.).

Publichearingsanddialogue

Publichearingsareformalmulti-stakeholdermeetings,whereendusersraisetheirconcernsregardingpublicserviceprovision(TIB,2017).InBangladeshthesehaveprovenaneffectivetoolforimprovingserviceprovisionandcombatingcorruption.TheAnti-CorruptionCommissionconducted35publichearingsacrossthecountry–30inupazilaswithin29districtsandfiveinDhakaMetropolitanCity–engaginglocalgovernmentrepresentatives,serviceprovidersandcommunitypeople(ibid).

TheEuropeanUnion-supportedSHARE(StrengtheningHealth,ApplyingResearchEvidence)programmeandicddr,bassistedlocalcommunitiestoimproveitshealthbyconnectingpeopletoresourcesthroughpublichealthdialogues.TeammembersengagedwithlocalhealthmanagersandhealthcareseekersthroughoutBangladesh,hopingtoencouragedeeperpublicengagementinthehealthsector(GlobalHealthInsights,2016)

InlinewiththeprinciplesandstrategiesofBangladesh’sNationalHealthPolicy,publicengagementdialogueonhealthissuescancreateaplatformforcollaborationbetweenthepublic,healthmanagers,policy-makers,researchersandotherrelevantstakeholders(ibid.).Itcangiveunderservedpeoplearealvoiceinhowhealthservicescanbeimprovedthroughlocalparticipation,andallowcommunitiestoinitiateconstructiveconversationswithhealthmanagers,governmentrepresentativesandotherstakeholders(ibid.).

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3.3. Organisationsthatfacilitateanti-corruptionactivitiesinBangladesh

Table3:Organisationstaskedwithfacilitatinganti-corruptionactivitiesinBangladesh

Governmentorganisations BangladeshMedicalandDentalCouncil(BMDC)BangladeshStateMedicalFaculty

Developmentpartners WorldHealthOrganization(WHO)NationalAssociationforMedicalEducation(NAME)CenterforMedicalEducation(CME)TransparencyInternationalBangladesh(TIB)Anti-corruptionCommission(ACC)

Professionalassociations BangladeshMedicalAssociation(BMA)BangladeshNursingAssociation(BNA)

TheBangladeshMedicalCouncilwasestablishedin1972toregulatepracticeandetiquetteofmedicaldoctorsinthecountry,andwaslaterexpandedtobecometheBangladeshMedicalandDentalCouncil(BMDC).

TheBMDCisanautonomousbody,withexecutivemembersselectedbythegovernmentfromamongstparliamentandotherhigh-rankedpeople(Kasturiaratchietal.,1999).Itsfunctionistooverseeongoingmedicalpractices,standardsofpracticeandeducation,andtoprotectthehealthandwellbeingofthepeopleinthecountry.TheCouncilisauthorisedtoregisterallqualifieddoctorsanddentistsinthecountry,assesstheirmedicalpractices,andtakedisciplinaryactioninthecaseofirregularities.But,inadequateadministrativeandtechnicalmanpower,lackofresourcesandweakaccountabilityandmonitoringmechanismsrestricttheBMDCfromenforcingtheirmandate,whichcanleadtocorruptionwithinmedicalpractice.Likewise,theBangladeshNursingCouncil,PharmacyCouncilandBangladeshStateMedicalFacultyareunabletofulfiltheirdutiestomonitorpracticesinaproperway(ibid.).

TheAnti-CorruptionCommissionistheonlyagencyresponsibleformonitoringcorruptivepracticesandtakingfurthersteps.However,theCommission’sstructureisweakduetopoliticalinfluenceoveritschairmanandtheselectionofcommissioners,itslowcoverageofthepopulation(only40%),andlackofawarenessamongstthepublicaboutitsactivities(TI,n.d.).

TheBangladeshMedicalAssociation(BMA)istheelectedbodyandforumtoprotectdoctors’interestsandtogiveadviceaboutmedicaleducationandhealthcarepractices(Kasturiaratchietal.,1999).TheBMAhasnoauthoritytotakeactionregardingmalpracticeandnegligence,however.

TheNationalAssociationforMedicalEducationrepresentsmedicalteachersandstudents,andorganisesawareness-raisingactivitiesonpatients’rightsandmedicalethics.TheCenterforMedicalEducationisaWHO-collaboratinglearningorganisationforhealthprofessionalstoimprove,promoteandsustainthequalityofhealthprofessionaleducationinBangladesh.Thisorganisationaimstodelivercontinuousprofessionaldevelopmentthroughbettereducation,trainingandresearch(ibid.).

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4. ConclusionandrecommendationsGlobally,corruptioninthehealthsectorhasdeleteriouseffectsonthedevelopmentofapro-poor,people-centered,andequitableandinclusivehealthsystemforachievinguniversalhealthcoverageforallby2030.Bangladeshalsohavehighlevelpoliticalcommitmenttoachieveuniversalhealthcoverageby2030andensurehealthcareforall.Evidently,‘business-as-usual’conventionalapproacheswillnotcombattheproblem.ThedevelopmentcommunityneedstodeviseinnovativewaysofaddressingthevariousformsofcorruptioninBangladesh,byimplementinglearningfromothercountriesandscalingupsomeoftheanti-corruptioninitiativesandstrategiesimplementedonasmallscaleindifferentpartsofBangladesh.

Baseduponourreviewofcorruptionandanti-corruptioneffortsinthehealthsectorinBangladesh,weputforwardaseriesofshort-andlonger-termrecommendationsforactionbyBangladeshgovernmentsanditsrelevantministries,private-andpublic-sectororganisations,developmentpractitioners,andcommunitiesandcitizengroupsofBangladesh.

Recommendationsfortheshortterm(one-twoyears):• Everypatientandcitizenshouldhaveaccesstoappropriateinformationabouthospital

servicesandfacilities.Citizencharters,web-basedhealthinformationandresourcesatthepointofservicedeliverycouldsupportaccesstoinformation.

• Awareness-buildingactivitiesamongpatientsthroughpublictheatre,anti-corruptioncampaigns,anddialogueandmediainitiativeswouldimproveknowledgeamongstend-users.

• Patienteducationcentresandpatientrightsgroupsshouldbeestablishedineverydistrict-levelhospital.

• DifferentstakeholdersfromNGOs,youthgroupsandothercitizengroupsshouldbeengagedregularlytoreviewhospitalservicesandensureeffectivehospitalmanagementandgoodgovernance.

• Existinglawsandpoliciesshouldbeimplementedfully,withimprovedsupervisionandmonitoringsystems.Centralgovernmentshouldincreasethenumberandqualityofauditsinthehealthsector.

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Recommendationsforthelongterm(beyondtwoyears):• Theactiveinvolvementoflocalgovernmentandcommunitiesinissuesofhospitaland

patientmanagementcouldimproveservicedeliverysystems.

• Trainingarounddifferentformsofcorruptionandethicalcodeswithinmedicalcurriculum(atbothundergraduateandgraduatelevel)couldmakehealthcareprofessionalsmoreawareof–andabletoavoidandreport–corruptionwithinthesector.

• Mechanismsshouldbedevelopedbetweencentral-andlocal-levelauthoritiestofacilitatetheexchangeofsupervisoryandmonitoringreports,withnecessarystepstakentoimproveservicedeliverybasedonthesharedinformation.

• District-levelhospitalsshouldbegivenautonomyaroundfinancialresourcesandtherecruitmentofdoctors,nursesandalliedhealthprofessionals.

• Keyinstitutionsandanti-corruptionapparatusshouldbestrengthenedandsupportedbycentralgovernmenttoactoncasesofcorruptioninthehealthsector.

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