Nahitun Naher , Muhammad Shaikh Hassan Roksana Hoque ...€¦ · July 2018 Nahitun Naher1, Muhammad...
Transcript of Nahitun Naher , Muhammad Shaikh Hassan Roksana Hoque ...€¦ · July 2018 Nahitun Naher1, Muhammad...
July 2018
Nahitun Naher1, Muhammad Shaikh Hassan2 Roksana Hoque3, Nadia Alamgir4
Syed Masud Ahmed5
1 [email protected] [email protected]
3 [email protected] [email protected]
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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5. ReferencesAhmed,S.andKhan,M.M.(2010)‘Amaternalhealthvoucherscheme:whathavewelearnedfromthedemand-sidefinancingschemeinBangladesh?’,HealthPolicyandPlanning26(1):25-32.
Andaleeb,S.S.,Siddiqui,N.andKhandakar,S.(2007)‘PatientsatisfactionwithhealthservicesinBangladesh’,HealthPolicyandPlanning22(4):263-73.
Azfar,O.andGurgur,T.(2008)‘DoescorruptionaffecthealthoutcomesinthePhilippines?’,EconomicsofGovernance9(3):197-244.
Berger,D.(2014)‘Corruptionruinsthedoctor-patientrelationshipinIndia’,BMJ2014(348):3169.
Bhuiyan,A.andRibax,A.C.(1997)‘Rethinkingcommunityparticipation:prospectsofhealthinitiativesbyindigenousself-helporganizationsinruralBangladesh.Dhaka:CenterforHealthandPopulationResearch,i,cddr,b(https://pdf.usaid.gov/pdf_docs/pnacm679.pdf).
Bloom,G.,Standing,H.,Lucas,H.,Bhuiya,A.,Oladepo,O.andPeters,D.H.(2011)‘Makinghealthmarketsworkbetterforpoorpeople:thecaseofinformalproviders’,HealthPolicyandPlanning26(suppl_1):i45-i52.
CentreforHealthandSocialJustice(2015)Womeninthelead:monitoringhealthservicesinBangladesh’.Delhi:CentreforHealthandSocialJustice(http://www.chsj.org/uploads/1/0/2/1/10215849/case_study_1.pdf).
Chattopdhyay,S.(2013)‘Corruptioninhealthcareandmedicine:whyshouldphysiciansandbioethicistscareandwhatshouldtheydo?’,IndianJournalofMedicalEthics10(3).
Demming,A.(2017)‘Incorporatingcorruptionandaccountabilityintopublichealtheducation’.TheGlobalAnticorruptionBlog(https://globalanticorruptionblog.com/author/ashleyanndemming/).
ECORYSandEHFCN(EuropeanHealthcareFraudandCorruptionNetwork)(2013)StudyonCorruptionintheHealthcareSector.HOME/2011/ISEC/PR/047-A2.Luxembourg:EuropeanUnion(https://www.ecorys.nl/sites/default/files/Study_on_corruption_in_the_healthcare_sector_en.pdf).
Factor,R.andKang,M.(2015)‘Corruptionandpopulationhealthoutcomes:ananalysisofdatafrom133countriesusingstructuralequationmodeling’,InternationalJournalofPublicHealth60(6):633-641.
Faguet,J.-P.andAli,Z.(2009)‘Makingreformwork:institutions,dispositions,andtheimprovinghealthofBangladesh’,WorldDevelopment37(1):208-18.
GlobalHealthInsights(2016)‘Engagingpeopleinhealthdialogues’,31October(http://blog.icddrb.org/2016/10/31/public-engagement-health-sector-icddrb-share/).
GoBCabinetDivision(2013)AnindependentreviewoftheNationalIntegrityStrategy(NIS).Dhaka:GovernmentofthePeople’sRepublicofBangladesh,CabinetDivision(http://cabinet.portal.gov.bd/sites/default/files/files/cabinet.portal.gov.bd/publications/90749cbc_ee7d_4a08_9acc_ce795235dc6e/CD_SPEC_GOVT_POLIC_bn_2_210.pdf).
Hechanova,M.R.M.,Melgar,I.,Falguera,P.Z.andVillaverde,M.(2014)‘Organisationalcultureandworkplacecorruptioningovernmenthospitals’,JournalofPacificRimPsychology8(2):62-70.
Hechler,H.(2010)‘UNCACinanutshell:aquickguidetotheUnitedNationsConventionAgainstCorruptionforembassyanddonoragencystaff’.U4Brief.Bergen:Chr.MichelsenInstitute(https://www.cmi.no/publications/3769-uncac-in-a-nutshell).
Holvoet,N.,Inberg,L.andSekirime,S.(2013)Institutionalanalysisofmonitoringandevaluationsystems:comparingM&EsystemsinUganda'shealthandeducationsector.WorkingPaperno.2013.03.Antwerp:InstituteofDevelopmentPolicy(https://www.uantwerpen.be/images/uantwerpen/container2143/files/Publications/WP/2013/03-Holvoet-Inberg-Sekirime.pdf).
Hope,K.R.(2015)‘Contextualizingcorruptioninthehealthsectorindevelopingcountries:reflectionsonpolicytomanagetherisks’,WorldMedicalandHealthPolicy7(4):383-401.
Irregularities,informalpractices,andthemotivationoffrontlinehealthcareprovidersinBangladesh
26
Huss,R.,Green,A.,Sudarshan,H.,Karpagam,S.S.,Ramani,K.V.,Tomson,G.andGerein,N.(2011)‘Goodgovernanceandcorruptioninthehealthsector:lessonsfromtheKarnatakaexperience’,HealthPolicyandPlanning26(6):471-484.
Kasturiaratchi,N.,Lie,R.andSeeberg,J.(1999)Healthethicsinsouth-eastAsia:healthethicsinsixSEARcountries.Vol.1,SEA/HSD/225.NewDelhi:WorldHealthOrganization(http://www.who.int/ethics/regions/en/searo_ethics.pdf).
Knox,C.(2009)‘DealingwithsectoralcorruptioninBangladesh:developingcitizeninvolvement’,PublicAdministrationandDevelopment29(2):117-132.
Lewis,M.(2006)Governanceandcorruptioninpublichealthcaresystems.WorkingPaperno.78.Washington,DC:CenterforGlobalDevelopment(https://www.cgdev.org/publication/governance-and-corruption-public-health-care-systems-working-paper-78).
Lodenstein,E.,Dieleman,M.,Gerretsen,B.andBroerse,J.E.(2016)‘Healthproviderresponsivenesstosocialaccountabilityinitiativesinlow-andmiddle-incomecountries:arealistreview’,HealthPolicyandPlanning32(1):125-140.
Mackey,T.K.,Kohler,J.C.,Savedoff,W.D.,Vogl,F.,Lewis,M.,Sale,J.,Michaud,J.andVian,T.(2016)‘Thediseaseofcorruption:viewsonhowtofightcorruptiontoadvance21stcenturyglobalhealthgoals’,BMCMedicine14(1):149.
Mahajan,V.(2010)‘Whitecoatedcorruption’,IndianJournalofMedicalEthics7(1).
Mahmud,S.(2004)‘CitizenparticipationinthehealthsectorinruralBangladesh:perceptionsandreality’,IDSBulletin35(2):11-18.
MoHFW(MinistryofHealthandFamilyWelfare)(2016)Comprehensivesocialandbehavioralchangecommunicationstrategy.Dhaka:MinistryofHealthandFamilyWelfare(http://www.bangladesh-ccp.org/assets/images/resources/completion/ComprehensiveSBCCStrategy-3-.pdf).
Mostafa,S.(2009)‘UNCACasabasisformonitoringofanti-corruptioneffortsinBangladesh’.Dhaka:InstituteofGovernanceStudies,BRACUniversity(https://www.oecd.org/site/adboecdanti-corruptioninitiative/meetingsandconferences/44442286.pdf).
Mostert,S.,Sitaresmi,M.N.,Njuguna,F.,vanBeers,E.J.andKaspers,G.J.(2012)‘Effectofcorruptiononmedicalcareinlow-incomecountries’,PediatricBloodandCancer58(3):325.
Muhondwa,E.P.Y.,Nyambanga,T.andFrumence,G.(2010)‘PettycorruptioninhealthservicesinDaresSalaamandCoastRegions’.SIKIKAPolicyBrief02.10.DaresSalaam:Sikika.
Paredes-Solís,S.,Villegas-Arrizón,A.,Ledogar,R.J.,Delabra-Jardón,V.,Álvarez-Chávez,J.,Legorreta-Soberanis,J.,Nava-Aguilera,E.,Cockcroft,A.andAndersson,N.(2011)‘ReducingcorruptioninaMexicanmedicalschool:impactassessmentacrosstwocross-sectionalsurveys’,BMCHealthServicesResearch11(2):S13.
Sachan,D.(2013)‘TacklingcorruptioninIndianmedicine’,TheLancet382(9905):e23-e24.
Savedoff,W.andHussmann,K.(2006)‘Thecausesofcorruptioninthehealthsector:afocusonthehealthcaresystems’,inGlobalcorruptionreport:corruptionandhealth.London:TransparencyInternationalandAnnArbor:PlutoPress(https://www.transparency.org/whatwedo/publication/global_corruption_report_2006_corruption_and_health).
Thappa,D.M.andGupta,D.(2014)‘Thegrowingpoisonofcorruptioninhealthsystems:howdeepistherot?’,InternationalJournalofAdvancedMedicalandHealthResearch1(1):1.
TheBangladeshPratidin(2017)‘Notreatmentinemergencywithoutmoney’,2February.
TheDailyIttefaq(2016)‘FeniSadarhospitalisfullwithbrokers’,20November.
TheDailyIttefaq(2017)‘Doctorpromotiondependonpersuasionandpoliticalcommitment:resultfromlawcommission’,11March.
TheDailyJugantor(2017)‘BaksheeshbusinessinChittagongMedicalCollegeHospital’,5March.
TheDailyKalerKantho(2017)‘Salaryof379nursesstopduetonotgivingbribery’,3March.
Irregularities,informalpractices,andthemotivationoffrontlinehealthcareprovidersinBangladesh
27
TheDailyKalerKanthoandDailyJugantor(2017)‘24brokersarepunishedfortakingpatientstotheprivateclinics’,12January.
TI(TransparencyInternational)(n.d.)‘Anti-corruptionagencystrengtheninginitiative’.Berlin:TransparencyInternational(https://www.transparency.org/whatwedo/activity/anti_corruption_agency_strengthening_initiative).
TI(2012)TICorruptionPerceptionsIndex.Berlin:TransparencyInternational(www.transparency.org/cpi2012).
TI(2015)‘Bangladesh:overviewofcorruptionandanti-corruptionwithafocusonthehealthsector’.Berlin:TransparencyInternational(https://www.u4.no/publications/bangladesh-overview-of-corruption-and-anti-corruption-with-a-focus-on-the-health-sector).
TIB(2014a)Governancechallengesinthehealthsectorandthewayout.Dhaka:TransparencyInternationalBangladesh(https://www.ti-bangladesh.org/beta3/images/2014/es_health_11-6-14_en.pdf).
TIB(2014b)Bangladeshnationalintegritysystemassessment.Dhaka:TransparencyInternationalBangladesh(https://www.transparency.org/whatwedo/publication/bangladesh_national_integrity_system_assessment_2014).
TIB(2016)Corruptioninservicesectors:nationalhouseholdsurvey2015.Dhaka:TIB,availablefrom,https://www.ti-bangladesh.org/beta3/images/2016/es_nhhs_16_en.pdf
TIB(2017)ACC’spublichearingasameansofcontrollingcorruption:effectiveness,challengesandwaysforward.Dhaka:TransparencyInternationalBangladesh(https://www.ti-bangladesh.org/beta3/images/2017/ACC/Full_Report_ACC_05_11_2017.pdf).
TIB(2018a)‘CommitteesofConcernedCitizens(CCC)’.Dhaka:TransparencyInternationalBangladesh(https://www.ti-bangladesh.org/beta3/index.php/en/about-us/what-we-do/engaging-people/committee-of-concerned-citizens).
TIB(2018b)‘AIdesks’.Dhaka:TransparencyInternationalBangladesh(https://www.ti-bangladesh.org/beta3/index.php/en/about-us/what-we-do/outreach-communication/ai-desk).
Vian,T.(2008)‘Reviewofcorruptioninthehealthsector:theory,methodsandinterventions’,Healthpolicyandplanning23(2):83-94.
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