Transparency International’s latest poll on corruption across the world was reported by the BBC with the concern that people perceive their countries as more corrupt over time. One of the key institutions responsible for demanding bribes is the police.
BBC’s own poll on the topic found people talking about bribery as a problem more often that poverty, unemployment and other national problems. Although health care was not featured when the issue of to whom bribes were paid was raised, public institutions generally came under scrutiny.
A 2006 press release by Transparency International addressed health care bribes directly. Concerns ranged from direct loss of life when people were denied services to the problem of corruption that allows counterfiet drugs into a country, thus jeopardizing more lives.
Specifically Transparency International stated that, “Corruption is undermining progress towards the United Nationsâ€™ Millennium Development Goals, in particular the three related directly to health: reduced child mortality; improved maternal health; and the fight against HIV/AIDS, malaria and other diseases.”
The issue of bribery does not feature prominently in the health literature although it is a major problem threatening quality of care.Â A multi-country research project on health worker and client relationships found that health workers were willing to talk about the problem:
… participants in many sites spoke openly about various forms of informal income generation engaged in by health workers. This took the form, for example, of insisting on â€˜tipsâ€™ before people received treatment and alternative prescribing methods or alternative charging structures for treatment and prescriptions. This open discussion continued despite people saying that talking about it made them feel â€˜ashamedâ€™.
Jennifer Hunt in a study of bribery in health care in Uganda found examples in both public and private sectors. Interestingly bribery may be associated with worse quality health care, and bribes may be an attempt to improve this, but to little effect.
When researching a story on health insurance in Nigeria a reporter from the Daily Independent found that, “… off record (some respondents) were soon to confide that a few workers demand inducements before attending to patients. (One) also remarked that while some personnel at the PHCs (Primary Health Centers) do not ask for bribes, most patients are compelled to give them packages when they notice that those who did before them were better taken care of.”
While we have recently reported on large scale corruption involving major donor funds, it is the small scale bribes at the front line level that immediately affect life and death access to malaria and other health services. Can we expect the front line health worker to behave any better than the big national program manager or policy maker? What can we do to end the culture of corruption and achieve our malaria elimination goals?