By Shalni Arora. Shalni is a Senior Adviser to Transparency International’s Pharmaceuticals & Healthcare Programme and CEO of Savannah Wisdom

Too many women still die in childbirth and too many children under five die from preventable causes, despite worldwide improvements in health over the last five years.  The $22 billion in aid allocated to achieve these and other Millennium Development Goals helped improve maternal and child mortality – but problems remain unsolved. Goal 3 of the new Sustainable Development Goals calls for ‘Ensuring healthy lives and promotion of well-being for all at all ages.’  That goal incorporates the MDG targets on maternal and infant mortality and also on communicable diseases such as AIDS, TB and malaria.

What can be done differently this time around?  Recent studies suggest one of the reasons for not achieving the health MDGs are weak health infrastructures and a lack of capacity to deliver services and goods to patients and communities.

Health systems are weakened by corruption. It is important for donors to understand how corruption can reduce health outcomes if those donors are to achieve their own goals.  Total global spending on health is nearly $7 trillion annually, and the WHO estimates that up to 25 per cent of global public health procurement is lost to corruption.

Research demonstrates a direct correlation between bribery and maternal mortality during childbirth.  Acase study demonstrating this was highlighted by Transparency International, Nepal.  In Nepal, women were given small cash allowances to give birth in the safer hospital environment rather than at home as is customary.  Health officials created lists of fake mothers and pocketed the cash.  In India, mothers and children often are not given treatment unless they pay a small bribe to the health worker making treatment unaffordable. As a result, these mothers remain untreated, significantly increasing the chances of complication during childbirth and risk of fatalities.

Corruption in the delivery of healthcare occurs at the patient level and the clinic level but donors should be aware that corruption at any point in the healthcare supply chain lowers the quality, volume and effectiveness of healthcare.  This increases health inequity and the cost burden to governments and to NGOs.

Donors often give funds to ensure supply of medical services, which, unregulated, can lead to corruption. Corruption occurs as resources are siphoned off for resale, and so do not reach the intended recipient.   Healthcare workers may not attend clinics as required, or may not have the right skills or experience – meaning service-delivery quality is very low.   Absenteeism reduces access to healthcare and may happen because salaries are low and/or there are incentives to work elsewhere. Petty bribes can be requested for treatment that should be given for free, so patients are no longer able to afford treatment.  Patient and treatment-based targets are not met.

To reduce corruption, donors must base their strategies on outcomes.  Have the patients received the vaccines or the necessary medications? Have they seen a doctor or attended family planning treatment and received sexual and reproductive health advice? As well as checking service delivery themselves, donors can put in place social accountability mechanisms. Attendance records managed by communities make health workers socially accountable to the patients.  Civil society groups can also be used to check the availability of essential medicines, and bribe-free access to free healthcare.

Corruption on a grander scale can happen further up the supply chain. For example, regulatory processes can be circumvented by bribe paying; licences can be granted for poor manufacturing facilities that result in poor-quality medicines.  Bribe paying and corrupt procurement practices at wholesalers and distribution centres are one way that substandard and counterfeit drugs enter the supply chain.  Patients and prescribers can be unaware they are using sub-standard or counterfeit drugs, which increases risk to the patient, leads to reduced health outcomes, and wastes donor resources.

Donors should audit the medicine supply chain e.g. checking licensing and manufacturing data, as well as simple random checks on patient information leaflets and barcodes within the packaging at the point of prescription.  Those responsible for procurement must adhere to compliance rules checking the source of medicines, and should also be trained in anti-bribery procedures so they are aware of the repercussions of accepting bribes that allow counterfeit and substandard medicines to enter the supply chain.

Goal 3.8 of the SDGs is the ‘achievement of universal health coverage,’ which means access  to quality healthcare services and access to safe, effective and affordable essential medicines and vaccines for all.  To achieve such a grand target, healthcare systems must be strengthened, and less resources wasted.  Progress can be made towards this by looking out for and addressing corruption within the healthcare industry.