Anti-corruption for health

Overview

Anti-corruption, transparency and accountability measures are central components of health systems strengthening for universal health coverage.

Corruption in the health sector diverts resources, leads to negative health outcomes, threatens people’s lives and undermines citizen trust in public institutions. It also reduces the quality of health services and products, increases their costs, limits access to them, causes waste of financial and non-financial resources, leads to poorer staffing, and human rights violations and aggravates inequities. According to Transparency International, corruption in the health sector causes losses of over $500 billion every year, more than the amount of resources needed for universal health coverage. In 2018, the World Bank estimated that in some countries, as much as 80 per cent of non-salary health funds do not reach health facilities because of corruption. The poorest and most vulnerable populations in society are ultimately the ones to suffer the consequences.

Corruption in the health sector can take several forms. Transparency International defines six in particular. 1) Informal payments from patients; 2) embezzlement and theft; 3) absenteeism; 4) corrupt service provision activities, such as overcharging and false treatment reimbursement claims; 5) favouritism; and 6) manipulation of data. Among the key corruption risks in the sector are weak or non-existent rules and regulations, over-regulation, lack of accountability, low salaries and limited offer of services ( i.e., more demand than supply). The large amounts of funds exchanging hands and the multiplicity of stakeholders involved in decision points during each transaction lead to ample opportunity for corruption to thrive.

Crisis such as the COVID-19 pandemic further exacerbate the risk of corruption, particularly when country systems are fragile and there are limited or no effective oversight, audit and accountability mechanisms. In particular, conditions such as flexibility in responses, the simplification of procurement controls, the rapid flow of large funds, and the need for urgent responses instigated by the crisis create increased opportunities for corruption and fraud in the health sector.

UNDP’s approach

Through its Global Anti-Corruption Initiative (GAIN) and regional anti-corruption programmes, UNDP provides policy and programme support on anti-corruption, transparency, and accountability across sectors in more than 80 countries annually, working with a broad range of partners. Building on its governance expertise and health systems strengthening portfolio, UNDP is well positioned to advance integrated work in health, development and good governance.

For more than a decade, UNDP has harnessed these experiences to develop and support countries to apply methods and good practices to map corruption risks, develop strategies to address them, and sustain partnerships to tackle corruption in the health sector.

This work is done in partnership with a broad range of stakeholders at the global, national and regional levels, including international financing institutes, civil society organizations, the United Nations Office on Drugs and Crime UNODC, the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), the World Health Organization (WHO) and the World Bank.

UNDP’s particular emphasis as a partner includes supporting the implementation of risk-based frameworks for corruption prevention, strengthening fiduciary control and internal audit systems in national institutions, and promoting social accountability, including through the use of digital technology.

UNDP’s entry points and Examples

Supporting the implementation of risk-based frameworks for corruption prevention

Building on lessons that emerged through the UNDP Anti-Corruption and Integrity in the Arab Countries (ACIAC) programme and regional expert group consultations in 2015-2016, UNDP developed the Conceptual Framework for Corruption Risk Assessment at Sectoral Level. Through the framework, UNDP has supported several countries to customize and apply a targeted approach to corruption prevention based on an understanding of risk, equipping partners with the conceptual underpinnings to focus on corruption as a starting point for more comprehensive governance reforms.

For more information and guidance on UNDP’s corruption risk management methodology, visit the following page.

Strengthening fiduciary controls and internal audit systems in national institutions

As part of its work to strengthen systems for health, UNDP’s technical assistance to ministries of health entails capacity development of systems and processes for financial management, oversight, audit, and accountability. Building institutional capacities in these areas plays a key role in reducing opportunities for corruption risks to emerge within health programmes and service delivery. It moreover enables the maximization of health benefits from public resources and builds public trust in the system. More broadly, UNDP proactively supports national institutions to integrate anti-corruption, transparency and accountability measures into national development plans and processes, including strategies specific to the health sector.

Promoting social accountability, including through the use of digital technology

UNDP works to strengthen social accountability in service delivery, oversight in health policymaking, and the monitoring and evaluation of services. This includes through the use of innovation and technology platforms that enable citizen monitoring and strengthen access to public information, to help expose and reduce corruption. More broadly, UNDP works to empower civil society organizations to independently engage with government, including through participation in multi-stakeholder anti-corruption and health fora and the design of national strategies for good governance in health.

Resources and partnership platforms

Guidance based on experiences at the global, national and regional levels

With its operational presence in countries and diverse experiences supporting countries to plan and implement anti-corruption, transparency and accountability measures, UNDP contributes to the global evidence base on effective strategies to fight corruption. It likewise plays a convening role to facilitate the exchange of good practices and lessons learned across countries and among different sectors. Over the years, UNDP has produced a wide range of knowledge products on corruption, including methods specific to the health sector. Examples are the study ‘Fighting Corruption in the Health Sector, Tools, Methods and Good Practices (2015)’. The first draft of the ‘Conceptual Framework for Corruption Risk Assessment at the Sectoral Level’ (2018), which was published by UNDP’s Regional Bureau for Arab States which has further guidance under development and the guidance note on ‘Integrating Transparency Accountability, and Anticorruption in Socioeconomic Impact Analysis, Needs Assessment and Response to the COVID-19 Pandemic’ (2020), published by the UNDP Global Anti-corruption team.

Promoting risk management within health programmes

Proactive risk management is a cornerstone of UNDP’s programme management approach in supporting countries to implement large-scale national health programmes, including through its role as interim Principal Recipient of Global Fund grants from the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) in countries facing significant capacity constraints. UNDP has developed robust systems and tools to help countries identify and manage potential risks, and ensure ethics and integrity are in place in processes for programme management. Further guidance and tools on UNDP’s approach to risk management in the context of Global Fund grants can be found in the UNDP-Global Fund and Health Implementation Guidance Manual.

Global partnership to fight corruption in health

In 2019, UNDP, the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) and the World Health Organization (WHO) – and subsequently the World Bank as well – formed the steering committee of the Coalition for Accountability, Transparency and Anti-Corruption in Health (CATCH), a dynamic network that brings together a multiplicity of partners (e.g. health, development and humanitarian agencies; governments; civil society and, private sector organizations; people from academia and citizens) to tackle corruption in the health sector. CATCH aims to build the evidence base on how to tackle corruption, enhance collaboration and coordination among stakeholders, foster partnerships across and between countries and support countries to mobilize resources for anti-corruption efforts, hence reducing countries’ vulnerability to corruption. UNDP plays a lead role in the workstream to implement corruption risk assessments at the country level, to help generate bespoke corruption prevention solutions.

Some joint knowledge products to date CATCH has collaborated on a number of activities. In September 2019, CATCH hosted a high-level side-event at the UN General Assembly, where the need for safe spaces to host open and honest conversations on the difficult realities that surround corruption was discussed. The WHO Special Bulletin on ACTA highlights outcomes from research. CATCH published a joint blog on COVID-19 and ACTA, hosted two webinars in Nov-Dec 2020 to train UNDP Country Offices on the corruption risk management methodology (see the “Corruption risk methodology” page for recordings), and continues to prioritize fundraising efforts to advance its workstreams

Some joint knowledge products of CATCH to date include a WHO special bulletin on anti-corruption, transparency and accountability (ACTA) for health, a joint blog on COVID-19 and anti-corruption, transparency and accountability, and two webinars hosted by UNDP on its corruption risk management methodology (see the “” page for recordings).

The coalition helps to unify multisectoral approaches to corruption and identify shared problems that demand collective action and can drive outputs that are implemented at the country level, supported by the research and policy communities. Among the priority areas that have emerged from multi-stakeholder consultations is the need for risk-based approaches to anti-corruption for health. UNDP plays a lead role within this workstream, helping to inform implementation approaches and provide technical assistance to support countries to leverage risk assessments tailored to health systems.

To date, CATCH has collaborated on a number of activities. In September 2019, CATCH hosted a high-level side-event at the UN General Assembly, where the need for safe spaces to host open and honest conversations on the difficult realities that surround corruption was discussed. The WHO Special Bulletin on ACTA highlights outcomes from research. CATCH published a joint blog on COVID-19 and ACTA, hosted two webinars in Nov-Dec 2020 to train UNDP Country Offices on the corruption risk management methodology, and continues to prioritize fundraising efforts to advance its workstreams.

Purpose

Challenges that have hindered the effectiveness of anti-corruption efforts in past decades have included the following:

• Good governance and public sector reforms are too broad and avoid tackling corruption directly.
• Anti-corruption interventions in health programmes are often disconnected from national health systems and the country context.
• Anti-corruption communities are disconnected from public health communities, with no common language between them.
• Anti-corruption communities focus mainly on punitive approaches and post-event detection, and preventive approaches are focused on awareness and implementing excessive controls.

Sectorial and preventive strategies to fight corruption need to be further strengthened to enhance the overall effectiveness of anti-corruption. A well-established approach to engage in prevention in a specific context is to conduct risk assessments, as addressing risks is one of the key components of prevention. In the field of anti-corruption, risk assessment can broadly be defined as the analysis and study of the likelihood and impact of specific corrupt acts for the purpose of mitigating them. It distinguishes itself from other corruption assessment approaches in that it focuses on the potential for – rather than the perception, existence or extent of – corruption.

UNDP’s approach

Based on gaps in traditional anti-corruption approaches and building on its longstanding engagement with governments, civil society organizations and other partners on corruption prevention initiatives over the years, UNDP developed a comprehensive risk-based methodology to help advance countries’ corruption prevention efforts: the UNDP methodology for corruption risk management. Starting in 2016, it first piloted the approach in six countries and territories in the Middle East and North Africa. It continues to share lessons, develop tools and guidance, and train countries to implement risk-based approaches to corruption in other regions, in partnership with the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), the World Health Organization (WHO) and the World Bank.

The framework uses a corruption risk assessment to help countries identify vulnerable “decision points” in the health system, or other sectors, based on the likelihood and impact of corruption at each point. The assessment is conducted through national multi-stakeholder teams. Following training on the methodology, country stakeholders are able to map decision points and identify respective stakeholders and action points through a function-based approach combined with process mapping. The resulting risk heat maps allow for prioritization of corruption risk mitigation measures and the development of a sectoral implementation plan.

The experiences implementing this approach to date have underscored that:

• The integrated corruption risk methodology helps to align and coordinate efforts of donor agencies and different health system functions to address corruption along the entire continuum of health service delivery, which is a key factor for sustainability.
• Preventive approaches minimize the sensitivity of countries to the topic, as it addresses risks of potential acts rather than focusing on punitive measures.
• Application through multi-stakeholder teams creates country ownership, ensures response to national priorities and improves access to information without jeopardizing confidentiality and sovereignty. It also builds national capacities and offers a platform for continuity of the process.
• A flexible two-pronged approach that entails direct interventions for immediate response combined with long-term strategic engagement on corruption helps country teams to respond to pressing needs while not losing strategic focus.

Additional benefits include the creation of a common language among stakeholders between and within sectors, the integration of health system strengthening efforts with specific programme needs and the promotion of country ownership.

Guidance and resources

This section provides a high-level overview of key steps in the process of applying UNDP’s corruption risk management approach, which can be adapted to different contexts and objectives. Full details on the activities, tools and concepts entailed in each step can be found in a forthcoming guide. A case study on the experience and lessons from Tunisia, the first country to roll out this approach and achieve results in the health sector in particular, can be found here. Additional guidance can be found in the webinar recordings in the key resources below. If you are a government partner or another stakeholder engaged in implementing a UNDP-supported health programme and would like to initiate this process in your country, please contact support.healthimplementation@undp.org for further information and guidance.