The 9th International Anti-Corruption Conference
CORRUPTION IN THE HEALTH SECTOR
M. J. Mwaffisi
Ministry Of Health
Dar Es Salaam
Corruption involves the payment of bribe, that is money or material
items offered to provide (often illegal or dishonest) services or
decision in favour of a giver.
The health sector is one of the areas that is prone to corruption. In
Tanzania, according to the Warioba Report, the health sectors was
ranked third in the list of sectors with the highest incidence of
corruption. This is also true to most developing countries and the
reasons are clear that health is a service which is in great demand
and touches the lives of most people, while on the other hand
resources are scarce.
Levels of corruption can be distinguished into two categories. There
are those who engage in petty corruption, that is those who receive
bribes as a supplement to their meagre income. This is referred to as
petty corruption and involves individuals being forced to pay small
amounts of money in order to get the service that they deserve to get
free or with a little payment. Majorities of the people who are forced
to pay bribe are poor, and thus, the amount of money, which is
involved, is a significant porting of their income. The impact to the
poor is in most cases enormous.
Clients pay bribes in almost all the departments of the hospital; the
outpatient, laboratory, X-ray, the labour ward and the mortuary are
notorious. The pharmacy and the general wards are also not free from
corruption. In fact, there is no "corruption free zone" as it is often
And on the other hand, we have those who engage in grand corruption,
these involve themselves in corruption because of greed. In the health
sector, this involves the payment of big sums of money by rich
individuals and institutions to some corrupt government officials in
order to win tenders for the supply of pharmaceuticals, medical
equipment and supplies. As a result of this unfair competition among
bidders, the Government does not get the supplies worth the money it
pays. The Government incurs loss through getting fewer supplies, which
are more expensive due to over-invoicing, substandard, and having
shorter life span or shelf life in case of medicines. This type of
corruption, apart from resulting into Government losing a lot of
money, delivers a heavy toll at the micro-level due to the effects
arising from the shortages it causes at the lower level. Thus macro-
level corruption causes and potentiates corruption at micro-level. And
all in all it retards development of a nation, as the government
cannot achieve its objectives, increase the debt of the country and
makes the country more poorer.
There are several causes of corruption in the health sector and these
include the following-:
The small budget allocated to the health sector, results in
shortages of medicines and other medical supplies. Patients have to be
put on waiting list for long periods before they are provided with
some elective services like surgical operations. At some stage,
hospitals are forced to do away with elective surgery and perform
emergency operations only, and this makes room for corruption.
At some stage, hospitals were forced to do away
with elective surgery and perform emergency operations only , and this
makes room for corruption.
Excessive Red Tapes and Long Queues
Some of the processes and
procedures that one has to go through are necessary. These procedures
combined with shortages and inefficiency result in long queues that
create an environment for soliciting and giving bribes.
Salaries for health workers are very low. Health workers
have won the sympathy of many who see them as deserving more for what
they do. Members of Parliament have been urging the Government to
review the salaries for health workers.
During the second Phase, the Government of the United Republic of
Tanzania, decided to allow doctors working in Government to open
private clinics and engage in private medical practice after their
official hours of service in a bid to increase their income while
retaining them in Government Service.
However, this move has had some negative consequences:
- Doctors spend some official hours in their private clinics, leaving
patients in public service facilities unattended.
- Doctors use public facilities and medical supplies to treat their
private patients who often get priority service over others.
- Doctors use public facilities as a conduit to channel clients to
their private facilities.
- Doctors prescribe medicines that they know are not available in
Government facilities and advise patients to procure them in their
- There has been increasing incidences of theft of medicines and
equipment from public health facilities.
- Due to these unwanted consequences, the Government is now rethinking
this policy decision.
Poor Management and Supervision
Poor management and inadequate
supervision of health workers leaves them unchecked to do whatever
they want to do. There is a general breakdown of moral ethics that is
making professionals feel comfortable even while breaking their own
code of ethics that gave them their credibility and identity.
Disregard to the Law Disregard of the law resulting into its breach
and lack of enforcement is another cause of corruption. There is
always a tendency to resort to reviewing the laws and regulations
while the existing ones may be adequate but not enforced.
Lack of Information
to clients Lack of information on what services
are provided, where and when they are provided, who provides them and
procedures to be followed creates an environment for soliciting and
paying a bribe. Clients need to know their rights and obligations so
that they know what to expect and what is their responsibility.
Sometimes, due to lack of information, they think that a bribe is
EFFECTS OF MACRO-LEVEL CORRUPTION:
Macro level corruption frustrates a
poor nation like Tanzania struggling to meet the basic needs of its
citizens with meagre resources. Despite the efforts being made to
increase resources for health service delivery, health status
indicators continue to show little or no improvement. With the
citizens being continuously exposed to ill health, the nation
continues to be poor. Citizens are dissatisfied with the Government as
they see no benefit from their efforts and the tax they pay. As
mentioned earlier, macro-level corruption causes and potentiates
corruption at the micro-level.
Frustrating Achievement of the Health Policy Goal
In Tanzania the
overall objective of the health policy is to improve the health and
well being of all Tanzanians with a focus on those at most risk, and
to encourage the health system to be more responsive to the needs of
the people. This boils down at ensuring equity in the provision of
quality health care. Corruption directly militates against the
achievement of this noble goal.
It is only those who can afford and who paradoxically have the least
need that get access to service. They pay bribes to get service and
those who really need it but are unable to pay bribes are left to
suffer. Those who struggle to pay end up in indebtedness and may
continue suffering due to failure to complete full course of
treatment. Incomplete treatment is poor quality treatment that may
lead to permanent disability and death.
Corruption also results into poor quality health services as those who
provide it have no incentive to make it better, in order to perpetrate
an conducive environment for corruption.
Due to the denial of access to health care to
the majority, corruption develops a disgruntled community which is
dissatisfied with health workers and the Government. The health
delivery system fails to develop the partnership with the community
that is necessary for the achievement of the primary health care goal
of health for all.
Loss of Credibility and identity by the Health Professions
is a vice. Those who solicit and take bribe lose credibility and
respect in the eyes of the giver and are taken to be cheap.
Corruption has spread like a cancer into our society and finally,
reached domains that were free of it, like the nursing and medical
professions. The Swahili word for corruption is "rushwa" was not heard
so frequently during the early period of independence up to the 80s.
It then got other names to justify it, like "a handshake" meaning a
present or "ahsante" meaning thank you for good service.
The way and extent to which it has entrenched into our society makes
it difficult to wipe it completely. However, the impact of corruption
is immensely detrimental to our development. However it takes and at
whatever cost and length, corruption has to be wiped out in our
society. Wiping corruption is not the responsibility of the
government, rather, it is for the whole society. There needs to be
concerted efforts of all individuals, Government and Non-Government
institutions and the donor community, the general public and the
Information to the Public
The public needs to be protected from
unfaithful health workers who have corruptive tendencies. They need to
know what services are provided, by whom, where, the price, where to
pay etc. They also need to know where they should go arid who they
should consult when they have a problem. If a health worker solicits a
bribe, they should feel safe and secure to report and see that action
has been taken against the culprit. The public should feel themselves
as masters rather than underdogs.
In order to be partners with the Government in combating corruption,
the public needs to be informed. Information must be made available to
the media and a partnership needs to be forged between government and
the media on how best to disseminate information to the public. This
information can be provided through various media like announcements,
posters, newspapers and electronic media.
Citizens need to be educated on their fundamental
rights, responsibilities and obligations.
External Evaluation of Health Services
Apart from internal assessment
of health facilities through self assessment and assessment by
supervisors from the higher levels, health facilities should be
evaluated by others not directly attached to the sector, and of utmost
importance, health services should be assessed by the clients who are
the beneficiary of the service being provided. Facilities should be
encouraged to solicit feed. back from clients on the service they
provide. Supervisors should always make it a point to talk to clients
and solicit their opinion on the quality of service being provided to
Increase budget to the Health Sector
The present Government efforts to
allocate more funds to the health sector should be enhanced to reduce
the widespread shortage of drugs and medical supplies to make it easy
for people to get health services and remove the environment for
soliciting and paying bribes.
Streamline Procedures and Increase efficiency
Innovative technology and management procedures should be improvised to enhance efficiency
and reduce long queues in health facilities.
Proper Analysis of Corruption environment
Rather than just dealing with individuals who solicit and give bribe, we should concentrate on
dealing with the different environments that provide incentives for
corruption and address those.
Involvement of Professional Bodies
All professional bodies should be
educated to realise that corruption is killing them as professionals
and that their trade may ultimately cease to be recognised as a
profession. A sense of professional self regulation should be
instituted among the various professional bodies.
need to be looked into in order to institute
effective and transparent systems and processes.
Corruption should be dealt with severely
Corruption is a criminal
offence. Any incidence of corruption should be taken seriously and the
culprits dealt with squarely in order to deter others from committing
it. We should work towards Zero tolerance for corruption by
strengthening community net-works against corruption.
- Health personnel need to be educated on the vices of corruption and
be reminded that they are servers and not masters. We have also got to
eliminate the doing you a favour attitude among health personnel.
Train health personnel in order to boost up morale and increase
competence and efficiency.
- Health personnel should be paid a wage in line with what is expected of them,
and good performance should be recognised and rewarded.
Above all, the international community has got a role to play in the
fight against corruption in developing countries. We know that
corruption is not just an internal issue involving developing
countries, but rather it goes across the borders. Practices of foreign
bodies, including donors and investors, fuel the extent of corruption
especially in procurement.