|MEDICINE AND SOCIETY
|Year : 2014 | Volume
| Issue : 2 | Page : 150-153
Combating corruption in health care organizations: Methods, tools, and good practices
Department of Pathology, Institute of Human Behaviour and Allied Sciences, Delhi, India
|Date of Web Publication||31-Jul-2014|
Prof (Dr) Sujata Chaturvedi
E-15, GTB Hospital Campus, Dilshad Garden, Delhi - 110 095
Source of Support: None, Conflict of Interest: None
Although corruption in health care reflects the ills of the society in general, some key areas to be focused upon are as follows: procurement processes; the so-called 'speed money'; theft, pilferage and malpractices; and staff recruitment. Each organization needs to devise its own mechanisms for transparency and accountability in procurements. A two-bid system of technical and price bid, asking for users' list, demonstration, or onsite visits to ascertain the functioning of equipments, 'Publish What You Pay' type of initiative, participation of users as in Rogi Kalyan Samitis, anticorruption networks are some of the tools to address corruption in hospital procurement. The menace of informal payments or speed money can be addressed by encouraging and facilitating users' feedback, involving hospital neighborhoods in anticorruption squads and having CCTV surveillance in key areas. Theft, pilferage, and malpractice siphons off goods and services meant for the ailing. Administrative vigilance and strict handling of the instances reported may serve as a deterrent. Having a labor law professional or a trustworthy NGO on the panel may help reduce corruption, especially seen in the case of contractual jobs. Phenomenon of corruption is difficult to capture in a single definition or measure. Sincere, intense, and sustained anticorruption measures have to be adopted and pursued by health care facilities top-down as well as bottom-up, providers as well as users, ex ante as well as post facto. All anticorruption measures have a use-by-date to them. Innovations would be required. Key ingredient would be sincerity of the management.
Keywords: Corruption, health care organizations, procurement, speed money, pilferage
|How to cite this article:|
Chaturvedi S. Combating corruption in health care organizations: Methods, tools, and good practices. Astrocyte 2014;1:150-3
| Introduction|| |
All institutions are prone to corruption and to the vices of their members. Health care institutions, whether public or private, are no exception. Corruption in this particular sector is more sinful because it directly impacts those who are already suffering, in misery, pain, or may be at the end of their lives. Some of them put at stake all their life's savings and come seeking respite for a dear one-someone whom they obviously value above everything-even money. Unfortunately, the system in which they repose so much of faith reciprocates by treating them not as the reason of health care facility's existence but only as a byproduct. Patients and their caregivers become the most unsuspecting victims of corruption in health care. The most genuine measures that the authorities come up to handle corruption are all post hoc methods in the form of audits/enquiries/reports. These not only fail to come out with convincing truths but are also perceived to be manipulated and create an atmosphere of unsubstantiated rumors. It is not uncommon to find employees planting stories against their rival colleagues in media and administrative offices. The happenings are enough to break the spirit of any institution by creating an excuse for inaction and generating a retinue of "courtiers" seeking to somehow align with the leadership. Room for independent and free thought, debate, and discussion is hard to find in institutes, supposedly, in an anticorruption mode. Far from stemming corruption, the health care facility itself becomes sick and deviates terribly from its mandate, that is, to utilize the given funds to provide the best possible care to patients reaching its doorstep. Handling of corruption in health care settings has to be done with a thorough understanding and insight into the system. By virtue of its scale and pervasiveness, corruption merits to be a priority in health systems and governance empirics.  A beginning can be made by focusing on some key areas.
| Procurement Processes|| |
It has been observed that the health care facilities end up overpaying for various equipments, medicines, other consumables, or services. There have been instances of collusion, bribes, kickbacks, and favoritism. Much worse, the actors involved are so engrossed in extracting pecuniary benefits that quality becomes a casualty. The small constituency of honest employees, in an effort to save their own skin, also ends up harming the system either by resorting to inaction or being a passive unquestioning bystander. More often than not, the honest adopt the policy of being strictly accountable for only their area of work. Taking up corruption-related issues may involve raising uncomfortable questions and a lonely sustained fight. It may become a fulltime job, often at the expense of one's professional work. Who is ready to pay this price when it is sure that not only will you not be rewarded but may even end up becoming an outcast? Although, no doubt, the honest few manage to preserve their own integrity, their contribution toward cleansing the system remains insignificant. Thus, the system and patient care services are affected both ways-the activity of the corrupt and passivity of the honest. Key administrators of a medical background are often unaware of rules and procedures. Desperate for solutions, they turn to middle-level managers and end up being manipulated toward inaction or a nondesirable action. Nuances of rules and regulations are not used to arrive at a positive, meaningful, and much needed action but to stall or unnecessarily delay important processes.
Corruption in public procurement has become a major area of concern, especially in Asia-Pacific region. To identify risk areas in their public procurement frameworks and to foster reform in this field, member governments of the Asia Development Bank/Organization for Economic Development and Cooperation (ADB/OECD) Anti-Corruption Initiative for Asia and the Pacific have reviewed the mechanisms and safeguards in place. This publication presents the findings of the Initiative's 2005-2006 thematic review on curbing corruption in public procurement.  Some measures have already been initiated at government level. Tenders are published in all important newspapers as well as on the web sites of the concerned organizations. Common Government tender portals have been created and their usage is expanding. Adequate time (not less than 45 days) is given for responding to the tenders. Selection and award criteria for procurement of goods and services are generally governed by the financial rules, which are subordinate legislations, prescribing in detail the criteria for selection. Technical requirements, qualification of bidders, expertise/experience are specifically mentioned in bid documents, which can be obtained from the concerned government office. All bids received are recorded. A two-bid system of technical bid and price bid is also of help. Asking for Users' list, demonstrations, or visits for onsite inspection can be a part of procurement process in order to ensure quality and performance. Details of all the procurement processes can be made public by posting them on the World Wide Web. The Right to Information Act, if used genuinely and judiciously, is a great tool both as a deterrent and a retributive aid. Each organization needs to devise its own mechanisms for transparency and accountability. In Argentina, the government adopted a strategy of monitoring how much the hospitals were paying for which medical supplies. This information was disseminated among all the hospitals. Purchase prices fell by an average of 12%. In Bolivia, increased citizen health board activism played a positive role. In Uganda, community representation in apex committees of the hospital increased accountability.  Closer home, the model of Rogi Kalyan Samitis in Gujarat and Madhya Pradesh is yielding good results in forming mechanisms of transparency.  A 'Publish What You Pay' type of initiative has yielded results in energy and mining industry.  It would be worthwhile to apply the concept to hospital procurements also to make the system more transparent and accountable.
It has to recognized that nonutilization and/or poor upkeep of equipments, medicines, and other items procured also tantamount to corruption. Hospitals where there are only a few doctors in a particular specialty need to be more careful as the few specialists available may have more influence over decision making. Keeping track of utilization, maintenance, and calibration record of equipment will ensure good patient care services. Strict warranty and maintenance clauses should be a part of any purchase order. For medicines, essential drug lists, hospital formularies, and pooled procurement may help but the possibility of pharmaceutical companies trying unfair means to make their product enter the essential list does exist. Quality of drugs also needs independent testing.
The results of a study conducted by Rossi et al,  show that if public hospitals have adequate purchase negotiation instruments and a uniform legal framework, they can achieve a good level of activity. However, it needs to be reminded that whatever are the safeguards adopted, they all have a use-by-date to them. Collusion and mal-intent are diehard traits and will find ways and means to circumvent any regulation. It is bound to be a cat and mouse chase. The think tank of the health care facility should innovate and improvise their anticorruption strategies. Anticorruption networking among hospitals may also help generate good workable mechanisms. European Healthcare Fraud and Corruption Network was formulated to improve European health care systems by reducing losses to fraud and corruption.  As long as the leadership conveys the seriousness of its anticorruption stance in terms of concrete action and outcome, there will be no dearth of genuine, out-of-the-box ideas from within the hospital staff and users themselves. One may even think of making some corporate houses a part of anticorruption deliberations. Genuine intention has to be supplemented with a robust hospital procurement policy and its implementation. The aim is to ensure that that there are no unnecessary delays, compromise on quality, and that procurements are according to patients' needs. Unfortunately, much of anticorruption talk remains an empty rhetoric, beginning and ending in the Board Rooms.
| Speed Money|| |
The India Corruption Study reports that 45% of respondents said that hospital staff frequently demanded bribes.  This is usually given at multiple points as "speed-money" in the hope of a swifter or better service. A study on "Informal payments in public hospitals in Greece" reports that the probability of extra payments is 72% higher for patients aiming to "jump the queue." Also surgical cases had a 137% higher probability for extra payments compared with nonsurgical patients.  Some informal payments have, sadly, become a routine practice. People find nothing wrong and even justify giving " baqshish" after a neonate is handed over or a surgery has been successful or even in return for a clean bed sheet or bedpan. Hospitals need to go on a war mode against these informal payments. Patients and their attendants have to be given confidence that quality of services will not be adversely affected if they do not make these informal payments. If they want to do something as a way of thank you gesture, donation facility is available in all hospitals. Signages at all important places requesting the users to help the hospital authorities in curbing corruption, asking for their feedback and suggestions or even allocating a regular time slot for interaction between the users and top hospital authorities may bring about some changes. User satisfaction surveys, if conducted religiously, may yield important information. Some heavy utilization areas of the hospital may need constant CCTV surveillance to make things difficult for such transactions. Hospitals can also rope in volunteers from the community to form "Friends of the hospital" type of groups. They can devote some time to the hospital, help patients find their way or even act as anticorruption squad. Hospital neighborhoods will have many genuine people ready to devote time and energy to make their hospitals better and corruption free. The one positive highlight of the Commonwealth Games was the participation of students as volunteers. Such participation can do wonders for our hospitals.
| Theft, Pilferage, and Malpractices|| |
Drugs and supplies are among the most commonly "leaked" products. This is a scourge that depletes any hospital of all types of goods and services, which are actually meant for the poorest of the poor. It is no longer surprising to find hospital goods being sold in the nearby shops. The concentration of private health services adjacent to public hospitals and clinics in many countries attests to the chronic shortages of basic inputs and malfunctioning equipment.  Besides some of the mechanisms listed to address the issue of informal payments, a sound, computerized inventory management with regular administrative checks and audits are a must. The stock entries have to be checked and cross-checked at various levels. From the time of receiving the supplies to their actual utilization, everything should be accounted for. Not only goods, even services are siphoned off. Who has not witnessed a hospital employee being used for domestic or personal work by hospital officials? Our acceptability levels and a skewed financial notion of corruption have turned these aberrations into norms.
Under a vigilant administration pick up rate of instances of pilferage and malpractice will definitely go up. What happens after that is more important and would set the tone and intensity of a hospital's anticorruption policy. Usually such cases are lost in the rigmarole of enquiries and clarifications. The administration should go the whole hog and punish the offenders in the strictest possible manner defined by government rules. Bringing to light, instances of malpractice and pilferage with no follow up action is more damaging than the act itself. It emboldens the offenders, encourages the dithering fence sitters, and demoralizes the person who helped bring matters to the fore. The only certain outcome is that the hospital and its patients are the losers.
| Staff Recruitment|| |
Most well-meaning hospital administrators dread the process of staff recruitment. The pulls, pressures, and IOUs to be settled can rattle even the toughest ones. The applicants also start putting their act together by finding that one important "link." Merit is an issue discussed on the sidelines. Not only the regular jobs, the contractual ones are also ridden with problems, albeit of a different kind. Most of the public hospitals have started outsourcing housekeeping and security services. Obviously the contractors have not entered the hospitals for a yeoman's service. They are there for business and will resort to any trick to make profit. The hapless jobseekers become their bonded laborers-voiceless and nameless. They sign on any salary receipt, run all types of errands, tolerate all types of labor law violations in a desperate effort to protect their "job." To borrow from Sainath's insightful work, "Everybody loves a good drought"  is so applicable for these contractors.
Here again, having a labor law professional or a trustworthy NGO representative might be of some help. An institutional anticorruption helpline for employees and users would also help to highlight instances of corruption. More than that, the authorities would have to walk an extra mile to instill confidence in the contractual employees that their complaints would be heard and heeded to with no threat to them or their job. Accepted that solutions are not going to be that simplistic but a beginning has to be made.
| Conclusion|| |
The magnitude and colors of corruption in health care settings make it a fiendishly complicated and daunting problem. Corruption can take on many forms ranging from the gross to the subtle, some of which are not widely understood. The phenomenon is thus difficult to capture in a single definition or measure.  Anticorruption measures have to be adopted and pursued in a sustained manner by health care facilities top-down as well as bottom-up, providers as well as users, ex ante as well as post facto. They can begin by formulating their Green Paper on anticorruption, devising their corruption barometer, launching an all out effort to identify the corrupt practices and people and, more importantly, following it up with suitable exemplary action.
"The point is simply to insist that there is no such thing as a general solution. The constant refrain, 'what is the solution,' can itself be a symptom of corruption when it becomes a means of avoiding that straight truth that is staring us in the face: We all have to do the duties appropriate to where we stand" - Mehta. 
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