FIGHTING CORRUPTION IN THE HEALTH SECTOR: SECURING IMPROVED HEALTHCARE SERVICE DELIVERY AND UTILIZATION IN UGANDA
Rogers Bariyo
Institute of Interdisciplinary Training and Research, Mbarara University of Science and Technology (MUST), Uganda
Pascal T. Ngoboka
University of Wisconsin Water Falls (UWRF), USA
ABSTRACT
Corruption is a serious problem in developing and transitional economies, threatening service delivery and eroding confidence in many governments. In Uganda, the healthcare sector has not been spared by corruption scandals, not only on the national level but even at local and community levels. Shoddy works have been done on health infrastructure, funds meant for the health sector are usually embezzled, fake drugs flood markets and under-the-table payments have not stopped at public health facilities. Despite various strategies and interventions put in place to curb corruption with an aim of attaining higher healthcare outcomes, the vice has not faded away, thus affecting healthcare service delivery and utilization. This paper explains why corruption in the health sector in Uganda has persisted; it shows the various types and manifestations of corruption, and its impact on the health sector.Furthermore, the paper highlights the vital mitigation strategies and policies that need to be scaled-up to combat corruption in order to secure improved healthcare service delivery and utilization inUganda.
Key words: Corruption, healthcare services
1
UNDERSTANDING OF CORRUPTION
There is no universally accepted definition of corruption. Many definitions, explanations and description of corruption have been advanced by scholars, political critics as well as religious leaders. For instance, according to Ruzindana et al (1998: v) corruption “encompasses the misuses of power, funds or resources by holders of public office for personal ends, gains, or self interest to the prejudice of public interest”. According to Hussmann (2011) corruption is anything from paying bribes to civil servants and large scale theft from public funds to a wider range of economic and political practices that people consider abuses of power and that are increasingly criminalized. However, there seems to be a consensus that corruption includes the abuse of public or entrusted power for private gains. This abuse of public or entrusted power is not only the public domain but also among all actors such as private sector staff, private firms, Non-governmental Organizations (NGOs) as well as Civil Society Organizations (CSOs) (Haussman, 2011).
HISTORICAL BACKGROUND OF CORRUPTION IN UGANDA
The history of corruption in Ugandan economy can be traced from the 1970s. At the time of independence Uganda had one of the vibrant economies in Sub-Saharan Africa with good economic and social indicators (Bariyo, 2012, Hutchison, et al 199). But the governments that come into power, especially the Amin regime of 1971-79 ruined the economy. Arising from the economic war of 1972 and poor economic and social policies that that regime adopted, the economy experienced catastrophic consequences on all the sectors. Informal economies thrived, social service sectors were destroyed as the trained human resource fled the country for safety and greener pastures. The few staff that were left on the ground, devised among of “copping” strategy to come to terms with acute shortage of basic services. Thus the class of people that emerged in that time, fueled corruption in the economy. From then corruption spread like wild fire into the subsequent decades.
According to the Second National Integrity survey (2003), the health sector was the second corrupt sector by 2003 in Uganda. In 2005, three cabinet ministers were charged with misappropriation of USD 1.8m. The Global Integrity report (2006), noted that more than half of the government’s annual budget amounting to USD 950bn is lost to corruption annually. It is important to note that corruption scandals in the health sector in Uganda, just like in other sector are highly pronounced among political heavy weights, civil servants and service providers at all levels.
In 2005, Afro-Barometer showed that corruption was most rampant in Uganda. 36% of all respondents believed that most or all the government officials (central and local) were involved in corruption. The 2008 Corruption Perception Index (CPI) ranks Uganda at 126th place with a score of 2.6 and World Economic Forum’s Global Competitive Report for 2008-2009, identified corruption as one of the major constraints of doing business in Uganda. The 2011 Transparency International Perception Index gives Uganda a decimal score of 2.4 on scale of 10, placing it as the 143rd out of the world’s 183 countries ( Such high incidences of corruption in Uganda have led to loss of public confidence, and many political critics have questioned President Museveni’s National Resistance Movement (NRM) government’s political will to fight and eradicate corruption in the country. This accusation of the governments’ inability to address corruption cases has fueled the current civil disobediences manifested in massive demonstrations led by the opposition pressure group (Activists for Change- A4C) across the country and attempt by the Opposition Members of Parliament to impeach the President.
CAUSES, FORMS AND MANIFESTATIONS OF CORRUPTION IN HEALTH SECTOR
From the healthcare workers/officials perspective, corruption may arise where an official has an opportunity to engage in corrupt practices due to some or all of the following: monopoly of the services, discretion to make decisions, poor accountability, weak civil society and poor transparency. Secondly, individual beliefs, social norms, and eroding public service values may create an environment in which corrupt practices appear justified. Lastly, public officials may feel pressured to engage in corrupt practices due to low salaries, personal financial debt and economic hardships (Ruzindana et al.1998).
In line with UN Conventions against Corruption, the followings forms of corruption exist in the Ugandan healthcare system;
Bribery and Embezzlement: These are probably the largest form of corruption in Uganda. They are manifested in many ways. First, healthcare users pay bribes to public healthcare service providers to get services or be attended too. The healthcare worker illegally overcharging of patients/service users and others ask for kick-back from patients/healthcare users. By law, drugs like all others services at the government healthcare facilities are free of charge (except at few hospitals where cost sharing still exists) (Bariyo, 2012), but patients still pay for these services. For instance, according to National Service Delivery Survey 2008, 15.5% of patients at government healthcare facilities paid for drugs (IGG, 2010). Secondly, in human resource management, those who are responsible for posting get bribes to post healthcare workers in urban and peri-urban areas or accessible places. With respect to embezzlement, usually public healthcare providers steal the money that is supposed to buy drugs and other medical related services.
Abuse of function has become so pronounced in the Ugandan healthcare sector. This is manifested in many ways: first, public civil servants misuse government healthcare facilities and infrastructure. In many cases, government healthcare workers admit and use government healthcare facilities on their private patients. The vehicles especially ambulances are instead used to run the health unit in-charges personal errands instead of transporting the patients. Secondly, there are over-claims and falsifications of documents by civil servants in the healthcare sector.Third, funds directed to the healthcare sector are usually invested in activities such as capacity building workshops, where the organizers take a big chunk of the budget. Fourth, ghost workers and ghost healthcare centres have been created by Ministry of Health Officials. Fifth, fraud and supply of air (bad procurements) are rampant, six, most public healthcare workers divertpatients to their private health facilities; lastly, drug-leakage and politicalinfluence in the procurement process are common.
Absenteeism and reduced labour hours at public healthcare facilities have become common phenomena in the health sector in Uganda. As a copping strategy to inadequate remuneration in the healthcare sector, majority of healthcare workers absentee themselves from the public work while attending to their personal income generating activities to supplement their meager salaries.
Corruption has a great impact on healthcare service delivery and utilization in Uganda invarious ways.Drug/medicine and other non-medical stock-outs, supplying “air” at public health facilities are usually blamed on corrupt public officers who steal them from public health facilities (IGG, 2010). Such stock-outs and supplying of “air” has resulted into patients running out of drugs for many months (Bariyo, 2012; MoH, 2009b).
Since health budgets are drained through corruption and embezzlement, less funding is left to pay workers salaries and improving the working condition hence resulting into de-motivated workers, low quality care and service use. Thus corruption has significant negative effect on health indicators like infant and mortality rate (Guptal et al, 2002).
Bad procurement activities for works, goods and services has resulted into shoddy health infrastructure, low quality products, substandard products hence posing a danger to the patients’ lives.Under the-table payment, extortion of money by healthcare workerhas caused delays in care-seeking behavior among poor patients, thus resulting into complications and eventually loose of lives. Where, the poor patients have been unable to pay bribes to public healthcare workers, they have often been left to die helplessly at public healthcare facilities (
Due to corruption scandals, donors have often suspended their funding to the health sector and this greatly affected most patients who were unable to get access expensive private healthcare services. Much impact of donor fund suspension has been felt by HIV/AIDS and Tuberculosis patients.
Bribes paid to avoid government regulation of drugs and medicines often lead to dilution of drugs, vaccines and counterfeit and fake drugs on the market, hence becoming the health hazard and loss of life. Unregulated drugs that are of sub-therapeutic value usually lead to development of drug resistant organisms increase the vulnerability of the body to resist diseases. As a consequence malaria has become more resistant to medication in Uganda (Bariyo, 2004).
Unethical drug promotion where companies influence physicians and other healthcare workers to prescribe their products, even if they may not be effective has led to non-rational prescribing habits among many healthcare workers.
Since corruption is perceived as cancer, a number of interventions have been put in place in Uganda to fight against it. These have especially been under the institutional and legal frameworks.The 1995 National Constitution has a number of sections that are aimed at tackling corruption. The 1997 Local Government Act (amended 2006) has stringent measures against corruption. The leadership Code Act 2002 requires all senior public servants to declare in writing to the IGG, all their wealth every three years- indicating their sources of wealth. This is aimed at checking the senior public servants from abusing their offices.The National Drug Authority which was formed with the enactment of the National Drug Policy (2002), mandated to regulate the supply of medicines consumed in the country, has various arrangements for controlling and mainting high quality standards of medicines in Uganda aimed at prohibiting abuse of office.
In 2003, The Public Procurement and Disposal of Public Assets Act (2003) was enacted and lead into the formation of Public Procurement and Disposal of Public Assets Authority (PPDA), to regulate and control all public procurements and disposal of public assets with coreprinciples of non-discrimination, competition, fairness, honesty, best value for money ethical behavior and public accessibility. Under this Act, a number of roles and duties for each actor involved in public procurement and disposal of public assets are clearly articulated (MFPED, 2003).
The penal code was also enacted in Uganda to guard against corruption in the country. This code is enforced by institutions such as the Inspector General of Government (IGG), the Auditor General (AG) and the Department of Public Prosecutions (DDP) as well as the Police Force (Criminal Investigation department -CID and anti-corruption desk) and the recently established anti-corruption court.The 1995 National Constitution grantees the autonomy of the IGG, DPP and AG in the fight against corruption. The Ministry of Ethics and Integrity has also been created to fight against unethical behaviors, abuses of public office and corruption.The other government institutions that are charged with the task of fighting corruption are the presidency, the parliament and the judiciary.
The Anti-corruption Act (2009), led to the fully functioning of the anti-corruption court that had been established a year before. Since the establishment of the anti-corruption court a number of cases have been handled. For instance, between 2009 and 2011, the Anti-Corruption court had 232 convictions and 127 were pending (
Recently, Drug and Service Delivery Monitoring Unit, under the State House has been formed to fight against corruption and poor service delivery in the health sector. This unit that is headed by the former presidential Physician who works hand in hand with other agencies such as the Uganda Police in making surprise checks act public and private healthcare facilities suspected of selling government drugs. Of recent person have been arrested for various offences ranging from drug siphoning, ghost workers, inflated and falsified documents as well as being in possession of government drugs in private premises (Bariyo, 2012).
With decentralised healthcare delivery system that come in place after the enactment of the decentralization policy as enshrined both in the 1995 National Constitution and LGA 1997 (2006 amendment), local governments are mandated to play a number of roles in healthcare delivery (MoH,2009b). Under the community participation element encouraged by decentrealised healthcare system, Health Unit Management Committees (HUMCs) have been formed to oversee the activities of health centres. Albeit their weakness, HUMC where there are active, have been instrumental in fighting against corruption (Bariyo, 20012).With the launching of another anti-corruption watchdog, namely the Accountability Sector Secretariat, community participation is expected to be further strengthened, as that body together with the ‘Whistleblower Law’ and ‘Village Barazas’[1] (public forums) (The New Vision, April 21, 2009) and the adoption of the 2009 Patients’ Charters (MoH, 2009b) will equip the citizens with necessary information to continue questioning and demanding accountability from their leaders and service providers (Holland et al., 2009). Furthermore, the formation of civil society organizations such as Uganda Debt Network, HEPS-Uganda and Uganda National Health Users’/Consumers’ Organisation (UNHCO) continues to provide a platform for healthcare users to voice their concerns to government and healthcare providers about the quality of services provided and check on corruption tendencies(
Lastly, with the 2009 Patients’ Charter that aims at empowering health consumers to demand high quality healthcare, to promote their rights and improve the quality of life of all Ugandans (MoH, 2009), where citizens have been empowered and actively involved in healthcare delivery, corruption instances have greatly reduced. In order to enhance accountability and transparency, in the decentralized system, all the money that is received by public health departments, health centres is displayed on public notice boards for the citizens to view and comment. The liberalization of mass media in Uganda, both print and electronic, has provided so far the best fora where citizens have voiced their concern and exposed corrupt elements in the healthcare sector (Bariyo, 2012).
Despite all the interventions put in place to fight against corruption in the health sector in Uganda, corruption has persisted. This scenario is due to the following reasons:
The legislative and institutional frameworks that are in place have not been effective in the fight against corruption. Despite being scored 99% on having very good legal and institutional frameworks, Uganda had an implementation gap of 54% (Global Integrity report, 2009). The country’s implementation ineffectiveness has been due to inadequate funding, under staffing, inadequate trained and poorly motivated staff and inadequate logistical support. Such poor working conditions have in most cases compromised their integrity. Instead of fighting against corruption, institutions like the Police, Judiciary, the IGG office are corrupt themselves.
There are important legislations in the fight against corruption in Uganda that have not been passed into law despite being debated in Parliament for several years. Such include, the anti-money laundering, the Whistle blower protection Bill (2009) and the Counterfeit Bill. The absence of such legislations provides an avenue for corruption to thrive.
Political and presidential interference. Much as the NRM government, seems to be dedicated to fighting against corruption in the country, the financial scandals involving top politicians as well as presidential “legal” advice on suspected corrupt top NRM officials, has created a negative image among many Ugandans. For instance, in 2003 when the Presidential Political advisor was dragged to Court by IGG for not adhering to the Leadership code, the President filed an affidavit in support of his advisor and eventually the IGG lost the cases. Secondly, when the former vice president was imprisoned in 2011 for corruption cases, the President “legally” advised that the Vice-President had no case to answer. Eventually, the Anti-corruption court dropped all charges against the Vice President. Politicians at all levels are the major culprits in corruption scandals in the health sector. For instance in 2005, all three Ministers of Health were charged with misappropriation of over Ugandan shillings 1.8bn donor money from Global Alliance for Vaccines and Immunisation, meant for the immunisation of children (Ortendal, 2007). Surprisingly, to-date, those Ministers have not refunded that money! (Bariyo, 2012). Furthermore, some politicians and NGOs, Community Based Organisations (CBOs) connected to the ruling government that have been contracted to deliver healthcare services on behalf of the central and local governments, have misused the funds.