The authors are staff members at LSHTM and are all involved in the health sector component of the SOAS Anti-Corruption Evidence (ACE) programme

Once, such things were only talked of in private. But this time it was different. Those present, coming from government, universities, civil society, and international agencies, were speaking openly about what they all knew was one of the main barriers to providing high quality healthcare to those in need – corruption. A dedicated World Health Organization meeting in Geneva in March 2018 focused on anti-corruption, transparency and accountability in the health sector.  And all those attending were united in their determination to find ways to make these tricky concepts into a reality.

Large bureaucracies are not known for their willingness to confront controversial and difficult issues, as is apparent from even a quick skim of the anthropology literature on international organizations, but thankfully this meeting felt different. There was a shared sense that something must and could be done, no matter how difficult it would be. Corruption could no longer be swept under the carpet. There was also a sense of relief, as everyone understood that this was the beginning of a conversation we should have been having years ago.

Although the topic could easily have generated despair, there was optimism. We saw the Sustainable Development Goals, with their commitments to Universal Health Coverage and to Leave No One Behind, as creating an imperative to tackle corruption throughout the health system. And many offered examples of excellent, innovative anti-corruption work, albeit in isolated pockets. It seemed that sharing experiences and mutual support offered hope for lasting changes in health systems. Crucially, there was a real sense of urgency and a recognition that action was needed at all levels, from the Ministry of Health to the individual community worker.

Back in London, we reflected on the meeting and kept coming back to the same question: why has the international community been relatively silent on corruption in health systems? We identified five main reasons:

1. We find it hard to define corruption. We are not alone; the United Nations Convention against Corruption does not even try. Instead, it identifies discrete corrupt practices.
2. Corruption may allow some fragile health systems simply to keep going. If we remove corruption without addressing the other weaknesses in the health system, will we threaten the delivery of care further and hurt the most vulnerable?
3. Blame shifting – those involved in graft often identify other, less powerful actors as corrupt and deflect attention from themselves. If we engage in anti-corruption research will we just be colluding with corrupt officials?
4. Some people view concerns about corruption as a manifestation of the neoliberal attack on the state. It was prioritized by development agencies in the 1980s during the Reagan-Thatcher era, when many public health systems were being dismantled.
5. The big one: We still don’t know how to tackle corruption. Despite years of investment in good governance, levels of corruption remain high and, in some places, growing. A Cochrane review found little good evidence on what to do in health systems – something we are now addressing through our work as part of the Anti-Corruption Evidence research consortium.

So, can we overcome these problems and begin the debate on corruption in health systems? A good start is to ask what and who we should focus on, even if we lack agreed definitions and tried and tested strategies?

First, policy makers, frontline health staff and NGOs must come together to identify corruption in their health system. Yet they cannot do this alone. They need support and, in some cases, protection, to expose corrupt practices that are clearly detrimental to the health system. Some corrupt practices undermine the system – but others may be essential to keep it going. Others may not actually matter much. If those concerned can focus on what matters, and what is damaging patient care, we can maximise our chances of success and minimize risks.

Second, we must focus on corrupt practices that can actually be changed. We can’t expect health workers to eliminate high-level graft but we can discover what drives rule breaking and elicits rent seeking by health workers and their managers and then formulate strategies to tackle them.

Thirdly, we need to look from many perspectives. We have found that corruption in health is explored in the anthropology and political economy literature but poorly recognized within the health community. In our Anti-Corruption Evidence research consortium we are conducting a series of projects on what encourages corruption among health workers. However, what has been written is largely missed by the main databases covering health systems, Pubmed and EconLit, as it is in other fields or in the grey literature. What we do know is that there is never one single factor but many. Consequently, there are no silver bullets. Instead, we will have to devise strategies based on an understanding of how different drivers interact with one another, with what effect, and who within the system can support policy makers as they promote adherence to rules.

It is striking that corruption remains largely absent from the international health systems agenda. It has failed to engage global policymakers, who seem to put it in the “too difficult” tray. Except for a few groups, such as Transparency International, no-one is pressing for it to receive attention. Nobody has defined a research agenda. It barely features at major conferences. Yet, within countries, there is widespread recognition that addressing corruption is the first, and not the last task when strengthening health systems.

Corruption is finally edging into the spotlight – what we do next is the real question.

To discuss these issues, please joint us at the satellite session at the Fifth Symposium for Health Systems Research in Liverpool, ‘Anti-corruption by design: understanding and tackling health system corruption on the road to Universal Health Coverage’ convened by David Clarke (WHO), Dina Balabanova and Eleanor Hutchinson (LSHTM), on 9 October 2018, 08:00 – 11:30 in conference room 11A, http://healthsystemsresearch.org/hsr2018/

 For more information on the subject, see The Conversation