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> The Link Between Corruption and Poor Health

Fact Sheet for Anti-Corruption Week 2007, Produced by the Anti Corruption Coalition of Uganda (03. December 2007)

Corruption in the Health Sector

The Link Between Corruption and Poor Health

The majority of Ugandans live in rural areas and are dependent on the public health system. A big proportion of the population in Uganda lives below the poverty line with 31.1% (2006) of population living in absolute poverty, this means that many people can not afford private medical services and therefore require free medical services provided by Governmental. User-charges abolished in 2001 in all government health facilities in Uganda.

The sector unfortunately suffers from high level corruption (The health services are rated, second most corrupt institution in Uganda1). This has implications for the health of the citizens especially the poorest citizens. The evidence on the link between institutions and heath has largely relied on analyzing the cross-country relationships between corruption and health outcome measures. Evidence from 89 countries including Uganda for 1985 and 1997 show corruption indicators negatively associated with child and infant mortality, the likelihood of unattended birth, immunization coverage and low birth weight2. A research undertaken in Uganda on the link between leakages of drugs and health outcomes has likewise demonstrated the negative implications of drug leakages on the quality and accessibility of care in public health facililies3. People are not using the health care facilities when medicine is not available.

Availability of Medicine

The overall goal of the Anti Corruption Week 2007 is to ensure a significant increase in the availability of essential medicines.

Several studies have shown a low availability of essential medicines in the public health facilities. A value for money audit by the Auditor General confirms that almost 40% of the heath centres visited by the Auditor General (2006) lacked essential drugs and the Ugandan Medicine Survey Report (2004) found the median availability of the essential medicines surveyed to be 55 % at the public sector facilities4.

According to the Government of Uganda Health Sector Strategic Plan II (2005/2006-2009/2010) the following essential medicines should always be available in any heath centre:

1. Coartem (anti malarial)
2. Fansidar (anti malarial)
3. Measles Vaccine
4. Depo Provera (Family Planning)
5. ORS (diarrhoea and dehydration especially for children)
6. Cotrimoxazole (e.g. cough)

Leakage of Medicine

This campaign will contribute to increased availability of essential medicines by reducing the level of leakage and waste in the drug distribution system / chain. A comprehensive study carried out by among others the Ministry of Health has shown a leakages rate to 73% in public health facilities5.

Medicines tend to be a commonly “leaked” product given that it can fetch a higher price in the private market. It is estimated that the problem of leakage of medicines is less rampant than it used to be in the 1970ies and 80ies when there was a great shortage of medicines in the private market and therefore a lucrative outlet for medicines stolen from the public system6. The problem by 1999 was however very grave with an average leakage rate for drugs in Uganda estimated at 73%7. This figure is confirmed by a World Bank study from that shows a leakage rate of 70% in Uganda for drugs and supplies8.

Poor Management

Often irregularities poor governance and corruption simply stem from poor management. The Office of the Auditor General Office (OAG) was not able to form an opinion on the management of medicines in their latest report to Parliament (Financial Year 2006) because the staff were absent at the health centres inspected. A value for money audit (2006) by the OAG confirms that there a whole row of problems related to management of medicines that that may lead to misappropriation of funds, drug leakages going unnoticed and drugs shortages at health centres such as absence of asset/inventory registers and lack of transparency in the procurement process. The OAG notes among others that 23.5 % of the health centres visited did not have proper drug records. When store records are not maintained, it is possible for drug leakages to go un-noticed and which also leads to delay in the identification of drug stock outs and expired drugs.

The districts authorities are in charge of supervision and monitoring of health centres whereas the MOH is in charge of overall quality control. All stakeholders consulted by ACCU have pointed to poor or absent monitoring by district authorities. The OAG report stresses that inadequate monitoring and supervision affects management and thereby the quality of health service delivery. In addition there is an absence of corrective action to ensure enforcement of regulations9.

The National Drug Policy (2002) acknowledges that decentralisation of health service delivery has exacerbated the situation because of what they call uncertainty regarding roles and responsibility in the area of management. One may add that decentralisation has also increased the vulnerability to corruption practices by introducing more actors in the distribution chain.

We need better community oversight

It is important to introduce a way of increasing the accountability of health providers to the consumers and the communities that they are supposed to serve. Consumers generally lack the organisation and power to discipline other actors by voicing criticism or choosing a different health care provider. This campaign seeks to strengthen social accountability understood as an “approach towards building accountability that relies on civic engagement where ordinary citizens and civil society organisations participate directly or indirectly in exacting accountability. It is a broad range of actions and mechanisms that citizens, communities and CSOs and independent media can use to hold public officials and servants accountable.”

Decentralisation has provided some opportunities for better community oversight by bringing management of health services closer to the people. The Mid-term review of the HSSP I however concluded that the involvement of the communities as consumers of health services was poor. It is confirmed by studies from UNHCO that have indicated that the public are largely unaware of their rights and of channels of complaint and seeking redress. There is a lack of effective community oversight. Management committees meant to oversee and advise at health centre level rarely meet the members are unclear on their responsibilities, and have little involvement with strategic planning, targeting or budget control11. Oversight and management committees are in practice powerless and need to be seriously empowered to monitor and supervise effectively in a health care decentralised system.

1 Second National Integrity Survey 2003

2 Governance and Corruption in Public Health Care Systems, by Maureen Lewis (January 2006)

3 McPake et al. 1999

4 Uganda Medicine Pricing Survey Report, Ministry of Health, WHO, HAI (2004)

5 Mcpake et al, 1999

6 Interview with the Quality Assurance Department, MOH

7 McPake et al, 1999

8 Governance and Corruption in Public Heath Care Systems by Maureen Lewis (January 2006)

9 Auditor General’s report to Parliament for the financial year 2005

10 Enhancing Community Empowerment and Social Accountability in Uganda’s Health Sector F Njie and Gibwa Kajubi (Jarnuay 2007)

11 Mcpake et al, 1990
Anti Corruption week 2007
http://www.ms.dk/sw88128.asp

[This years’ Anti-Corruption Week will focus on: Transparency and accountability in distribution of essential medicines. The week runs from 3rd to 9th December and the national wide campaign will run throughout 2008. The activities will include processions, debates, forum theatre and an extended media campaign.]
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