The GAVI Alliance – an alliance of the world's major players in global immunisation – uncover... more The GAVI Alliance – an alliance of the world's major players in global immunisation – uncovered massive misuse of its grants in Cameroon in 2011. GAVI's Transparency and Accountability Policy triggered an investigation into the financial management of Cameroon's Health Systems Strengthening grant. The investigation revealed that, of US$5.1 million programme expenditures, US$3.7 million had been misspent, partly due to fraud. Different types of corruption affected this programme. Analysing how misuse was detected and how GAVI and the government responded, provides lessons on how similar abuses can be prevented in the future. In order to avoid grant mismanagement, programmes should have integrated transparency and accountability systems. This is also applicable to programmes in other sectors. GAVI's support to Cameroon and its immunisation programme GAVI is a public-private partnership whose mission is to save children's lives and protect people's health by inc...
Performance-based budgeting (PBB) is a public finance reform meant to increase accountability, tr... more Performance-based budgeting (PBB) is a public finance reform meant to increase accountability, transparency, and effectiveness of government resource allocation. The purpose of this study is to describe and model the factors affecting progress of performance-based budgeting reform in hospitals in Lesotho. We analyzed four case studies each centered on a single hospital's implementation of PBB. Data included document review (budgets, plans) and 52 in-depth interviews. We apply an organizational change theory--the Transformational Change (TC) model--to describe progress in implementing PBB reform in Lesotho. The hospitals showed little progress in budget reform which means that the researchers cannot relate the model's constructs to differences in outcomes. However, the TC model provides a lens to understand why the reforms may have failed. Factors of particular relevance include absence of reform leadership, lack of alignment of the structures, resources, and capabilities nee...
... Special Issue Article. CONFRONTING CORRUPTION IN THE HEALTH SECTOR IN VIETNAM: PATTERNS AND P... more ... Special Issue Article. CONFRONTING CORRUPTION IN THE HEALTH SECTOR IN VIETNAM: PATTERNS AND PROSPECTS. Taryn Vian 1,* ,; Derick W. Brinkerhoff 2 ,; Frank G. Feeley 1 ,; Matthieu Salomon 3 ,; Nguyen Thi Kieu Vien 3. ... Email: Taryn Vian (tvian@bu.edu). ...
According to the G20 2010 Anti-corruption Action Plan “corruption threatens the integrity of mark... more According to the G20 2010 Anti-corruption Action Plan “corruption threatens the integrity of markets, undermines fair competition, distorts resource allocation, destroys public trust, and undermines the rule of law.” However, how much it undermines, distorts and destroys -- and in what sectors it threatens the integrity of markets the most -- is difficult to quantify. The design of efficient strategies and priorities requires improved knowledge of the problem’s extent, its causes and the mechanisms at play. This paper is based on a stock-taking review of the existing data and literature by researchers with competence on corruption in various sectors, augmented by analysis undertaken by international organizations. The study is conducted for the G20 Anti-Corruption Working Group under the leadership of the OECD Secretariat in collaboration with staff of the World Bank Group. Governments and multilateral organizations have the responsibility to enforce anticorruption rules and promote...
Universal Health Coverage seeks to assure that everyone can obtain the health services they need ... more Universal Health Coverage seeks to assure that everyone can obtain the health services they need without financial hardship. Countries which rely heavily on out-of-pocket (OOP) payments, including informal payments (IP), to finance total health expenditures are not likely to achieve universal coverage. The Republic of Moldova is committed to promoting universal coverage, reducing inequities, and expanding financial protection. To achieve these goals, the country must reduce the proportion of total health expenditures paid by households. This study documents the extent of OOP payments and IP in Moldova, analyses trends over time, and identifies factors which may be driving these payments. The study includes analysis of household budget survey data and previous research and policy documents. The team also conducted a review of administrative law intended to control OOP payments and IPs. Focus groups, interviews, and a policy dialogue with key stakeholders were held to validate and discuss findings. OOP payments account for 45% of total health expenditures. Sixteen percent of outpatients and 30% of inpatients reporting that they made OOP payments when seeking care at a health facility in 2012, more than two-thirds of whom also reported paying for medicines at a pharmacy. Among those who paid anything, 36% of outpatients and 82% of inpatients reported paying informally, with the proportion increasing over time for inpatient care. Although many patients consider these payments to be gifts, around one-third of IPs appear to be forced, posing a threat to health care access. Patients perceive that payments are driven by the limited list of reimbursable medicines, a desire to receive better treatment, and fear or extortion. Providers suggested irrational prescribing and ordering of tests as drivers. Providers may believe that IPs are gifts and do not cause harm for patients and the health system in general. Efforts to expand financial protection should focus on reducing household spending on medicines and hospital-based IPs. Reforms should consider ways to reduce medicine prices and promote rational use, strengthen administrative controls, and increase incentives for quality health care provision.
The Global Fund to Fight AID, Tuberculosis and Malaria and the World Health Organization host pub... more The Global Fund to Fight AID, Tuberculosis and Malaria and the World Health Organization host public databases containing information of medicine procurement transactions. In this paper we describe how publicly available data can be obtained and enhanced towards the promotion of transparency and accountability in the pharmaceutical sector. Drawing on more than 5 years of data containing more than 10,000 procurement transactions for antiretroviral medicines, we present 2 different transparency tools to illustrate how transparency and accountability can be linked to promote better outcomes and value for money. The first tool is an outlier analysis to identify and investigate prices that are far in excess of the global distribution of prices paid for that same product. Low price outliers are worthy of investigation to learn best practices, while high price outliers are worthy of investigation to identify and address reasons for excessive prices. Applying this tool to our procurement da...
Per diems are used to pay work-related expenses and motivate employees, yet they also can distort... more Per diems are used to pay work-related expenses and motivate employees, yet they also can distort incentives and may be abused. This study was designed to explore perceptions of per diems among 41 high-, mid- and low-level government officers and non-governmental organization (NGO) officials in Malawi and Uganda. Interviews explored attitudes about per diems, benefits and problems for organizations and individuals, and risks and patterns of abuse. The study found that per diems provide benefits such as encouraging training, increasing staff motivation and supplementing salary. Despite these advantages, respondents voiced many discontents about per diems, stating that they create conflict, contribute to a negative organizational culture where people expect to be paid for all activities, and lead to negative changes in work time allocation. Work practices are also manipulated in order to maximize financial gain by slowing work, scheduling unnecessary trainings, or exaggerating time ne...
Strategies to increase transparency and accountability often include complaints mechanisms by whi... more Strategies to increase transparency and accountability often include complaints mechanisms by which organisations can respond to individual suspicions of corruption and other grievances. This Brief discusses how complaints mechanisms have been used by the vigilance director for health's office in Karantaka state, India, and by Partners in Health – an international NGO that manages health service delivery projects. These cases suggest that complaints mechanisms should be reinforced by political and judicial systems that support investigation and prosecution. A focus on individual level grievances should be balanced with institutional reforms that address management and accountability problems that complaints may reveal. Benefits of complaints mechanisms Complaints mechanisms are an important way an organization can get a "tip" about ongoing fraud or misuse. This can help organizations to investigate fraud and improve systems to reduce risk in the future. Complaints mech...
We conducted a synthesis of peer-reviewed literature to shed light on links between governance me... more We conducted a synthesis of peer-reviewed literature to shed light on links between governance mechanisms and health outcomes in low- and middle-income countries. Our review yielded 30 studies, highlighting four key governance mechanisms by which governance may influence health outcomes in these settings: Health system decentralization that enables responsiveness to local needs and values; health policymaking that aligns and empowers diverse stakeholders; enhanced community engagement; and strengthened social capital. Most, but not all, studies found a positive association between governance and health. Additionally, the nature of the association between governance mechanisms and health differed across studies. In some studies (N = 9), the governance effect was direct and positive, while in others (N = 5), the effect was indirect or modified by contextual factors. In still other studies (N = 4), governance was found to have a moderating effect, indicating that governance mechanisms ...
Health care public-private partnerships (PPPs) between a government and the private sector are ba... more Health care public-private partnerships (PPPs) between a government and the private sector are based on a business model that aims to leverage private-sector expertise to improve clinical performance in hospitals and other health facilities. Although the financial implications of such partnerships have been analyzed, few studies have examined the partnerships' impact on clinical performance outcomes. Using quantitative measures that reflected capacity, utilization, clinical quality, and patient outcomes, we compared a government-managed hospital network in Lesotho, Africa, and the new PPP-managed hospital network that replaced it. In addition, we used key informant interviews to help explain differences in performance. We found that the PPP-managed network delivered more and higher-quality services and achieved significant gains in clinical outcomes, compared to the government-managed network. We conclude that health care public-private partnerships may improve hospital performa...
The GAVI Alliance – an alliance of the world's major players in global immunisation – uncover... more The GAVI Alliance – an alliance of the world's major players in global immunisation – uncovered massive misuse of its grants in Cameroon in 2011. GAVI's Transparency and Accountability Policy triggered an investigation into the financial management of Cameroon's Health Systems Strengthening grant. The investigation revealed that, of US$5.1 million programme expenditures, US$3.7 million had been misspent, partly due to fraud. Different types of corruption affected this programme. Analysing how misuse was detected and how GAVI and the government responded, provides lessons on how similar abuses can be prevented in the future. In order to avoid grant mismanagement, programmes should have integrated transparency and accountability systems. This is also applicable to programmes in other sectors. GAVI's support to Cameroon and its immunisation programme GAVI is a public-private partnership whose mission is to save children's lives and protect people's health by inc...
Performance-based budgeting (PBB) is a public finance reform meant to increase accountability, tr... more Performance-based budgeting (PBB) is a public finance reform meant to increase accountability, transparency, and effectiveness of government resource allocation. The purpose of this study is to describe and model the factors affecting progress of performance-based budgeting reform in hospitals in Lesotho. We analyzed four case studies each centered on a single hospital's implementation of PBB. Data included document review (budgets, plans) and 52 in-depth interviews. We apply an organizational change theory--the Transformational Change (TC) model--to describe progress in implementing PBB reform in Lesotho. The hospitals showed little progress in budget reform which means that the researchers cannot relate the model's constructs to differences in outcomes. However, the TC model provides a lens to understand why the reforms may have failed. Factors of particular relevance include absence of reform leadership, lack of alignment of the structures, resources, and capabilities nee...
... Special Issue Article. CONFRONTING CORRUPTION IN THE HEALTH SECTOR IN VIETNAM: PATTERNS AND P... more ... Special Issue Article. CONFRONTING CORRUPTION IN THE HEALTH SECTOR IN VIETNAM: PATTERNS AND PROSPECTS. Taryn Vian 1,* ,; Derick W. Brinkerhoff 2 ,; Frank G. Feeley 1 ,; Matthieu Salomon 3 ,; Nguyen Thi Kieu Vien 3. ... Email: Taryn Vian (tvian@bu.edu). ...
According to the G20 2010 Anti-corruption Action Plan “corruption threatens the integrity of mark... more According to the G20 2010 Anti-corruption Action Plan “corruption threatens the integrity of markets, undermines fair competition, distorts resource allocation, destroys public trust, and undermines the rule of law.” However, how much it undermines, distorts and destroys -- and in what sectors it threatens the integrity of markets the most -- is difficult to quantify. The design of efficient strategies and priorities requires improved knowledge of the problem’s extent, its causes and the mechanisms at play. This paper is based on a stock-taking review of the existing data and literature by researchers with competence on corruption in various sectors, augmented by analysis undertaken by international organizations. The study is conducted for the G20 Anti-Corruption Working Group under the leadership of the OECD Secretariat in collaboration with staff of the World Bank Group. Governments and multilateral organizations have the responsibility to enforce anticorruption rules and promote...
Universal Health Coverage seeks to assure that everyone can obtain the health services they need ... more Universal Health Coverage seeks to assure that everyone can obtain the health services they need without financial hardship. Countries which rely heavily on out-of-pocket (OOP) payments, including informal payments (IP), to finance total health expenditures are not likely to achieve universal coverage. The Republic of Moldova is committed to promoting universal coverage, reducing inequities, and expanding financial protection. To achieve these goals, the country must reduce the proportion of total health expenditures paid by households. This study documents the extent of OOP payments and IP in Moldova, analyses trends over time, and identifies factors which may be driving these payments. The study includes analysis of household budget survey data and previous research and policy documents. The team also conducted a review of administrative law intended to control OOP payments and IPs. Focus groups, interviews, and a policy dialogue with key stakeholders were held to validate and discuss findings. OOP payments account for 45% of total health expenditures. Sixteen percent of outpatients and 30% of inpatients reporting that they made OOP payments when seeking care at a health facility in 2012, more than two-thirds of whom also reported paying for medicines at a pharmacy. Among those who paid anything, 36% of outpatients and 82% of inpatients reported paying informally, with the proportion increasing over time for inpatient care. Although many patients consider these payments to be gifts, around one-third of IPs appear to be forced, posing a threat to health care access. Patients perceive that payments are driven by the limited list of reimbursable medicines, a desire to receive better treatment, and fear or extortion. Providers suggested irrational prescribing and ordering of tests as drivers. Providers may believe that IPs are gifts and do not cause harm for patients and the health system in general. Efforts to expand financial protection should focus on reducing household spending on medicines and hospital-based IPs. Reforms should consider ways to reduce medicine prices and promote rational use, strengthen administrative controls, and increase incentives for quality health care provision.
The Global Fund to Fight AID, Tuberculosis and Malaria and the World Health Organization host pub... more The Global Fund to Fight AID, Tuberculosis and Malaria and the World Health Organization host public databases containing information of medicine procurement transactions. In this paper we describe how publicly available data can be obtained and enhanced towards the promotion of transparency and accountability in the pharmaceutical sector. Drawing on more than 5 years of data containing more than 10,000 procurement transactions for antiretroviral medicines, we present 2 different transparency tools to illustrate how transparency and accountability can be linked to promote better outcomes and value for money. The first tool is an outlier analysis to identify and investigate prices that are far in excess of the global distribution of prices paid for that same product. Low price outliers are worthy of investigation to learn best practices, while high price outliers are worthy of investigation to identify and address reasons for excessive prices. Applying this tool to our procurement da...
Per diems are used to pay work-related expenses and motivate employees, yet they also can distort... more Per diems are used to pay work-related expenses and motivate employees, yet they also can distort incentives and may be abused. This study was designed to explore perceptions of per diems among 41 high-, mid- and low-level government officers and non-governmental organization (NGO) officials in Malawi and Uganda. Interviews explored attitudes about per diems, benefits and problems for organizations and individuals, and risks and patterns of abuse. The study found that per diems provide benefits such as encouraging training, increasing staff motivation and supplementing salary. Despite these advantages, respondents voiced many discontents about per diems, stating that they create conflict, contribute to a negative organizational culture where people expect to be paid for all activities, and lead to negative changes in work time allocation. Work practices are also manipulated in order to maximize financial gain by slowing work, scheduling unnecessary trainings, or exaggerating time ne...
Strategies to increase transparency and accountability often include complaints mechanisms by whi... more Strategies to increase transparency and accountability often include complaints mechanisms by which organisations can respond to individual suspicions of corruption and other grievances. This Brief discusses how complaints mechanisms have been used by the vigilance director for health's office in Karantaka state, India, and by Partners in Health – an international NGO that manages health service delivery projects. These cases suggest that complaints mechanisms should be reinforced by political and judicial systems that support investigation and prosecution. A focus on individual level grievances should be balanced with institutional reforms that address management and accountability problems that complaints may reveal. Benefits of complaints mechanisms Complaints mechanisms are an important way an organization can get a "tip" about ongoing fraud or misuse. This can help organizations to investigate fraud and improve systems to reduce risk in the future. Complaints mech...
We conducted a synthesis of peer-reviewed literature to shed light on links between governance me... more We conducted a synthesis of peer-reviewed literature to shed light on links between governance mechanisms and health outcomes in low- and middle-income countries. Our review yielded 30 studies, highlighting four key governance mechanisms by which governance may influence health outcomes in these settings: Health system decentralization that enables responsiveness to local needs and values; health policymaking that aligns and empowers diverse stakeholders; enhanced community engagement; and strengthened social capital. Most, but not all, studies found a positive association between governance and health. Additionally, the nature of the association between governance mechanisms and health differed across studies. In some studies (N = 9), the governance effect was direct and positive, while in others (N = 5), the effect was indirect or modified by contextual factors. In still other studies (N = 4), governance was found to have a moderating effect, indicating that governance mechanisms ...
Health care public-private partnerships (PPPs) between a government and the private sector are ba... more Health care public-private partnerships (PPPs) between a government and the private sector are based on a business model that aims to leverage private-sector expertise to improve clinical performance in hospitals and other health facilities. Although the financial implications of such partnerships have been analyzed, few studies have examined the partnerships' impact on clinical performance outcomes. Using quantitative measures that reflected capacity, utilization, clinical quality, and patient outcomes, we compared a government-managed hospital network in Lesotho, Africa, and the new PPP-managed hospital network that replaced it. In addition, we used key informant interviews to help explain differences in performance. We found that the PPP-managed network delivered more and higher-quality services and achieved significant gains in clinical outcomes, compared to the government-managed network. We conclude that health care public-private partnerships may improve hospital performa...
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