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Skip to 0 minutes and 7 seconds OLUWASEUM AKINYEMI: The Power of Incentives– The Role of Corruption. First, before we get into an example of how corruption has influenced polio eradication, let’s take a moment to think about what corruption is and what it is not and steps that can be taken to curb it. Corruption can be found in different forms in all society and at all levels of health system. Do you agree with this assertion? Corruption is not something that is limited to local health systems or poorly resourced health system, as many times we are tempted to think. It can be found in different forms at all levels of health systems. Let’s take one example from WHO deliberations in Geneva.

Skip to 1 minute and 3 seconds In 2018, a resolution to promote breastfeeding, the best food for the health of babies, was expected to pass quickly at the World Health Assembly, but it was blocked by the US delegation, who pressured other countries not to support it, a move that helps formula manufacturers and hurts children. The point is not that corruption is inevitable, some systems have much less of it than others. But that should not be thought of as an issue that affects only local health system in poor countries. So corruption is not just a problem of poor countries. It is a problem of both the poor and the richer countries. Let’s go a little into history. Corruption is influenced by history.

Skip to 1 minute and 58 seconds Let’s take the case of former British colonies– Bangladesh, India, and Pakistan. In South Asia, the practice of making money from bureaucratic posts has a deep history in South Asia. British civil servants in the East India Company in the late 1700s faced with extremely high mortality rates that meant death was more likely than return to England. According to Barrow in 2017, they sought to make as much money as possible as quickly as possible. They used the advantages of their East India Company position to engage in private trade, demand and keep rents for East India Company property, and amass fortunes collected from wealthy Indians who were dependent on them.

Skip to 2 minutes and 59 seconds The extreme wealth of returned East India Company employees created a scandal in Britain. As a result, the British parliament began pulling the East India Company under its control. And the focus on writing documentation as a symbol of transparency and accountability arose. Then, as now, a bureaucrat’s ability to extract resources from results [INAUDIBLE] bureaucracy dependent on their ability to create the paperwork legitimizing the scam. The echoes or the ghosts of this bureaucracy can still be felt in modern South Asian practice. So corruption is not just about money. It’s also about politics and power. The governance and funding structure of global immunization programs led to policies that are often more heavily influenced by donors than by local government.

Skip to 4 minutes and 3 seconds Sometimes corruption is explained with reference to the low wages of [INAUDIBLE]. This is part of the story but not the whole story. Wealthy bureaucrats engage in corruption too. Within governments, both corruption and efforts to curb it are often shaped by interaction between national and local actors. [INAUDIBLE] again make conflicts. Corruption is a set of practices embedded in the power relation, power struggles of political entities at multiple levels. Why will this be something to understand when thinking about corruption? You might think, how my local staff justify corrupt practices in polio eradication? Answers include that local staff might not be that into the eradication objective. And they may see stealing from the obviously deep pockets of international organizations as a victimless crime.

Skip to 5 minutes and 3 seconds So corruption doesn’t always directly negatively impact service delivery. Someone might argue. But smooth operators can make money and still vaccinate children. Let’s take a look at how this might work. We’ll give an example here of the village that didn’t exist. Let me tell you a short story. Let’s take one small, concrete example to understand the complexities of dealing with an issue of corruption. Let’s use the example of microplanning since we have just been discussing it. We’ll leave the identifying information, including the country, out of this example. And this sort of thing happened in multiple countries. But is a real example from polio eradication.

Skip to 5 minutes and 53 seconds In this example, an enterprising ground-level worker had created an entire village on paper in an area that was, in fact, unpopulated deserts. The microplans are lavishly drawn maps, local influences, and even migratory populations. They were truly excellent microplans that checked every box. The only issue was that the whole community was made up. None of the neighborhoods actually existed, nor did the workers who were supposed to vaccinate the children in this population. Why would a worker do this, you might ask? And I’d like you to think about it. Why do you think anyone would do that, create a village, a whole village that didn’t exist?

Skip to 6 minutes and 47 seconds The answer is that, as you may have guessed, the worker can now pocket all the resources for trainings, per diems, and so on, that have been allocated for vaccination coverage in this imaginary village. However, given the low rates of reimbursement, this accounted for less than $30 per campaign. This is an example of corruption where the staff have to work for their money. Now, when are supplementary immunization activities monitored? There are three phases, as you can see on this slide, precampaign supervision– that is before the supplementary immunization. And then in-process monitoring, that is during the supplementary immunization. And that might have some other sub-state, one, two, three, four.

Skip to 7 minutes and 43 seconds And finally, the post-supplementary immunization, which is end process monitoring just after the supplementary immunization activity. During the pre-supplementary immunization activity, we want to assess preparedness. And this may be used for immediate corrective measures. And during the in-process monitoring, we want to assess ongoing operations and unvaccinated children and areas while the supplementary immunization is going on. This can also be used for immediate corrective measure. Whereas the end process monitoring, which is just after the supplementary immunization, is used to assess unvaccinated children and areas so that you can possibly plan for a mop up and future supplementary immunization. So let’s go back to this slide from the lecture one.

Skip to 8 minutes and 45 seconds So what part of this monitoring do you think are designed to fight corruption? Is it the pre, the in-process, or the end process monitoring? Let’s take this a step further. If you are an enterprising local vaccinator, are there ways you could use the monitoring system itself to make money? Not an easy endeavor, to be sure, but given years of work in a sometimes boring job, you could probably come up with some ways. In the case of faked microplans described above, the local staff also created fake monitoring documents for this fake population. Perhaps unsurprisingly, the coverage was excellent. A creative game– in many health systems, data collection practices are sites of complex and creative money making and exchange system.

Skip to 9 minutes and 41 seconds Rules for collecting and reporting data can be the playing ground for a sophisticated game. Workers and officials may create, manipulate, and deploy data in complex ways to make the numbers look better and also to divert vaccination funding into their own pockets. In the case of the fake village we describe earlier, the fake village was used both to make money and to improve coverage numbers. See, the fake monitoring documents evaluating coverage in the fake village [INAUDIBLE] represent vaccination coverage. So what can the independent monitor do? It’s been said that you get what you inspect, not what you expect.

Skip to 10 minutes and 30 seconds In your opinion, which parts of the monitoring process, the pre, during, or post, do you think the independent monitor has direct power over? In the example of the fake village, both independent monitors and WHO staff knew about this problem. In fact, it was widespread in this district. They brought it to the attention of the local health administrator. Nothing was done. The people who were creating fake village were politically connected. So the next question is how bent out of shape will you get over these things? It doesn’t affect vaccination of children in other areas. Do you go after it aggressively on principle and risk ruining a relationship? Or will you let it go? What would go into making this decision?

Skip to 11 minutes and 28 seconds I’d like to think about this. So this explains the utility of independent monitoring and lot quality assurance sampling, the L-Q-A-S. This came as a result of problems like this. But why does finding problems not always eliminate the problem? It is one thing to find a problem. But it’s another thing to eliminate it. Improving accountability– and this is an example from Nigeria. One approach that did lead to an increase in performance came from Nigeria. In 2011, a review committee noted underperformance and weak accountability at many levels of the system. In response, several steps were taken.

Skip to 12 minutes and 18 seconds One was that each local government area was tasked with identifying four critical impediments to achieving population immunity against polio and for carrying out a specific solution. Progress against these solutions was also tracked using this table, as you can see. The first column has critical impediment to achieving greater than 90% population immunity, the second, specific evidence for decision, then specific solution, and after that additional resources if required, then individual responsible for implementation, and finally, deadline for such implementation. Do you think this would be helpful in the example we discussed? Why? Or why not? Do you think it’s useful in your own country, in your context? Could it create additional opportunities for corruption? Another example from Nigeria [INAUDIBLE] improving accountability.

Skip to 13 minutes and 26 seconds Standard operating procedures with deliverables for staff at all levels, standard operating procedures with very specific performance indicators were developed. These included collecting data. And they were evaluating things like surveillance, percent of acute flaccid paralysis cases, AFP cases, investigated within 48 hours, and 7 days of [INAUDIBLE],, percentage of cases with timely 60 day follow up. It also evaluated things like immunization, routine immunization centers monitored during campaigns, percentage of facilities with vaccine stock out, and supplementary immunization activities, particularly in wards with updated microplans, proportion of local government area scoring higher than 85% in LQAS monitoring, and data quality, for example, dates on all surveillance reports. Whether the date’s on all surveillance reports makes sense.

Skip to 14 minutes and 31 seconds Cases can’t be investigated before they occur, for example. So if the dates on surveillance reports comes before the problem, then you knew that something is wrong. And this is used across different levels, national, zonal, state, cluster, local government area, and at the ward level. The third example from Nigeria on improving accountability– as this chart shows, after introducing quality indicators, many more staff were identified for needing some discussion about improvement. In the end, 400 low performing staff were fired. And many good performing staff were promoted.

Skip to 15 minutes and 22 seconds Some with familiarity with these programs said that was a major turning point for GPI and the endemic countries which all had such frameworks that resulted in removing many people from the polio program, both nationals, and WHO, to UNICEF staff, for poor or nonperformance and replacing them with new staff. Now we will discuss the sandwich strategy for accountability framework solution. Here is the social accountability framework. Do you think this would be helpful in the example we just discussed? Why do you think this would be so, or why not? This framework says this specific [INAUDIBLE] chain here is that the construction of accountability, driven by a coalition of pro-accountability forces the bridge the state-society divide.

Skip to 16 minutes and 25 seconds Anti-accountability forces deeply embedded in both states and society are often stronger than pro-accountability forces. To break these low accountability traps, resistance is likely. And therefore, conflicts will be both expected and necessary. The main determinant of a subsequent pro-accountability power shift is whether or not pro-change actors in one domain can empower the others, thereby triggering a virtuous cycle. This is scenario of mutual empowerment. Reformists within the state need to have actual capacity to deliver to their societal counterparts. So far, however, people have tended to assume that citizen voice by itself is supposed to be able to do the work of the state’s own [INAUDIBLE] accountability institution. Yet few voice-led initiatives are well coordinated with relevant public sector reforms that encourage responsiveness.

Skip to 17 minutes and 40 seconds That is audits, anti-corruption investigative bodies, information access reforms, grievance redress mechanisms, and access to cuts. Do accountability systems eliminate corruption or give new opportunities? I’m going to share quotes by Anuradha Sharma, “Corruption exists not because there are insufficient laws and rules but because of their teeming overabundance.” Do you agree with this quote? Polio eradication officials have sometimes found themselves in a game of metrics, cat and mouse. International agencies and national governments have found new ways to evaluate vaccination coverage and data quality, like the LQAS system. At times, local government has found new ways to use those systems to their advantage. Theorists of corruption have argued each anti-corruption effort transformed the logic of corruption practices.

Skip to 18 minutes and 49 seconds And each corrupt practice called forth new kinds of anti-corruption measures. Do you agree? It seems as new measures are developed to reduce corruption, the corrupt tends to evolve and try to beat the system. What’s your opinion about this? What will you do in the case of fake microplans? What steps would you need to take to understand how best to deal with this situation? How could your planning and management system plan ahead for corruption? Now, there are no easy answers to these questions. But preparing for and considering corruption at all levels is an essential part of good management. So it is good practice to plan ahead and consider what you will do when corruption rears its ugly head.

Skip to 19 minutes and 50 seconds Ignoring that it will not happen might be like living in a fool’s paradise. We just need to think about it ahead and have plans how to curtail it before it happens. I believe that is the way to go.

The Power of Incentives: Role of Corruption

Oluwaseun Akinyemi, MD, MPH, FWACP, FRSPH, PhD College of Medicine, University of Ibadan & University College Hospital, Nigeria

Preparing for and considering corruption at all levels is an essential part of good planning and management.

In the example of the fake village described in the lecture, both independent monitors and WHO staff knew about this problem. In fact, this practice was widespread in this district, and was brought to the attention of the local health administrator. But, nothing was done about it. The people who were creating fake villages were politically connected.

How do you react to such a situation? It doesn’t affect vaccination of children in other areas. Do you go after it aggressively on principle and risk ruining a relationship? Or will you let it go? What would go into making this decision?

Using the contents of the lecture and the provided reading on The Uncertain Relationship Between Transparency and Accountability, post your answer in the discussion.


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