Roundtable discussion: Accountability and Corruption

ANNA KALBARCZYK: Hi, everyone. Welcome back. I’m Anna Kalbarczyk. And today, I’m joined by Dr. Svea Closser and Dr. Kunle Alonge. And we’re all faculty at the School of Public Health, the Johns Hopkins Bloomberg School of Public Health. And today, I want to raise a divisive issue and discuss corruption. Corruption happens in every health system in every country in the world. It’s not just a disease control program issue or an issue for low and middle income countries. And I know that this topic is very near and dear to Svea. So I’ll ask her to start. From your experience, where does corruption exist in the health system and why?

SVEA CLOSSER: Well, as you said, corruption exists in all health systems. And it exists because there’s a lot of money that flows through health systems. And so in any health system, there are going to be people trying to figure out how they can divert some of that money into their own pockets. Some people will choose to do that. Some people will choose not to do that. But you can say that’s probably a human universal, that anytime you’ve got people in a system with lots of money flowing through it, there will be people looking at trying to get their hands on some of that money.

So when we think about something like the polio program, it’s particularly helpful when thinking about corruption to look at where the money is flowing, where it’s coming from, and where it’s going, because you can sort of follow the money to where the corruption is going to happen, right? So in the polio program, you’ve got a huge amount of money, relatively speaking, compared to other diseases, coming mostly from external donors outside a country and flowing into health systems that may be quite underfunded. And so that’s the backdrop for thinking about or understanding corruption in this context.

So it’s going to look different than it would, say, in health system like the United States, where a lot of the money gets funded through insurance and reimbursements. And so you see corruption in places like pharmaceutical kickback, stuff like that. So the structure of the funding is going to shape the way that corruption looks. And so is it an issue in polio eradication? Yes. And that is a result of it there being so much money entering into a system that might not be quite set up to handle it in a way that can prevent corruption.

OLAKUNLE ALONGE: Yeah. If I can just chip in, I think the last point, with regards to money coming into systems or into settings that may not be able to handle it is really key. Just as Svea kind of mentioned, the corruption is at every level, even from the source where the money is coming from or even in the places where the money is used. You’ll find inflow of large sum of money to areas that are deprived and to people that have– they’ve kind of missed a lot of opportunity. I mean, they don’t have the basic necessities. The natural tendency for human is to seek personal advantages, even within– within those settings. And people do that to different– to different extent.

So it’s really important to not just think about the flow of the resources, but to also think about the background in terms of how the money– how the money contrasts against the background or the setting in which it’s flowing into. And trying to make sure that the system is such that it can actually accommodate that. And the people within the system also can actually effectively manage the resources.

SVEA CLOSSER: Yeah. I couldn’t agree more. And I think it’s– that points to this issue that it’s really helpful to think of corruption not as a moral issue, but rather as a function of the way the system is set up.

OLAKUNLE ALONGE: Exactly.

SVEA CLOSSER: So when you’re thinking about trying to reduce corruption, it’s not particularly helpful to get on a moral high horse about it. It’s much more helpful to think about how is the system structured and why is it getting used in this way?

ANNA KALBARCZYK: As we talk about systems, one of the things I recall really emerging from our data were conversations around accountability systems, so accountability systems to combat corruption. But do you think that accountability systems really do eliminate corruption or maybe sometimes offer new opportunities for corruption?

OLAKUNLE ALONGE: From my personal experience, and of course, given my interest on my work in implementation science, is I see accountability system as a set of strategies or interventions to address corruption or to create efficiency within the system. It’s run for any kind of intervention. So for you to achieve its objective, it has to be properly set up. So if it’s not properly set up, then we have the scenario where we have intervention failures. So I mean, there are things that you would expect from the accountability system to include. And it’s obviously participation of the people that are involved. Voice, people should be able to speak to the issues at hand and [? teeth.

?] They should be able to reprimand. They should be able to punish. They should be able to control reward and punishment to ensure that the right action takes place. So you think about accountability system for polio program, and you kind of reflect what extent does this really address all of these key principle? Put it in another light, how well does interventions kind of design? And you will see that it’s improbable for you to design an effective accountability system, without actually working and join legitimacy from the system where the accountability intervention is supposed to take place. And that’s some places where you find a disconnect. So you will have mechanisms that are a little bit [?

foreign, ?] imposed to a system. And that in itself can begin to see– show to you why some– some of this mechanism might– might have– might not produce the effect that you want to see. And again, the same way you can look at it as implementation failure. So you could actually have a perfect system. It has all of the transparency measures, all of the participation, voice, [? teeth, ?] and everything is there. But it’s not effectively implemented, either because people don’t have the incentive to implement it as such. So again, you really cannot diverse the design of the accountability system and the implementation of it from the settings and the context in which you’re supposed to operate.

And I think the extent to which you can do this will determine whether it’s going to be effective in addressing corruption or whether you’re going to create opportunity for someone [INAUDIBLE] those incentives.

SVEA CLOSSER: Yeah. Yeah. I mean, I think sometimes the tendency is when managers know there’s corruption in a system to try to implement more paperwork to try to follow this flow of money. And that can be effective in the kind of context that Kunle is talking about. But if you only introduce the paperwork, what can happen is you just introduce– you get another way for people to game the system.

OLAKUNLE ALONGE: That’s right.

SVEA CLOSSER: So you can actually add in additional opportunities. And a bored person at the very bottom of a health hierarchy with not a very interesting job may have a lot of time to think about ways to gain transparency mechanisms. So adding paperwork as a level– there’s a lot of anthropological work on this right now, that adding paperwork as a transparency mechanism doesn’t always– in fact, can have the opposite of the desired effect. You can end by creating more work for people and also giving them more opportunities to create paperwork that makes it look like a certain thing is going on, even when something else is actually happening.

ANNA KALBARCZYK: So you both raised issues of incentives but also who. So I was hoping maybe in our last minute, you could think about who has the power to hold systems accountable and [AUDIO OUT] incentivize. So this is an and question. And you’re just thinking about the who and the incentives.

SVEA CLOSSER: Well, yeah. I mean, I think there’s a blame game that often happens. And it doesn’t often happen in public settings but in private settings. You will hear people who donated the money, saying that governments are corrupt. And it’s like the government’s fault that it wasn’t spent correctly. And I think that narrative is a dangerous one, because it can place blame on local governments, instead of thinking more comprehensively about this larger system and how it’s set up. So do donors, for example, have the power to end corruption everywhere? No, nor perhaps should they have total power over what happens at the district level.

But the fact that they’ve put large amounts of money into specific initiatives does make them culpable in some way. So it’s a very– this question of who can fix it is like super complex, because it involves thinking about everybody who’s contributing to the system, not just the person who’s actually trying to make $5. Right? But it’s a lot more complex than that, which is sort of a non-answer. [CHUCKLES] But it is context specific, I think. And we have to think about it as an issue that involves everybody, even people who think that they’re not corrupt. You know, they’re not taking money out of the system.

But the fact that they’re putting money into it in particularly interesting strange ways might be creating the right situation for it, if that makes sense.

ANNA KALBARCZYK: Kunle, anything you’d like to add?

OLAKUNLE ALONGE: Yeah. I think to right on that. Everybody has a part to play, to address corruption in a global program like the polio. And I think it’s easier to think about it as hierarchies. And at different levels within the hierarchy, there are key actors that has a role to play. I mean, from the very grassroots, you have the community. The community kind of hold– they are representative accountable. They kind of hold their district of officers accountable. And they should be given the power to do that. That mean they should be given the voice and the [? teeth ?] to do that.

And then, at the interphase of the– of the– of the district office and the provincial or state at office, you also have managers that are supposed to be accountable to supervisors. And in the same way, it’s supposed to cascade hope to elected officials and to political officials. And it should go back to power. I mean, in terms of how power is distributed within societies and who’s what power and so on. Ultimately, some of this power is drawn from– from election. Some of this power is drawn from delegation, and so on. And like Svea said, it’s also important for the donors not to see themselves as being completely absolved of the– of blame, and just to pass on the bulk.

I mean, some of the ways the fundings are set up in some places creates an avenue for corruption. So when you have funding that is so restricted and people can look– people who are [INAUDIBLE] to the issues cannot innovate or [? target ?] funding appropriately. Then, you have– you have some [INAUDIBLE] for corruption. So for the donor, I think there’s a need for them to have ongoing conversation in terms of– and the attitude should be one of collaboration and participation to understand the system better, to understand the actors within the system, and then to co-convene solutions together. Because ultimately the power that you do not withdraw lies with the resources that have been able to put into the system.

But the ultimate power really lies with the people. And you need to co-convene with– with some of the elected legitimate officials within the system.

ANNA KALBARCZYK: So I know we could go on and on about this topic. There’s a lot of layers. It’s very complex. But I think we’ll stop here. Thank you so much for concisely describing some of these issues in corruption. And thank you for joining us. We’ll see you next time.

OLAKUNLE ALONGE: Thank you.

SVEA CLOSSER: Thanks.