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Casals & Associates, Inc. Taryn Vian, Boston University
Anticorruption
Strategies and Tools
Rwanda
Designing an AnticorruptionStrategy
Nature of Corruption Causes,
Vulnerabilities; sound technical analysis—depoliticizes the problem
Political Will Stakeholders
Champions Risks Likely Opposition Timeline
Anticorruption ToolsIncrease
Awareness
Prevent
DetectProsecute
Sanction
Increase Awareness
Assessments of corruption vulnerabilities
• Procurement• Informal payments/service delivery• Drug leakage
Generate information about costs of corruption in the health sector
Surveys: perception, victimization, costs
Publicize results; encourage public debate Media Campaigns
Power of Data
National cost of corruption survey in Mexico
PET en Uganda Measured problem, Government
convinced to act Publicized budgets at local level Decreased leakage from 78% in 1996
to 18% in 2001
Vulnerability Scores in Four Countries (WHO 2006)
Lao PDR
Malaysia Philippines Thailand
Registration 5.6 6.8 6.8 7.0
Selection 6.1 5.7 6.1 8.0
Procurement 6.9 7.1 8.5 7.1
0.0-2.0 = extremely vulnerable; 2.1-4.1 = very vulnerable;
4.1-6.0 = moderately vulnerable; 6.1-8.0 = marginally vulnerable;
8.1-10.0 = minimally vulnerable
WHO/PSM/PAR/2006.7, p. 7
Prevention and Detection
Controls and AuditProcurement Reform Bureaucratic Simplification Transparent BudgetingHealth Management Information
SystemsSocial auditing and complaintsRegulatory reform
Complexity of medicines supply in Kenya
Contra-ceptives and
RHequipment
STIDrugs
EssentialDrugs
Vaccinesand
Vitamin ATB/Leprosy
BloodSafety
Reagents(inc. HIV
tests)
DFID
KfW
UNICEF
JICA
GOK, WB/IDA
Source offunds for
commodities
CommodityType
(colour coded) MOHEquip-ment
Point of firstwarehousing KEMSA Central Warehouse
KEMSARegionalDepots
Organizationresponsible
for delivery todistrict levels
KEMSA and KEMSA Regional Depots (essential drugs, malaria drugs,
consumable supplies)
ProcurementAgent/Body
CrownAgents
Governmentof Kenya
GOK
GTZ(procurement
implementationunit)
JSI/DELIVER/KEMSA LogisticsManagement Unit (contraceptives,
condoms, STI kits, HIV test kits, TBdrugs, RH equipment etc)
EU
KfW
UNICEF
KEPI ColdStore
KEPI(vaccines
andvitamin A)
Malaria
USAID
USAID
UNFPA
EUROPA
Condomsfor STI/
HIV/AIDSprevention
CIDA
UNFPA
USGov
CDC
NPHLS store
MEDS(to Missionfacilities)
PrivateDrug
Source
GDF
Government
NGO/Private
Bilateral Donor
Multilateral Donor
World Bank Loan
Organization Key
JapanesePrivate
Company
WHO
GAVI
SIDA
NLTP(TB/
Leprosydrugs
Commodity Logistics System in Kenya (as of July 2006) Constructed and produced by Steve Kinzett, JSI/Kenya - please communicateany inaccuracies to [email protected] or telephone 2727210
Anti-RetroVirals
(ARVs)
Labor-atorysupp-lies
GlobalFund forAIDS, TB
and Malaria
PSCMC(CrownAgents,GTZ, JSI
and KEMSA)
BTC
MEDS
DANIDA
Mainly District level staff: DPHO, DPHN, DTLP, DASCO, DPHO, etc or staff from the Health Centres,Dispensaries come up and collect from the District level
MEDS
Provincial andDistrictHospital
LaboratoryStaff
Organizationresponsible fordelivery to sub-district levels
KNCV
MSF
MSF
JSI/DELIVER
KEMSA
JSI
WHO
Transparency and Access to Information
Discloser Recipient
Civil ServantManager
EmployeeClient/PatientDonor
Facts and FiguresMechanisms and ProcessesJustification for Decisions
Duty…Trust
Type of Disclosure Means of Disclosure
Information
Health Management Information SystemsDistrict Health Planning and Financial Management System in
South Africa
0
100
200
300
400
500
600
Tesgona Nimane S. Keri N. Keri
Cost per IP day
Internal Controls
Network Cash registers in Kenya
Registers gave receipts of transactions
Possibility to track resources
Lower opportunities to cheat
Resulted in 47% increase in revenue after 3 months
Transparency of Medicines in Argentina
Compiled monthly drug procurement price data starting in 1996 (ended in 1998)
Highlighted highest & lowest price paid, fed info back to hospitals
Prices fell 12% After 3 months, prices
climbed back, but never to pre-1996 levels
Procurement Reform
•Standards and technical specifications quoted in bidding documents should be generic to promote competition •Specifications should be based on relevant characteristics and/or performance requirements. •Transparency and public disclosure of information•System for addressing complaints•Citizen participation in the system
Integrity Pacts Ecuador
The NGO community wanted to be involved in the oversight of the project
To provide effective review during the process, the government entered into an Integrity Pact with the local chapter of Transparency International
TI hired international consultants that advised the stakeholders, helping the NGO community to become effective watchdogs
The procurement actions surrounding the project were deemed to be fair and transparent by all the parties involved
In 1999, Ecuador built a major Dam system. The project had a budget of over 300 million USD
Increasing TransparencyPrice Monitoring Tools
WHO and Health Action International, 2002
Developed methodology for collecting and analyzing prices of medicines, affordability, availability and component costs
Online catalogues of prices, so international comparisons are possible
Drivers of Informal Payments
PressureLow salaries of medical staffPressure from patients Social normDesire for better/faster careInability to access care otherwise
OpportunityInformation asymmetryInelastic demandLack of controls, oversight
RationalizationLegal; coping mechanism“Patients want it”
Reducing informal payments Hospitals in Cambodia
Formalize user fees Increase salaries
while establishing formal sanctions for accepting informal payments
Increase transparency and information
What they did Introduced formal
fees and an equity fund (for free care)
Government subsidy increased over time
Formal fee revenue shared among staff, as bonuses
Takeo Provincial Hospital, Cambodia Results
After implementation, utilization increased 50%
Patients ended up paying less than the informal payments
Citizen Participation
Social Auditing of:
Procurement Service Delivery Public Works Budget Execution
Participatory Budgeting and Social Auditing
Community Health Boards in
Bolivia
Citizen Report Card Experiences: Bangalore India
Report Card for Maternal Care in 2000 Public Affairs Centre (PAC)
Report card measured patient satisfaction, facility maintenance, informal paymentsonly 43% of patients had
access to usable toiletsless than 40% had access to
free medicines as required by government policy
Citizen Report Card Experiences: Uganda
Citizen Report Card Project in Uganda
increased quality and quantity of services
increased immunization rates
reduced waiting time
Prosecution and Sanctioning
Judicial ReformSpecial Task Forces
(Prosecutors, Judges, Lawyers)
Anti-Corruption Commissions
Repatriation of AssetsEffective Sanctions
Punishing Corrupt
DCEC
Anti-Corruption Agency
Botswana
Punish Corrupt Officials
What have we learned?
There are no magic wandsPolitical Will is essentialGood diagnosis is essential –
interventions have to be tailored to needsSanctions are not effective without
preventionAnti-corruption interventions are long
term effortsSustainability is important
Takeo Provincial Hospital, Cambodia Transparent
affordable flat fees + Equity Fund
Decreasing unmarked SRC subsidy to fill gap
(boost at start)
Increasing Govt financing
(contracts)
Sufficient official revenues
Supplementation of staff revenues based on performance
Increased staff motivation & diligence
Improved hospital management & high quality of care
Increased utilization rate
Financial sustainability
Utilisation
Income of personnel Resources
Staff Motivation
Quality of services
SRC Govt
+ rationalization
+ staff co-management
Source: Jean-Marc Thomé, www.medicusmundi.ch
Integrity PactsArgentina
In 2001, a provincial government in Argentina wanted to make a significant
investment in computers for office use
Procurement guidelines required the specifications to be generic
The government lacked sufficient information and market intelligence to make the specifications generic
The procurement office sent out the specifications in draft form to every IT provider before starting the procurement action
Major players such as IBM, Dell, Sun Microsystems, Oracle and Microsoft provided suggestions and amendments, thus ensuring that they could all compete fairly
The procurement process was followed and all stakeholders were satisfied with the result