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 skinzett@cb.jsikenya.com 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