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Corruption in public health 89
by under-trained medical students operating on patients without
supervision (Lewis, La Forgia and Sulvetta, 1992).
Staff accountability for misconduct is rare. Its absence in
accountability is noted for the Dominican Republic (La Forgia et al.,
2004), although Cohen (2002) reports that in Costa Rica 27 per cent
of users know of a case where sanctions were imposed or a public
employee was terminated for corruption or theft. So there are some
countries where at least egregious misconduct is disciplined.
Collusion among public officials has also been identified as perpetuating
corruption. In Bosnia and Herzegovina (World Bank,
2001e) 35 per cent of officials said health colleagues who refuse
bribes face retribution, and similar views were expressed in focus
group discussions among public health staff in Ethiopia.
Supplies: mismanagement and corruption
Availability of drugs and supplies complement health professionals
and their absence reflect poor management or corruption.
Drug management and leakage
Virtually all qualitative studies that have probed this issue have
emerged with the view that quality and drug availability are virtually
synonymous, and lack of drugs has been repeatedly shown to
discourage utilization of public facilities (World Bank, 2005a). A
recent in depth assessment of the Costa Rican pharmaceutical
system’s registration, drug selection, procurement, distribution and
service delivery revealed both great strengths and glaring weaknesses.
The study used a combination of (i) interviews with public
officials; (ii) industry interviews with local pharmacies and multinational
companies; (iii) focus groups with health care professionals;
and, (iv) exit surveys for a representative sample of patients.
Clear publicly available procedures, pharmaceutical lists and
criteria; reliance on defined, generic drugs; and distribution audits
were deemed excellent. The greatest weaknesses were in procurement,
specifically in the lack of performance monitoring, quality
monitoring, audits and uncontrolled political interference; and in