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Corruption in public health 111
some cases, and it may apply in health care. However, business
effectiveness studies in the FSU show how inspectors can undermine
the system through bribes to certify acceptable performance,
so it is important to ensure that such arrangements are working as
intended if they are adopted.
In a recent experiment, Leonard (2005) assesses the importance
of training and incentives in determining physician performance in
Tanzania across a sample of public and private providers. He concludes
that while ability is important, institutional incentives, particularly
the ability to hire and fire staff, are far more powerful than
education or experience in explaining the quality of care provided
patients, offering an empirical basis for the priority of putting in
place incentives to foster improvements in health care.
A fundamental initiative is the establishment of clear procurement
and contracting rules. Evidence for Argentina and Colombia
shows a potential role for effective oversight as discussed. To effectively
achieve such results requires existence of clear rules, effective
oversight to detect problems, enforcement of rules, and rewards and
punishments for good and unacceptable behavior, respectively. The
lack of minimal managerial order and oversight are fundamental
weaknesses in many public health systems which permit such
abuses. In fairness, however, battling these kinds of problems
persist in even the wealthiest countries and relentless effort are
required to control corrupt practices.
In the Philippines multivariate analysis found that the frequency
of audit by central government and autonomy of local government
increased immunization coverage, suggesting that local governments
can benefit from authority, and auditing will further
encourage responsible public performance (Azfar and Gurgur, 2001).
In Madagascar, sanctions for misuse of funds led to systematic following
of financial procedures. Most important among sanctions
was criticism from supervisors and transfer to less desirable locations.
Though the effect of accountability is diluted by the fact that
the most common reasons for transfer is displeasing local officials
without discussion or vetting of the merits of the transfer, frequent