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Health Sector Corruption in Ethiopia 49
(44 percent) and with lack of drugs (40 percent) (Urban Institute 2009).
However, relatively few (18 percent) cite problems with the availability
of staff (absenteeism), long waits (17 percent), or disrespectful treatment
by staff (16 percent). Except for drug availability, these results suggest
that many of the resources expended on front-line delivery may actually
be getting through to patients, although a more detailed public expenditure
tracking study would be required to confirm such a judgment.
Bribery. Although illegal fees at public health facilities are a problem in
many developing countries, they are not a significant issue in Ethiopia. A
national survey of households found that the practice of extracting bribes
from patients in Ethiopia exists but is relatively rare (FDRE 2008).
Among households who had contact with a public health facility in the
past year, only 3.6 percent reported paying more than the official fees to
receive services. The most commonly cited reasons for paying any additional
amounts were to gain admission to the facility or to obtain medicines,
and most of those who reported making such payments said they
had initiated the transaction rather than the provider.
Favoritism. In our interviews, respondents claimed that patients with
personal connections to providers or of higher social status received preferential
treatment in government health facilities. This finding was consistent
with a 2005 study in which respondents frequently mentioned
that health care providers provided priority access to services to friends
or by patronage (Lindelow, Serneels, and Lemma 2005). Although this
form of favoritism does not require patients to pay a bribe, it may account
for some patients’ willingness to voluntarily pay extra to visit a clinic and
could limit equitable access to government facilities.
Dual public-private job positions. The most common problem cited by
informants at public health facilities involved poor-quality care or lack
of medicines, often leading patients with resources to seek private care.
Although such a decision can be a legitimate choice between options,
it appears that health care workers—including nurses, health officers,
and doctors—sometimes intentionally divert patients to private practices
where they can charge fees and earn more income. An earlier
study of health care providers and patients identified the unregulated
relationship between private and public practice as a large and growing
threat to the integrity of health care provision (Lindelow, Serneels, and
Lemma 2005).