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58 Diagnosing Corruption in Ethiopia
Recommendation 4: Address the public-private relationship.
The most common concern raised by citizens and staff regarding irregularities
in health care provision involves health workers, doctors, nurses,
and pharmacists who divert patients to, or remove supplies and equipment
for use in, private practices. Better regulation of the relationship
between health care providers’ public and private roles is needed, with
particular attention to how the government’s strategies affect the relationship
between public and private health care provision.
One of the key complaints from citizens and health workers is that
poor public sector working conditions and lucrative private sector opportunities
are distorting health care provision. The government has a range
of sensible programs to harness private sector activity in support of
expanding health care access; however, it is not clear whether the government
has a clear overarching strategy that addresses both the publicprivate
institutional relationships and the impact on personnel
management and health worker behaviors.
It is advisable for the government to reflect on how its different strategies
are affecting the relationship between public and private health
care provision. Improving human resource management in the public
sector will address only one side of this equation, and it is necessary for
the government to clearly delineate acceptable and unacceptable ways
for public staff to combine public and private practices. Once these roles
are delineated, systems must be implemented to enforce them.
Recommendation 5: Improve surveillance of pharmaceutical sales.
The relationship between public and private pharmacists, the existence
of a private market for drugs that are formally available for free, and evidence
of a black market in drugs from abroad all suggest that Ethiopia
needs to strengthen its information gathering on pharmaceuticals.
Ethiopia’s drug agency, DACA, needs adequate resources to conduct
postmarket surveillance and lab testing to conduct sweeps for counterfeit
and stolen medications. Further recommendations are likely to come
from an ongoing study that has been commissioned as part of WHO’s
assessment of pharmaceutical governance (WHO 2009).
Recommendation 6: Monitor foreign aid inflows.
Foreign aid to Ethiopia is increasing so rapidly that it has surpassed the
government’s own expenditures. These and other changes in international
assistance are bringing both advances and risks: Coordination among