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Corruption in public health 89by under-trained medical students operating on patients withoutsupervision (Lewis, La Forgia and Sulvetta, 1992).Staff accountability for misconduct is rare. Its absence inaccountability is noted for the Dominican Republic (La Forgia et al.,2004), although Cohen (2002) reports that in Costa Rica 27 per centof users know of a case where sanctions were imposed or a publicemployee was terminated for corruption or theft. So there are somecountries where at least egregious misconduct is disciplined.Collusion among public officials has also been identified as perpetuatingcorruption. In Bosnia and Herzegovina (World Bank,2001e) 35 per cent of officials said health colleagues who refusebribes face retribution, and similar views were expressed in focusgroup discussions among public health staff in Ethiopia.Supplies: mismanagement and corruptionAvailability of drugs and supplies complement health professionalsand their absence reflect poor management or corruption.Drug management and leakageVirtually all qualitative studies that have probed this issue haveemerged with the view that quality and drug availability are virtuallysynonymous, and lack of drugs has been repeatedly shown todiscourage utilization of public facilities (World Bank, 2005a). Arecent in depth assessment of the Costa Rican pharmaceuticalsystem’s registration, drug selection, procurement, distribution andservice delivery revealed both great strengths and glaring weaknesses.The study used a combination of (i) interviews with publicofficials; (ii) industry interviews with local pharmacies and multinationalcompanies; (iii) focus groups with health care professionals;and, (iv) exit surveys for a representative sample of patients.Clear publicly available procedures, pharmaceutical lists andcriteria; reliance on defined, generic drugs; and distribution auditswere deemed excellent. The greatest weaknesses were in procurement,specifically in the lack of performance monitoring, qualitymonitoring, audits and uncontrolled political interference; and in