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Abstract
Objectives Corruption undermines the quality of healthcare and leads to inequitable access to essential health products. WHO, Global Fund, United Nations Development Programme (UNDP) and World Bank are engaged in anti-corruption in health sectors globally. Throughout the COVID-19 pandemic, weakened health systems and overlooked regulatory processes have increased corruption risks. The objective of this study is thus to explore the strengths and weaknesses of these organisations’ anti-corruption mechanisms and their trajectories since the pandemic began.
Design, setting and participants 25 semistructured key informant interviews with a total of 27 participants were conducted via Zoom between April and July 2021 with informants from WHO, World Bank, Global Fund and UNDP, other non-governmental organisations involved in anti-corruption and academic institutions. Key informant selection was guided by purposive and snowball sampling. Detailed interview notes were qualitatively coded by three researchers. Data analysis followed an inductive-deductive hybrid thematic analysis framework.
Results The findings demonstrate that WHO, World Bank, Global Fund and UNDP have shifted from criminalisation/punitive approaches to anti-corruption to preventative ones and that anti-corruption initiatives are strong when they are well funded, explicitly address corruption and are complemented by strong monitoring and evaluation mechanisms. Weaknesses in the organisations’ approaches to anti-corruption include one-size-fits-all approaches, lack of political will to address corruption and zero-tolerance policies for corruption. The COVID-19 pandemic has highlighted the necessity of improving anti-corruption by promoting strong accountability and transparency in health systems.
Conclusions Results from this study highlight the strengths, weaknesses and recent trajectories of anti-corruption in the Global Fund, World Bank, UNDP and WHO. This study underscores the importance of implementing strong and robust anti-corruption mechanisms specifically geared towards corruption prevention that remain resilient even in times of emergency.
- COVID-19
- health policy
- public health
Data availability statement
No data are available. No additional data available. As per the University of Toronto ethics approval, key informant interviews were confidential.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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STRENGTHS AND LIMITATIONS OF THIS STUDY
This study collected data from individuals directly involved in anti-corruption programmes within the four studied international organisations.
Conducting interviews over Zoom provided us with access to individuals from around the world who would have otherwise been inaccessible.
We were not able to discern whether data provided by interviewees were influenced by their personal beliefs and/or ideas.
Recruiting participants from some of the international organisations was difficult, with many individuals well suited to participate in this study unable to dedicate time to an interview (specifically very few individuals from the World Bank agreed to participate in this study, and thus there are fewer results about this organisation than about the others).
This study lacked country-level input from individuals directly impacted by anti-corruption initiatives.
Introduction
Health system corruption
Corruption is a global wicked problem, meaning that it is dynamic and has numerous causes and grave implications.1 Within the health sector, corruption limits the efficiency of health systems, reduces trust in healthcare institutions and undermines universal health coverage and the right to health.2–4 Corruption can limit access to and undermines the quality of health services and products such as essential medicines.5 This impacts poor and marginalised populations most profoundly as they tend to be most reliant on publicly provided services.6
Corruption is defined by Transparency International as ‘the abuse of entrusted power for private gain’.7 It can range from petty corruption to high-level multinational corruption and can manifest as bribery, extortion, theft, embezzlement and undue influence, among other forms.8 9 Corruption threatens the achievement of the United Nations (UN) Sustainable Development Goals (SDGs), most severely SDG 3: good health and well-being for all at every stage of life.5 10
The ongoing COVID-19 pandemic has increased risks of health sector corruption globally, thus further threatening the achievement of the SDGs. Specifically, national and international health systems are overwhelmed as they attempt to control virus spread and respond to unprecedented demand for health services. This leaves health systems increasingly vulnerable to corruption as normal procedures are bypassed in the interest of rapid public health responses and the urgent procurement of emergency health products.11 Examples of corruption during the COVID-19 pandemic include falsified COVID-19 vaccines,12 13 substandard personal protective equipment14 15 and counterfeit COVID-19 vaccine certificates.16 17
Anti-corruption, transparency and accountability in health systems
Research suggests that high levels of transparency and accountability in health systems can reduce susceptibility to corruption.18–20 Transparency in health system processes such as public procurement and hospital financing makes prices visible, thus reducing the incidence of price gouging and shedding light on demands for bribes and kickbacks.8 11 Additionally, transparency permits for the monitoring of prices across regions and health facilities, thus permitting authorities to ensure that prices remain fair and consistent. Further, high levels of transparency in the health sector permit for governments and healthcare providers to be held accountable for their roles in healthcare funding and the delivery of health services. This allows those who administer and fund health services to be responsive to those who rely on their services and who require that services be provided with integrity.8 11
Recognising the dire implications of corruption on health service provision and as a result of the important role that transparency and accountability play in reducing the incidence of corruption, many international organisations (IOs) and non-governmental organisations (NGOs) have committed to promoting anti-corruption, transparency and accountability (ACTA) in health systems. Notably, the WHO is leading efforts for the Global Network on Anti-Corruption, Transparency & Accountability in Health (GNACTA), which aims to support countries in minimising health sector corruption. While some literature has delineated the specific anti-corruption mechanisms these IOs have implemented in health sectors around the world,20–22 there has been no examination of whether these mechanisms are effective, the facilitators to their implementation, and how they have evolved over time.
Understanding the nuances of the anti-corruption mechanisms employed by these IOs is particularly critical in light of the ongoing COVID-19 pandemic as the increased corruption risks brought forth by the injection of funding for health services and the high demand of COVID-related products have underscored the urgency of anti-corruption in health.23 As a result, this study analyses anti-corruption mechanisms for health systems around the world implemented by WHO, UNDP, Global Fund and World Bank and addresses the research question: what are the strengths, weaknesses, facilitators to implementation and recent trajectories of anti-corruption mechanisms by these IOs?
Methods
Data collection
This study, conducted from a postpositivist point of view, builds on previous work exploring similar research questions, including a targeted website review20 and a document analysis.21 We contacted 55 individuals, and from this pool we conducted 25 semistructured key informant interviews with informants from each of the four IOs (WHO, World Bank, Global Fund and UNDP), NGOs involved in anti-corruption work and academic institutions; one interview involved two participants (table 1). A 27th informant was unable to participate in an interview but provided written responses to the interview questions. Key informant recruitment was guided by purposive and snowball sampling24 through which informants were selected based on their professional positions or expertise in the anti-corruption field and/or were recommended by other participants from within or outside their organisation.
Study sample
Interviews were conducted on Zoom between April and July 2021, were between 30 and 45 min in duration and were conducted in English. The interview guide is provided in online supplemental appendix 1. All interview participants provided written and verbal consent for their participation in an interview. Interviews were not recorded, though detailed notes were taken by both the interviewer and a secondary researcher to capture the information provided; direct quotes were recorded when possible. At the end of each interview, notes from the note taker and interviewer were combined. To ensure that data from interviews were accurately captured, interviewees were offered the option to review their combined interview notes; seven interviewees asked to review their notes and provided feedback to researchers. Data collection was stopped when saturation was reached.25
Supplemental material
Data analysis
The combined interview notes were qualitatively coded by the interviewer and a secondary coder, then by a third coder. All data analyses were conducted on NVivo, a qualitative data analysis software. Data analysis followed an inductive-deductive hybrid thematic analysis framework,26 meaning that an initial coding guide was created prior to coding and was amended as necessary during data analysis. The initial coding guide was informed by the research aim and researcher expertise on the topic. Data analysis began after the first interview and continued as interviews took place. Codes were amended iteratively throughout the data analysis process and links were made to the research aims and existing literature. The final list of codes is provided in online supplemental appendix 2. Codes were then organised into themes based on topics that were commonly discussed by participants; summaries of these themes including quotes (where available) were created then used to produce the Results section of this paper; participants’ identities were kept strictly confidential and participants have been deidentified in this manuscript. The final list of themes is provided in online supplemental appendix 3.
Patient and public involvement
This study did not engage patients or the general public; individual participants were engaged solely in their capacity as key informants.
Results
Overview of IOs’ approaches to anti-corruption
Fourteen interviewees identified that there are two main approaches to anti-corruption: (1) a criminalisation/punitive approach, in which organisations identify corruption and sanction offenders, and (2) a preventative approach in which organisations aim to prevent corruption before it occurs. In 2019, the World Bank sanctioned and debarred 53 companies from working with the organisation; this is an example of a punitive approach to anti-corruption (NGO participant 5). On the other hand, as an example of a preventative approach, the UNDP has started focusing on capacity building as a means to prevent corruption within its partner countries (IO participant 2). Seven interviewees also noted that many of the organisations under study have recently shifted from the former to the latter. The reason for this shift is IOs’ recognition that when anti-corruption efforts are geared towards criminalisation, by the time any measures have been taken against a corrupt actor or actors, damage due to corruption has already occurred. As an interviewee from an NGO explained:
Corruption is a problem, a threat to development, a threat to injustice, a threat to social justice so we should be trying to address it and reduce it as much as possible. And any efforts we can make in this regard is worthwhile. (NGO participant 3)
The criminalisation approach confines anti-corruption agencies to operating in contexts where corruption exists and to where its implications are rampant. For IOs, this can lead to a loss of valuable resources such as money allocated for improving access to and the quality of health services. Preventative approaches, on the other hand, uniquely hamper the implications of corruption by reducing the incidence of corruption itself.
Two interviewees from IOs identified that the UNDP is in the process of adopting a preventative approach to anti-corruption. The UNDP’s shift from criminalisation to prevention appears to have stemmed from its recognition that fraud and corruption deplete the organisation’s funds, assets and other resources required to achieve its mandate, hinder donors’ trust in the organisation and damage their international reputation. Specifically, two interviewees from IOs explained that the UNDP Policy Against Fraud and Other Corrupt Practices places emphasis on corruption prevention by raising awareness about the implications of fraud and corruption, outlining the importance of implementing controls aimed at mitigating these risks, and advocating for the early detection of acts of fraud and corruption that occur.
In addition, an interviewee from an IO underscored that WHO has been shifting from a punitive to a preventative approach to anti-corruption in the health system. WHO’s earliest focus on anti-corruption can be traced in 2004, when WHO established the Good Governance for Medicines (GGM) programme: the first global programme to address corruption prevention in the pharmaceutical sector through a focus on elements related to good governance. Through the GGM, corruption prevention was advanced primarily through efforts to strengthen transparency and accountability in the health and pharmaceutical sectors. According to an interviewee at an IO, the majority of WHO’s current work with respect to corruption prevention in the pharmaceutical sector is focused on preventing and responding to the presence of substandard and falsified health products.
Furthermore, two interviewees from IOs identified that effectively preventing corruption requires commitments to anti-corruption from national and/or regional actors. Corruption is context dependent, varying tremendously between counties and regions. As an interviewee from an NGO explained, corruption is
…not just as a problem that exists on its own and can be solved on its own. It is a wider challenge connected to governance, history, and other things going on in any given politic. (NGO participant 3)
As a result, corruption prevention cannot occur effectively if anti-corruption initiatives are solely informed by international anti-corruption experts. Instead, two interviewees suggested that corruption prevention initiatives should use national anti-corruption task forces acquainted with local needs who can provide regionally appropriate recommendations for mitigating corruption risks.
The UNDP, for example, has implemented regional anti-corruption programmes that entail the development and implementation of tools to identify, assess and evaluate sector-level risks of corruption. In so doing, the UNDP encourages collaboration between national actors within a given sector and those involved in anti-corruption at the country level. One interviewee also noted, however, that national task forces, while more effective at promoting anti-corruption than external anti-corruption experts, can have stake in or agendas pertaining to corrupt activity; as a result, the information they provide with respect to anti-corruption may contain biases.
The World Bank employs a combination of punitive and preventative approaches to anti-corruption. An interviewee from an IO explained that the World Bank believes corruption to be an issue that should be prevented. According to two interviewees at NGOs, on the other hand, the World Bank also places great emphasis on asset recovery and sanctioning corrupt actors. For example, the World Bank has a preventative service unit that mainstreams compliance to anti-corruption projects that are focused on corruption prevention. If, however, they detect that any suppliers have engaged in corruption, they blacklist those suppliers; this demonstrates the World Bank’s commitment to sanctioning offenders of corruption as well. The World Bank’s sanction list is adhered to very strongly. Suppliers barred by the World Bank are also barred by other UN and private agencies.
The Global Fund’s approach to anti-corruption is different from those of the other three organisations. According to one interviewee:
The Global Fund of the four [organizations] is probably the one that has the tools and approach that are most advanced in anti-corruption at the programme level. (IO participant 11)
To complement the detection and response components of its anti-corruption framework, the Global Fund is evolving its prevention model to integrate a programmatically driven, risk-based approach to anti-corruption. This evolution has been ushered in by the board-level Policy to Combat Fraud and Corruption, which states, under chapter 3.3, that ‘fraud and corruption are program and mission risks and prioritizes the prevention, detection and response to prohibited practices to advance the Global Fund’s mission of ending the epidemics’.27 In practice, this means that the Global Fund is focusing on preventing those forms of fraud and corruption that can undermine its grants’ ability to deliver on their health objectives. As an interviewee explained, the Global Fund is
… targeting those forms of abuse that can lead to under- or non-delivery of health services, material manipulation of health data, or lead to egregious levels of overpayment. (IO participant 9)
The same interviewee further described the benefits of this approach to corruption prevention by explaining:
If we have adequately robust, independent, reliable controls to assure ourselves that grant financed-activities actually took place at market rates, then we have adequate assurance that the scale of fraud and corruption within that grant did not arise to a severe level.
Strengths of IOs’ approaches to anti-corruption
Interviewees identified a number of strengths in WHO, UNDP, Global Fund and World Bank’s approaches to anti-corruption. To begin, the UNDP’s history as a development agency of the UN means its mandate is attached to that of the UN. As a result, the UNDP receives UN funds that can support its anti-corruption work. Unlike many other IOs, therefore, the UNDP has the financial means to create and execute anti-corruption initiatives. Similarly, the World Bank’s large size and near global reach permits it to work across a variety of sectors in a multitude of countries. Two interviewees further explained that the World Bank, like the UNDP, has significant financial resources; as a result, they have the ability to invest in sustainable anti-corruption mechanisms that can grow to become self-reinforcing as opposed to requiring constant active implementation.
Interviewees also identified that successful anti-corruption initiatives are often explicit in their use of the word corruption. Many IOs and NGOs hesitate to use the word corruption because they perceive it as ‘a filthy word’ (IO participant 4), and instead address anti-corruption under the guise of governance, transparency and accountability. Doing so, however, means that initiatives do not directly address corruption. An interviewee from an IO, on the other hand, explained that one of the UNDP’s strengths is its willingness to put anti-corruption at the forefront of other development interventions and reforms, and thus to tackle corruption head on.
Facilitators to implementing anti-corruption mechanisms
Interviewees discussed a number of facilitators to effectively and efficiently implement anti-corruption mechanisms. First, seven interviewees discussed the importance of implementing strong monitoring and evaluation (M&E) systems for anti-corruption initiatives. Although there has been a considerable increase in the amount and scope of anti-corruption work conducted in the previous three decades, there remains a dearth of information about how best to transform systems in which corruption is endemic into systems in which corruption is a rarity. As a result:
It is hard to know if changes are due to reducing corruption or fostering efficiency, tracing issues back to root of either corruption or governance is almost impossible. (IO participant 2)
Another interviewee explained:
This is a huge problem because today we have very little information about what works. (NGO participant 9)
The main reason M&E is not often implemented is:
It would take a significant amount of resources to evaluate anti-corruption work and people aren’t willing to fund that. (Academic participant 1)
That said, an interviewee from an IO noted that the UNDP is advancing more than other IOs in its implementation of M&E because it has a risk management methodology that allows for the M&E of its anti-corruption programmes. The methodology consists of five steps: (1) setting up and training an anti-corruption task force; (2) conducting assessments; (3) creating a corruption mitigation plan; (4) implementing the mitigation plan; and (5) monitoring and evaluating the plan. The efficacy of the mitigation plan can be quantified in terms of time and/or money saved. This methodology was implemented for the first time in Tunisia. The Tunisian government wrote and published a report about their use of the methodology; Lebanon is now employing the methodology as well.
Other facilitators of anti-corruption identified by interviewees include involving private corporations in anti-corruption work; building technical capacity for anti-corruption; dedicating resources to ACTA; creating incentives to engage in anti-corruption; offering ethics courses that promote anti-corruption among IO staff and which draw attention to the importance of anti-corruption work; and promoting transparency and accountability in anti-corruption.
Weaknesses in IOs’ approaches to anti-corruption
While interviewees identified promising advances in the approaches by the World Bank, UNDP, Global Fund and WHO to anti-corruption, they also identified several weaknesses. These include one-size-fits-all approaches to anti-corruption, a lack of political will and unrealistic zero-tolerance policies for corruption.
Five interviewees explained that corruption risks vary by sector. As a result, implementing effective anti-corruption mechanisms requires anti-corruption initiatives that mitigate the risks of corruption specific to a given sector. As three interviewees explained, however, IO employees often work in isolated domains within their organisations (ie, in anti-corruption, financial management, health systems strengthening, etc). They also explained that there is seldom collaboration between employees in different domains. Anti-corruption initiatives, therefore, are often created and implemented by individuals who work in anti-corruption without input from those acquainted with the needs of a given sector. As a result, IOs do not generally create sector-based anti-corruption interventions.
For example, within WHO, though anti-corruption work is ‘starting to have an existence’ (NGO participant 8), corruption remains underaddressed. As one interviewee from an IO stated:
Anti-corruption isn’t really a big part of our work. (IO participant 6)
Another interviewee (from an NGO) noted that one reason anti-corruption has failed to gain traction within WHO is because of its internal politics. The interviewee explained that WHO has internal, territorial teams (independent teams who work in distinct and siloed domains) that do not often communicate with one another. As a result, creating well-informed, sector-based anti-corruption initiatives is difficult.
The second major weakness interviewees identified in IOs’ approaches to anti-corruption is that there is a general lack of political will to conduct anti-corruption work. As one interviewee stated, organisations
…need both political will and technical capacity for an anti-corruption program to successfully be implemented. (IO participant 8)
As another interviewee similarly explained:
Increasing awareness of corruption is not enough, there needs to be political will. (Academic participant 2)
For example, WHO (run by its member states) cannot conduct anti-corruption work if their constituencies are not committed to anti-corruption. As an interviewee explained:
…the weakness of some organizations and their progress on anti-corruption is related to the lack of appetite of the board or member states to take a good hard look at what they are doing and how exposed they really are because they might not like the answer. (IO participant 12)
As a result, interviewees identified that WHO has had challenges in securing funding from donors for anti-corruption work. One interviewee (an academic) explained that even when IOs or national governments have good anti-corruption policies, these policies are seldom enforced. Often, those with enforcement power (ie, managers of anti-corruption projects) lack the will to tackle corruption, thus hindering the efficacy of anti-corruption policies, projects and interventions.
Finally, informants identified that most IOs have zero-tolerance policies for corruption. While it is well-intentioned to strive toward abolishing corruption, actually abolishing it is nearly impossible because corrupt actors will always find a way to engage in corruption. As one interviewee explained:
Zero tolerance is unrealistic—sometimes the more you audit the more you miss. (NGO participant 10)
As a result, an interviewee from an IO explained that preaching zero tolerance for corruption results in IOs knowingly misrepresenting their boards and stakeholders.
Zero-tolerance policies for corruption can also cause organisations’ funding to become locked down in ineffective and inefficient anti-corruption controls. Interviewees noted that the Global Fund, for example, has rigorous checks and balances consisting of stringent documentation requirements. Ensuring that programmes are adequately and properly documented, however, is an onerous process that can delay the execution of programmes themselves. According to one interviewee:
Majority of funds are going to the controls of the funds rather than the implementation of programs and delivery services…the controls are worse than the risks themselves. (IO participant 9)
The narrow interpretation of fraud, coupled with the zero-tolerance stance on it, generates several paradoxes which get in the way of the actual health and fiduciary accountability objectives. Donors tend to interpret fraud and corruption as happening principally in procurement and financial processes. Hence, they focus on evaluating the completeness and compliance of documents evidencing the compliant purchase and spend on budgetary inputs. For example, to evaluate if fraud occurred in a malaria mass campaign, the donor would focus on fraud in documentation evidencing proper procurement of training venues, pencils and notebooks, and catering services to train campaign workforce. However, budgetary inputs are often not where the large-scale and severe fraud schemes can occur; for example, population sizes which form the basis for the budget may have been inflated, or distribution data may have been manipulated with ghost households in an effort to divert them into the black market. Even more concerningly, by taking a ‘zero-tolerance’ stance on the completeness and compliance of budgetary inputs, donor policies result in a perverse incentive for recipients to overfocus on generating and policing expenditure documentation, all to the detriment of operational efficiency and quality assurance of health data and service delivery.
The trajectory of ACTA in IOs in and beyond the COVID-19 pandemic
Interviewees explained that the COVID-19 pandemic has impacted corruption in the health system in the following ways. First, the pandemic and the measures to address the pandemic have created conditions for corruption to thrive. Second, the pandemic has highlighted the need for greater attention to and action on ACTA in health systems.
The COVID-19 pandemic and the measures implemented to mitigate virus spread have increased risks of corruption within and beyond health systems. This has occurred as a result of the large amounts of money that have been poured into health systems to respond to the COVID-19 virus. Furthermore, eight interviewees explained that the urgency of the pandemic has led to the bypassing or simplifying of procedures in place to prevent and identify corruption. According to an interviewee at an IO, these shortcuts, while necessary to rapidly respond to the virus, have created an environment in which
…the soil [is] rich for corruption to grow. (IO participant 2)
Additionally, six interviewees explained that the pandemic has resulted in decreased levels of institutional, organisational and civil oversight of health system governance. An example provided by an interviewee at an IO and two from NGOs is that travel restrictions have severely limited in-person oversight of processes (ie, public procurement) that are at high risk of corruption and have limited the number and frequency of corruption investigations. Two other interviewees, both from NGOs, were particularly concerned about the significant decrease in the amount of civil society and media monitoring of health systems; as one of the interviewees stated:
What has also changed is the limited ability for civil society to be the watchdogs against corruption because they themselves are impacted by the pandemic. (NGO participant 2)
The pandemic has also amplified corruption-related issues that existed before the pandemic, thus highlighting the significant amount of work that needs to be done with respect to implementing and promoting anti-corruption initiatives in the health sector. According to an interviewee at an NGO:
COVID has exposed how little progress has been made in integrating anti-corruption in health services and making it a central part of health and health service delivery. (NGO participant 3)
The interviewee explained that this has been exemplified by the absence of anti-corruption provisions in the pandemic response plans of many countries and IOs.
Further, three interviewees described how COVID-19 has brought underlying corruption issues to the forefront of policy conversations because it has exposed the real and devastating implications that corruption has on responses to health crises. Three other interviewees explained that this has helped advance efforts for more transparency, specifically in pricing, procurement and allocation of health products, as well as transparency in clinical trials for vaccines and therapeutics. As an interviewee from an NGO described:
What we would like to see is transparency embedded throughout the systems and stronger accountability loops in the system. (NGO participant 4)
With respect to IOs, the increased incidence of and attention to corruption brought on by COVID-19 has underscored the need for high levels of organisational transparency, accountability and integrity.
Despite the increased attention to, opportunities for and implications of corruption during the pandemic, three interviewees emphasised that IOs have taken relatively little action to address new corruption risks. Two interviewees noted that though corruption is being discussed more frequently, little has changed at the policy level, and most substantially, ACTA measures have not changed to reflect the pandemic’s unique impacts on health systems. In a bleak prediction, one interviewee from an NGO asserted that they do not foresee any significant changes to ACTA resulting from the COVID-19 pandemic.
Discussion
Results from this study demonstrate that IOs’ anti-corruption work varies and that each IO has unique strengths and weaknesses in its approaches to anti-corruption. The UNDP and the World Bank, for example, have the resources necessary to fund anti-corruption efforts. Additionally, the UNDP directly addresses corruption, embedding anti-corruption efforts into many of its development interventions. WHO, on the other hand, lacks political will for anti-corruption, and thus has not yet fully incorporated anti-corruption into their programmatic work. Lastly, the Global Fund has evolved its corruption prevention model to integrate risk-based approaches to anti-corruption, through which it has demonstrated the benefit of focusing on preventing forms of fraud and corruption that undermine their ability to deliver on health objectives.
Furthermore, this study has highlighted a number of areas in which IOs can improve their anti-corruption programmes. Generally, anti-corruption initiatives would benefit from improved M&E systems to optimise anti-corruption programmes; findings from this study support existing literature about the need for improved M&E systems for anti-corruption initiatives.28 Additionally, IOs should work directly with national champions and/or civil society organisations to increase the political will for anti-corruption at the national level.
This study expands on the current literature about anti-corruption mechanisms in WHO, UNDP, World Bank and Global Fund20–22 by examining whether the ACTA mechanisms these organisations employ are effective, the facilitators to their implementation, and how they have evolved over time. This study thus contributes to the existing body of literature about anti-corruption in the health sector; it offers concrete mechanisms by which IOs can improve on their anti-corruption efforts and through which they can benefit health systems in their partner countries.
The COVID-19 pandemic, not surprisingly, has had a clear impact on ACTA efforts. Before the onset of the pandemic, while anti-corruption appeared to have been gaining traction within IOs, there remain large research gaps about anti-corruption for health systems, both generally and within the studied IOs.8 20 21 As the world now enters into its third year of the pandemic, underinvestment in anti-corruption initiatives is ever more prominent, as IOs have been focused on supporting health systems to ensure they can manage the strain caused by COVID-19. The pandemic has also brought forth, however, the difficult balance between the need for urgency and anti-corruption.11 For example, the bypassing of normal procedures (ie, oversight procedures) has at once led to increased corruption risks and the timely flow of funds for the procurement of emergency health products.11 The pandemic has thus demonstrated a tension between anti-corruption and health systems strengthening in times of emergency.
This study thus underscores the importance of addressing corruption in health systems around the world, particularly when health system oversight is sacrificed for the rapid implementation of emergency health initiatives. Given the increased amount of health system corruption experienced during the COVID-19 pandemic,12–17 21 29 this study highlights the importance of strengthening anti-corruption systems to make pandemic responses—and responses to other future emergencies—more robust, resilient and effective. This study contributes to the existing body of literature about anti-corruption during the COVID-19 pandemic21 23 29 by providing mechanisms by which the four studied IOs can reduce corruption that has led to health system failures around the world.
Strengths and limitations
This study had two main strengths. The first is that we collected data from individuals directly involved in anti-corruption programmes; thus, the data represent first-hand accounts from informants with lived experience working towards anti-corruption in health systems around the world. Second, all interviews were conducted over Zoom. Conducting the interviews over Zoom provided us with access to individuals from around the world who would have otherwise been inaccessible.
A limitation of this study was that we were not able to discern whether data provided by interviewees were influenced by their personal beliefs and/or ideas. As a result, we interpreted all data as objective and impartial. To mitigate this limitation, future studies should triangulate data from interviewees with that from other data sources so that the presence of any personal biases is balanced by more objective sources.
Furthermore, recruiting participants from some of the IOs was difficult, with many individuals well suited to participate in this study unable to dedicate time to an interview. While this study had representation from each of the four IOs, significantly more participants were from the UNDP and WHO than were from the Global Fund and the World Bank. Specifically, very few individuals from the World Bank agreed to participate in this study, and thus there are fewer results about this organisation than about the others.
Lastly, although this study offers initial insight into anti-corruption mechanisms within WHO, Global Fund, UNDP and World Bank, all interviewees worked for one of these IOs, for NGOs involved in anti-corruption or in academia within the anti-corruption field. This study, therefore, lacked country-level input from individuals directly impacted by anti-corruption initiatives (eg, government officials, healthcare providers, etc). Future studies should include data from individuals more acutely impacted by anti-corruption initiatives and who may offer different perspectives on anti-corruption in the health sector than did interviewees for this study.
Conclusions
This study explored anti-corruption, accountability and transparency in WHO, World Bank, Global Fund and UNDP, as described by 27 key informants. Results demonstrate that these IOs have shifted from criminalisation/punitive approaches to anti-corruption to preventative ones, in which focus is placed on limiting the impacts of corruption on health outcomes and healthcare provision before they occur. Additionally, results suggest that large amounts of funding for anti-corruption programmes, explicitly addressing corruption, and implementing strong M&E mechanisms, can contribute to effective anti-corruption initiatives.
While the four studied IOs have made considerable and meaningful improvements in their anti-corruption agendas in recent years, there remain areas in which they struggle. Notably, weaknesses in the IOs’ approaches to anti-corruption include a general lack of political will to address corruption, one-size-fits-all—as opposed to sectoral—approaches to anti-corruption and zero-tolerance policies for corruption. Lastly, the COVID-19 pandemic and its attendant corruption risks have underscored the importance of addressing these weaknesses by implementing strong accountability and transparency mechanisms that promote integrity in pandemic responses.
Data availability statement
No data are available. No additional data available. As per the University of Toronto ethics approval, key informant interviews were confidential.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and was approved by the University of Toronto Research Ethics Board (protocol number: 00040020). Participants gave informed consent to participate in the study before taking part.
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
AG, AB and GS contributed equally.
Contributors AG conducted the interviews and wrote the manuscript. AB and GS wrote and edited the manuscript. JK conceived the paper content, supervised the project and edited the manuscript. JK was the study's guarantor.
Funding This work was supported by the Connaught Global Challenge Award.
Competing interests JK is the Director of WHO Collaborating Centre for Governance, Accountability, and Transparency in the Pharmaceutical Sector. AB is a research assistants there and AG and GS were research assistants there when the research was conducted.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
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