Article Text
PDF
Abstract
Objectives This study aimed to identify the types of transparency interventions in the health systems of the low-income and middle-income countries and the outcomes of such interventions in those systems.
Method We searched major medical databases including PubMed, Embase and Scopus, for any kind of interventional study on transparency in health systems. We also looked for additional sources of information in organisational websites, grey literature and reference checking. Using the PRISMA algorithm for identifying related studies, we included 24 articles.
Results Our initial search, from 1980 to August 2021, retrieved 407 articles, 24 of which were narratively analysed. Response to a problem (mostly corruption) was the main reason for the initiation of a transparency intervention. Transparency interventions differed in terms of types, performance methods, collaboration partners and outcomes. They help improve the health system mostly in the short term and in some cases, long term.
Conclusion Although our findings revealed that transparency initiatives could reduce some problems such as counterfeit drugs and corruption, and improve health indicators in a short term, still their sustainability remains a concern. Health systems need robust interventions with clearly defined and measured outcomes, especially sustainable outcomes to tackle corruption fundamentally.
- systematic review
- health policy
- public health
Data availability statement
Data sharing not applicable as no datasets generated and/or analysed for this study. All data relevant to the study are included in the article or uploaded as supplementary information.
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/.
Statistics from Altmetric.com
STRENGTHS AND LIMITATIONS OF THIS STUDY
The study examines data on health outcomes of transparency intervention in the health systems of low and middle-income countries.
Some relevant studies did not purely discuss transparency interventions. Nevertheless, they provided some information to the public, using which they could enhance the right to know information environment.
As the identified studies were heterogeneous, conducting quantitative synthesis was out of the scope of this research.
Introduction
Transparency is ‘characteristic of governments, companies, organisations and individuals of being open in the clear disclosure of information, rules, plans, processes and actions’.1 Transparency interventions range from strategies countering corruption and enhancing auditing practices to accountability mechanisms reported by civil society, yet these remain understudied in the literature and lack a standardised framework.2 3 As transparency is one of the pillars of good governance,4 accountability and transparency are essentially coupled, each one is a requirement of the other.5 It is expected that transparency could empower efforts to change the behaviour of powerful institutions, by holding them accountable in front of public eyes.6 Therefore, many countries have approved ‘right to know’ laws and have provided opportunities to enhance access to information for their citizens.7 Even in communist states, some degree of transparency is visible, especially in healthcare systems.8 9 In addition to general laws on access to information, some countries have enacted specific laws for disclosing information in the health system. The Physician Payment Sunshine Act in the USA, and similar legislations in several European countries, have led to the mandatory reporting and public disclosure of the financial relationship between healthcare professionals and the pharmaceutical and medical device industries.10 For some industrialised countries, ‘transparency is no longer an optional extra. It is necessary for fair, effective, and accountable healthcare’.11 Therefore, during the past two decades, to ensure monetary aid spent for targeted populations, transparency and accountability policies have been integrated into international aid organisations as well.12 The WHO has also introduced some programmes to help countries increase transparency in their health systems, ie, Good Governance for Medicines (GGM), and Medicines Transparency Alliance (MeTA), both focusing on pharmaceutical transparency.13 14
Lack of transparency can increase potential vulnerability to corruption in all building blocks of health systems, namely human resources for health,15 medical procurement and supply chain,16 financial resources, service delivery, information and governance.17 The COVID-19 pandemic and the need for rapid responses to the crisis have created situations that subjected countries to corruption, such as falsified products and overpriced medical supplies. Transparency can shed light on corruption risks and inefficiencies areas, which can help prevent them.5 In societies where the rule of law, transparency and trust are in place, corruption in healthcare is less likely.18 Evidence from Transparency International showed a positive correlation between increased transparency, accountability and integrity and better education, health and water outcomes in 48 countries.19 Public reporting can improve performance through two pathways, selection and changing the way; in the selection pathway, patients by comparing published information on performance give rewards to the better providers by ‘selecting’ them, and in the changing pathway, performance data help providers know weakness points and ‘change’ them.20
There are many strategies for the implementation of anti-corruption, transparency and accountability policies. These include the use of electronic platforms,21 open contracting,22 participatory budgeting,23 community involvement24 or at least, providing simple information about patient fees and healthcare prices.25 In line with its context and infrastructure, each country may adopt one or some of these strategies.26 Access to information has a wide spectrum. In the simplest form, health education could be considered as one kind of access to information, which would be beneficial for the health system, especially for social participation in health.27 Disclosing administrative information to the public is an advanced form of right to know, which aims to provide an atmosphere of participatory decision-making and accountability.23 28 Among various types of transparency strategies, the one that provides comprehensible information for the public is the right option.29
The way that interventions are executed in any setting is crucial for its outcomes. Evidence shows that citizen engagement would be more effective when implemented incrementally in a collaborative manner.30 Implementation and definition of transparency and accountability efforts might differ across different countries.31 Civil society, for example, can facilitate community engagement, and programme design should consider all players in the intervention setting.30 Transparency needs continuous improvement in all settings, high, middle and low-income settings alike. For instance, in the UK, although the majority of NHS Trusts facilitate conflict of interest registration, still some concerns remain about the completeness and quality of data registered.32 In the context of low- and middle-income countries (LMICs), the implementation of transparency to fulfil desired expectations appears more difficult than in industrialised nations. Evidence shows that despite limited progress in this regard,12 33 most transparency interventions in LMICs failed or remained unsustainable.34 35 We found a knowledge gap on transparency interventions in the health systems of LMICs and their consequences. This study aimed to identify the types of transparency interventions in the health systems of LMICs as well as the outcomes of such interventions.
Methods
This systematic review followed the PRISMA approach. The inclusion criteria were:
Population
Based on the World Bank classifications by income level, people residing in LMICs, in 2019–2020, were low-income (under US$1026), lower-middle-income (US$1026–US$3995) and upper-middle-income (US$3996–US$12 375).36
Interventions
Any intervention related to transparency and accountability, disclosing information, community engagement, whistleblowing, infrastructure enhancement for increasing transparency and increasing access to information for the public;
Comparisons
Condition before intervention
Outcome
Promoting accountability, health outcomes, and service delivery.
Study designs
Any experimental study related to transparency, and access to information in the health sector, directly or indirectly.
Exclusion criteria
We excluded studies that were unrelated to transparency interventions in the health sector or were related to high-income countries.
The synonyms and various search terms were used to find relevant articles. We searched three databases: PubMed, Embase and Scopus, from 1980 to August 2021. The search was conducted at the end of August 2021. Table A1 presents the search strategy and keywords we used in each database (see online supplemental appendix).
Supplemental material
During the initial search, we applied no language limitation. We only found one non-English relevant article in Spanish, which was excluded. All included studies were in English.
We imported the initial retrieved references to EndNote X7 and deduplicated them. To ensure comprehensiveness, we also hand-searched the governmental and organisational websites, plus institutions whose organisational mission was transparency and fighting corruption. In addition, we searched related grey literature and screened the reference lists of all retrieved articles (included and excluded) and reports to find relevant studies. Two reviewers screened the papers independently, and any discrepancies were resolved through discussion and consensus. We then conducted data extraction of relevant information regarding transparency interventions, including the main trigger or problem that led to transparency intervention, implementing body, intervention area, and short-term and long-term consequences of the interventions. Because of the nature of such interventions, assessment for study risk of bias was not applicable.
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.
Findings
Our initial search retrieved 407 articles, complemented by 384 articles and reports during reference checks and hand searching, resulting in a total number of 791 articles. After reading the title and abstract, 645 articles were excluded. We then read the full text of 72 articles, excluded 48 articles and included 24 remaining articles in the final analysis. The included studies and their characteristics are described in Table A2 (see the online supplemental appendix). Due to the significant heterogeneity of the interventions, setting and consequences, a quantitative analysis was not feasible and we therefore report the results narratively. Figure 1 presents the PRISMA diagram.37
PRISMA diagram for selection of articles.
18 LMICs reported transparency intervention (including six African, six Asian, two European and four American countries). Most transparency interventions were initiated in response to a problem or series of general concerns. For example, the existence of different types of corruption was among the most important triggers for transparency interventions (either in the health sector or all governmental bodies). At least in 17 out of 24 studies, corruption was a concern. The reasons are classified in table 1.
Triggers for transparency initiatives in the health sector
Transparency interventions were different, ranging from purely transparency interventions like transparency in the Nigerian public pharmaceutical sector16 or providing access to information, transparency and accountability to the public in Greece,21 to those indirectly providing information to the public such as empowering rural residents about their health services entitlement in India,24 or cases that transparency was a component of a main intervention, like what implemented in Kyrgyzstan; the system of single-payer combined with transparent payment system in healthcare facilities.38
21 out of 24 interventions involved the flow of information from the government to the public, while only three studies reported interventions regarding information provision from the public to the government.39–41 Most interventions at the national level were implemented by senior governmental officials,16 42 43 while expectedly, local interventions were executed by local officials and research teams.25 44 45 In the same way, transparency interventions were conducted by the government itself, and its related agencies,46 47 in collaboration with developmental partners, eg WHO,42 World Bank,40 42 USAID,25 41 GAVI,12 Transparency International,39 other international institutions39 41 and civil societies.25 42 The scale of the interventions was diverse, from a single hospital25 to the national level.21 42
Most studies (21 out of 24 studies) reported some degree of short-term positive impact following the interventions, like a reduction in the circulation of counterfeit drugs in Nigeria,16 a decrease in infant mortality rate, maternal mortality rate in India48 and public access to information in Greece.21 Three studies reported no significant change following intervention including
ICT-based interventions in Uganda41;
pharmaceutical pricing transparency in Brazil43 and
Transparency for Development (T4D) in Tanzania.45
In three studies,24 43 46 we did not find robust evidence to support the long-term effectiveness of the interventions. In the case of Kyrgyzstan, the short-term improvements regarding the reduction of informal payment faded and changes reverted after a few years34 (See table 2).
Classification of outcomes
In addition to identifying short and long-term effects of interventions, we also attempted to investigate the sustainability of results. Changes that continued for several years were considered as sustainable changes.12 16 21 23 33 For instance, after 8 years of implementing transparency in the public pharmaceutical sector in Nigeria, most of its achievements were sustainable, like the reduction of counterfeit drugs.16 Nevertheless, we could not determine the sustainability of transparency interventions in some studies,24 46 mainly because we could not find any further evidence about their follow-up.
Discussion
Transparency is perceived as an essential element of good governance and democracy.26 Expectedly, we found corruption or misconduct as the most significant rationale for implementing transparency interventions.25 39 Although the policy dialogue of transparency is still in its early stages, the movement for legitimisation of transparency has been fairly rapid. Many countries are working toward enhancing transparency measures to guarantee better accountability and more efficient government.7 Despite the common belief that transparency can prevent corruption, a systematic review of corruption in the health sector concluded that transparency alone cannot guarantee reduction of corruption.3 The findings of this systematic review have demonstrated that reasons for initiating transparency interventions are specific to individual country contexts.
Although transparency is assumed to be the provision of information for the public by the government,49 it can also be defined as the flow of information from the public to the government; ‘transparency upwards’,50 such as public reporting or whistleblowing to administrative bodies.51 One example is the civil societies in Mexico that conducted a ‘Citizens’ audit to investigate corruption in altering the women’s health budget to a private organisation.18 In such cases, through participatory initiatives, such as citizen report cards,40 people disclose information about public service delivery. Moreover, interventions involving public participation and decentralisation require access to a range of information and reducing information asymmetries for the public48 52 to achieve a tangible impact.33 To reduce such information asymmetries, there is a need for suitable infrastructures, that is, electronic infrastructures like the internet or mobile phones, to facilitate the flow of information on both sides: government and public.21 39 43 Electronic networks provide a system for tracking financial data and help protect financial health resources from theft, fraud and embezzlement. For example, the networked cash registry in Kenya prevented user fee fraud,25 and the ‘OPEN’ system in South Korea helped to track the process of applications.53 Alongside infrastructures, social context is also important. Most transparency interventions need community involvement. Evidence shows that poor health services can be reduced by the active involvement of the community in reporting them to the officials, which indicates the need to motivate citizens to report misconduct through a suitable manner. Some strategies, eg, a toll-free number, creating a feedback loop, availability of report receiver and confidentiality of whistle-blower identity, may work as enablers here.26 In this regard, we must remember the grass-roots level may need international technical assistance for the implementation of transparency interventions in some LMICs.
Our review revealed that nine out of 24 interventions were conducted in collaboration with international development partners, including WHO, World Bank, Global Fund, USAID, UNICEF, GAVI, Spider (Swedish Programme for ICT in Developing Regions), Swiss Red Cross, U-Bridge, RTI International, Health Action International, Oxfam and UK Department for International Development, that help the implementation of good governance in health systems.13 50 In particular, countries receiving international aid were pushed to move toward transparency on spending aid budgets, for instance, in Uganda, some measures have been adopted in collaboration with international partners (Spider and Transparency International) for promoting transparency in the health sector.54 MeTA and GGM are good examples in this regard which are conducted in many countries in collaboration with WHO to tackle corruption in the pharmaceutical sector and enhance accountability.55–57 In the context of countries with emerging democratic institutions, transparency initiatives are mostly led by non-governmental organisations, whereas in older democracies, civil society might play the main role.7
Previous evidences suggest that even partial access to information can be useful. For example, the experience of mailing ‘Raskin identification cards’ in Indonesia showed that despite only 30% of eligible households in treatment villages receiving ‘Raskin cards’ and instructions on how to use them, they received 26% more subsidy compared with the control villages who did not receive cards and information.46 Another study showed that when a community has little access to information, stimulating participation has a lower impact on health workers or the quality of healthcare. In contrast, informed communities result in better agreements on their health needs and greater achievements in healthcare delivery and health outcomes.33
Although our review showed positive results in favour of transparency interventions, in fact, few of them had real and robust impact on health. The most prominent health indicator we found was the reduction in infant mortality rate, which was reduced following the implementation of four interventions.23 25 39 48 This may be because such interventions need time to be deeply institutionalised in the attitude and real practice of the societies. This is similar to an earlier study that showed a direct relationship between child mortality rate and corruption, wherein the higher the rate of corruption, the higher the rate of child death.58 Another study revealed significant improvements in drug registration and reduced circulation of counterfeit drugs, despite serious challenges in the management of conflict of interest within the pharmaceutical sector.16 The experience of Armenia revealed that efforts to reduce informal payments were only effective in reproductive, maternal and child health; whereas, high informal and out-of-pocket payments remained a problem in the rest of the health system.35 59 In addition, there are some confounding factors influencing such intervention. In Uganda, for instance, very few number of text messages which were reported regarding poor health service delivery were actionable for officials. It was in result of the limited access of the population to mobile phones and the digital gender gap.54 These examples might indicate that the impact of transparency interventions is sometimes limited and underlying contextual issues still remain unsolved; hence, the need to make transparency interventions more sustainable. In fact, defining or deciding on what constitutes a sustainable outcome can be difficult, but one can be cautiously optimistic if a positive outcome has been sustained over several years.16 39 Contextual issues play a determinant role on the result of such interventions. Transparency, as a pillar of good governance, can help reduce corruption in conjunction of side improvement in other pillars, for example, accountability, partnership, etc. This can justify why the sustainability of such intervention remained under question.
The main limitation of our study was the limited number of studies regarding the issue of transparency intervention in LMICs, most of which were related to the pharmaceutical sector. Briefly, transparency interventions are not very common in LMICs, and as stated in previous paragraphs, some of such interventions were pushed by international agencies. In addition, the context, design, domain and purpose of them were varied. Therefore, it is hard to generalise the results of these studies to other countries. There should be more studies in this regard to have comparable and generalisable findings.
Conclusions
Transparency interventions are among the most useful approaches for confronting corruption and increasing accountability in health systems, whether they address problems directly or indirectly. Our study showed that transparency interventions come with some positive outcomes, and most of them have started in response to a problem in health systems. Most problems in public service delivery have been shaped as a result of long-term multifactorial interactions; therefore, no single solution will be able to deal with them. We advocate the implementation of tailored transparency interventions to each health system; thus, there is no ‘one size fits all’. Transparency can be one of the several strategies to reduce corruption in the health systems and move toward good governance. Those who implement transparency interventions should consider the sustainability of interventions. Transparency is necessary, but not sufficient to improve social accountability,6 and more than one anti-corruption intervention should be employed to deal with this problem. While most health systems are dealing with the COVID-19 aftermath, that is, financial instabilities, increasing demand and inefficiencies in medical supply, a holistic perspective to address all components of good governance in healthcare and other public services is a must, now more than ever, to provide quality healthcare and improve citizens’ well-being through meaningful implementation of universal health coverage.
Data availability statement
Data sharing not applicable as no datasets generated and/or analysed for this study. All data relevant to the study are included in the article or uploaded as supplementary information.
Ethics statements
Patient consent for publication
Ethics approval
We obtained research approval by the ethics committee of Tehran University of Medical Sciences (ID: IR.TUMS.SPH.REC.1399.279).
Acknowledgments
We thankfully acknowledge Tehran University of Medical Sciences for the supporting of our project.
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
Contributors AT and MG conceived the study. MG conducted searching, data extraction, analysis and drafting of the manuscript. MJK, AO and MM contributed to data analysis. All authors read, critically reviewed, commented and approved the manuscript. AT is the guarantor.
Funding This study is a part of PhD thesis in Health Policy, in Tehran University of Medical Sciences. There was no special funding for this study.
Competing interests None declared.
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.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.