Introduction
The critical role of governance in health systems strengthening,1 2 achieving Universal Health Coverage3 and equitable financing4 has long been recognised.5 Among health systems researchers, this has come with significant intellectual investment in the development of theory and methods,3 6 reflected in findings from a recent review which identified 17 governance frameworks used in health systems research.7 Theoretical development has been followed by considerable empirical work, with analysts moving beyond examinations of governance as a normative goal to descriptions of how people make and apply rules across the health system.8–10 This shift in focus has provided intellectual space for a more nuanced understanding of the formation and application of rules in different settings. Under the rubric of ‘everyday governance’ an analysis of ‘practical norms’11 has explored informal rules and norms that emerge as health workers and patients respond to different aspects of the contexts in which services are delivered.3 9 These studies have sought to persuade the global health community to recognise these informal practices,4 although agreement on how to manage informality when developing formal governance arrangements has proven elusive.
Corruption and anticorruption fall within the field of research on governance but our reading indicates that there has been less interest in these topics among health systems researchers than in other governance concerns (eg, participation, institution building and accountability). Often defined as practices by which individuals and groups exploit public resources for individual benefit, corruption in health systems may be ignored for various practical, social and political reasons.12–15 Not all forms of informality are corrupt, and some practices are forms of ‘survival corruption’ offering practical solutions to the difficulties of delivering care, especially in severely underfunded health systems.14 16–18 Work on corruption can also be hindered by the fact that it is difficult to define.14 19 Early descriptions, ‘the abuse of public resources for private gain’ ignored corruption within the private sector and failed to provide an explicit acknowledgement of the central role of power in its manifestation.20 More recent definitions, ‘the abuse of power for private gain’ enables a focus on both public and private sectors but continues to rely on a clear division between public and private spheres—a distinction that is not always clear or universally recognised.21 This definition continues to focus excessively on the individual. Moreover as Gaitonde argues, the system in which they are embedded and the enactment of corruption for the benefit of a group, organisation, party or others close to the person who is abusing power, is obscured in these definitions.19 It also makes it difficult to take account of the fact that corruption is socially construct and sits on an axis between moral/immoral and legal/illegal activity (with some forms recognised as legal but unethical and others as illegal but morally defensible).22
Policy-makers have sidestepped these debates by identifying actions or offences that can commonly be agreed on as corrupt (United Nations Convention Against Corruption 2003). In the health sector, these include theft (of money, medicines and consumables); demands for informal payments or bribes; absenteeism among staff; inappropriate referral and diversion of patients from public to private facilities; and inappropriate prescribing (often under pressure from pharmaceutical firms) and provision of misinformation19 23 Each of these is likely to significantly challenge the central goals of health systems—the realisation of the right to the highest attainable standard of health and financial protection.24 Recognition of the threat that corruption poses to the realisation of Sustainable Development Goal (SDG) 3 (Ensure healthy lives and promote well-being for all at all ages) and SDG16 (Promote peaceful and inclusive societies) has driven recent efforts by multilateral and international organisations and some governments.25 The World Health Organization (WHO), the Global Fund and United Nations Development Programme (UNDP) have proposed a Global Network on Anti-Corruption, Transparency and Accountability.26 Their work is, however, significantly undermined by a lack of data on effective strategies and solutions (even on a pilot basis) that have been tested in high, middle or low-income settings.19 27–29 Gaitonde’ striking conclusion in a 2016 Cochrane review states that there is ‘a paucity of evidence regarding how best to reduce corruption in any (ie, in high, middle or low-income) setting’.19 A Transparency International report suggests that many of the current anticorruption approaches within health are either ineffectual or ad hoc or both.30
This paper examines the potential for a new direction in anticorruption research and practice within health systems. It draws on the governance literature and in particular the idea of ‘developmental governance’. This approach is distinct from the dominant liberal approach to governance known as ‘good governance’ that has been advocated primarily by the World Bank and the International Monetary Fund. The good governance framework is heavily influenced by free-market economics, pays scant attention to historical change and is deeply problematic in its reliance on norms and benchmarks drawn from the features of (mostly) western, capitalist economies. Developmental governance, on the other hand, comes from heterodox political economy and uses a historical institutionalist approach to understand conflictual political processes of economic change. It examines the structural nature of informality and corruption as a feature of the economy and social relations, rather than something that has emerges from social norms and culture. Unlike the good governance framework, its concern is not with transforming whole societies but rather it focuses on anticorruption measures as central to tackling specific informal practices that are detrimental to development (the efficiency of the economy and the equitable distribution of high-quality services). It is known as ‘developmental governance’ because the framework demands that any intervention explicitly couple governance goals with identified development goals. It is particularly salient for the present discourse on decolonising public health because it is rooted in a rereading of history that explicitly recognises how colonialism has affected governance.
Anticorruption research has only recently started to draw on this framework, it has been used by researchers in Bangladesh to identify a strategy to tackle fraud in the skills training sector by improving organisational capability the demand for skilled workers31 and in Nigeria to make changes in the electricity sector.32 Anticorruption researchers from Nigeria, Bangladesh, Pakistan and Tanzania have also started to use this framework for anticorruption work in the health sector,23 33–36 but its theoretical implications for health systems have yet to be presented in detail. This paper seeks to add to the literature by settings out the theoretical and practice changes that a developmental governance approach to anticorruption work in health. Our case study focuses on front-line staff, in part responding to research that shows that clinics and health centres in many countries are dominated by informal practice3 and that policy-makers need frameworks and guidance on how to manage and when to act on this informality.
We are cognisant and supportive of the call for decoloniality within global health. This paper is the result of a long partnership between South-North institutions and is one of several papers to be published collectively. It has explicitly sought to present a theoretical framework that challenges ideas of improvements in governance as a northern-focused benchmarking process. The paper has three sections. First, it traces the history of corruption research in international/global health. It shows how dominant theoretical frameworks have largely ignored key contextual factors, namely political power, social networks and everyday forms of informal distribution of resources. Following this, it examines the potential of innovative approaches in anticorruption research from other sectors for health systems research. Finally, the paper presents research on absenteeism among doctors in rural Bangladesh to show how a nuanced account of the formal and informal structures in which health workers operate draws out hitherto unexplored elements of informal practice. This detailed knowledge provides the canvas on which effective and feasible anticorruption strategies can be formulated. We conclude by considering the potential impact of these theoretical approaches to the field and discuss possible intersections and collaborations between researchers and policy makers around these new approaches.