Corruption in the health sector in Anglophone West Africa: Common forms of corruption and mitigation strategies

Executive summary

Corruption is commonly defined as the misuse of entrusted power for private gain. In West Africa, corruption features across sectors, including health, where it can undermine the delivery of care, exacerbate health inequities and can mean the difference between life and death. This review sets out to understand the patterns of health-sector corruption in Anglophone West Africa by reviewing the literature on health and corruption in Ghana, Liberia, Nigeria, Sierra Leone and The Gambia. A total of 283 relevant publications were identified and retrieved, of which 61 met the inclusion criteria for detailed review. The review describes the incentive structures identified in the literature that give rise to corruption, the impact of corruption on health workers and patients, and interventions that have successfully curbed particular behaviours. In so doing, the paper synthesises existing evidence to inform the planning, design, and implementation of feasible anti-corruption strategies in the region. Five types of corruption in the health sector are commonly identified in the literature, namely: (1) absenteeism; (2) diversion of patients from the public to the private sector; (3) inappropriate prescribing; (4) informal payments/bribery; and (5) theft of drugs and supplies. Other more subtle manifestations of corruption are also discussed in the literature.  Generally, most studies discuss many different types of corruption, rather than analyse one behaviour or practice. While this is beneficial in identifying the diverse concerns and types of corruption in the region, a narrower focus on a particular form of corruption would provide the detailed understanding needed to design effective interventions or programmes to counter each behaviour. Some studies identify governance structures as the origin of corruption. However, the evidence suggests that corruption is then driven through informal social networks as patients seek out providers that they know socially, alongside economic drivers such as unpaid salaries, lack of credible opportunities to increase salaries, and stalled or slow promotion of health workers, which together encourage a culture of bribes where informal payments are often considered to be the norm. The literature describes interventions that hold the potential for curbing corruption in the health sector, but better monitoring and evaluation are needed to ascertain how cost-effective the different strategies are and their suitability for different contexts. The main anti-corruption interventions and strategies evidenced to date include 1) incentives for health workers, 2) greater monitoring and evaluation of regulatory compliance, 3) improved transparency and accountability in health systems, and 4) education and awareness campaigns for patients and health workers.  Overall, the review demonstrates that corruption is increasingly recognised across Anglophone West Africa as a problem that restricts access to essential care and limits the effective functioning of health systems. To be effective, anti-corruption strategies must be comprehensive in nature and integrate coordinated reforms across the sector so that vertical approaches such as leadership initiatives, the setting up of regulatory bodies and auditors, and improved incentives are complemented by horizontal strategies that engage frontline health workers and patients. Such reforms and anti-corruption strategies must also be sensitive to the broader social, legal, political, and economic structures within specific countries in Anglophone West Africa.