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The 9th International Anti-Corruption Conference

The Papers


M. J. Mwaffisi
Permanent Secretary
Ministry Of Health
Dar Es Salaam

Corruption involves the payment of bribe, that is money or material items offered to provide (often illegal or dishonest) services or decision in favour of a giver.

The health sector is one of the areas that is prone to corruption. In Tanzania, according to the Warioba Report, the health sectors was ranked third in the list of sectors with the highest incidence of corruption. This is also true to most developing countries and the reasons are clear that health is a service which is in great demand and touches the lives of most people, while on the other hand resources are scarce.

Levels of corruption can be distinguished into two categories. There are those who engage in petty corruption, that is those who receive bribes as a supplement to their meagre income. This is referred to as petty corruption and involves individuals being forced to pay small amounts of money in order to get the service that they deserve to get free or with a little payment. Majorities of the people who are forced to pay bribe are poor, and thus, the amount of money, which is involved, is a significant porting of their income. The impact to the poor is in most cases enormous.

Clients pay bribes in almost all the departments of the hospital; the outpatient, laboratory, X-ray, the labour ward and the mortuary are notorious. The pharmacy and the general wards are also not free from corruption. In fact, there is no "corruption free zone" as it is often claimed.

And on the other hand, we have those who engage in grand corruption, these involve themselves in corruption because of greed. In the health sector, this involves the payment of big sums of money by rich individuals and institutions to some corrupt government officials in order to win tenders for the supply of pharmaceuticals, medical equipment and supplies. As a result of this unfair competition among bidders, the Government does not get the supplies worth the money it pays. The Government incurs loss through getting fewer supplies, which are more expensive due to over-invoicing, substandard, and having shorter life span or shelf life in case of medicines. This type of corruption, apart from resulting into Government losing a lot of money, delivers a heavy toll at the micro-level due to the effects arising from the shortages it causes at the lower level. Thus macro- level corruption causes and potentiates corruption at micro-level. And all in all it retards development of a nation, as the government cannot achieve its objectives, increase the debt of the country and makes the country more poorer.

There are several causes of corruption in the health sector and these include the following-:

The small budget allocated to the health sector, results in shortages of medicines and other medical supplies. Patients have to be put on waiting list for long periods before they are provided with some elective services like surgical operations. At some stage, hospitals are forced to do away with elective surgery and perform emergency operations only, and this makes room for corruption.

Surgical operation
At some stage, hospitals were forced to do away with elective surgery and perform emergency operations only , and this makes room for corruption.

Excessive Red Tapes and Long Queues
Some of the processes and procedures that one has to go through are necessary. These procedures combined with shortages and inefficiency result in long queues that create an environment for soliciting and giving bribes.

Poor Salaries
Salaries for health workers are very low. Health workers have won the sympathy of many who see them as deserving more for what they do. Members of Parliament have been urging the Government to review the salaries for health workers.

During the second Phase, the Government of the United Republic of Tanzania, decided to allow doctors working in Government to open private clinics and engage in private medical practice after their official hours of service in a bid to increase their income while retaining them in Government Service.

However, this move has had some negative consequences:

  • Doctors spend some official hours in their private clinics, leaving patients in public service facilities unattended.
  • Doctors use public facilities and medical supplies to treat their private patients who often get priority service over others.
  • Doctors use public facilities as a conduit to channel clients to their private facilities.
  • Doctors prescribe medicines that they know are not available in Government facilities and advise patients to procure them in their facilities.
  • There has been increasing incidences of theft of medicines and equipment from public health facilities.
  • Due to these unwanted consequences, the Government is now rethinking this policy decision.

Poor Management and Supervision
Poor management and inadequate supervision of health workers leaves them unchecked to do whatever they want to do. There is a general breakdown of moral ethics that is making professionals feel comfortable even while breaking their own code of ethics that gave them their credibility and identity.

Disregard to the Law Disregard of the law resulting into its breach and lack of enforcement is another cause of corruption. There is always a tendency to resort to reviewing the laws and regulations while the existing ones may be adequate but not enforced.

Lack of Information
to clients Lack of information on what services are provided, where and when they are provided, who provides them and procedures to be followed creates an environment for soliciting and paying a bribe. Clients need to know their rights and obligations so that they know what to expect and what is their responsibility. Sometimes, due to lack of information, they think that a bribe is being solicited.

Macro level corruption frustrates a poor nation like Tanzania struggling to meet the basic needs of its citizens with meagre resources. Despite the efforts being made to increase resources for health service delivery, health status indicators continue to show little or no improvement. With the citizens being continuously exposed to ill health, the nation continues to be poor. Citizens are dissatisfied with the Government as they see no benefit from their efforts and the tax they pay. As mentioned earlier, macro-level corruption causes and potentiates corruption at the micro-level.

Frustrating Achievement of the Health Policy Goal
In Tanzania the overall objective of the health policy is to improve the health and well being of all Tanzanians with a focus on those at most risk, and to encourage the health system to be more responsive to the needs of the people. This boils down at ensuring equity in the provision of quality health care. Corruption directly militates against the achievement of this noble goal.

It is only those who can afford and who paradoxically have the least need that get access to service. They pay bribes to get service and those who really need it but are unable to pay bribes are left to suffer. Those who struggle to pay end up in indebtedness and may continue suffering due to failure to complete full course of treatment. Incomplete treatment is poor quality treatment that may lead to permanent disability and death.

Corruption also results into poor quality health services as those who provide it have no incentive to make it better, in order to perpetrate an conducive environment for corruption.

Public Dissatisfaction
Due to the denial of access to health care to the majority, corruption develops a disgruntled community which is dissatisfied with health workers and the Government. The health delivery system fails to develop the partnership with the community that is necessary for the achievement of the primary health care goal of health for all.

Loss of Credibility and identity by the Health Professions
Corruption is a vice. Those who solicit and take bribe lose credibility and respect in the eyes of the giver and are taken to be cheap.

Corruption has spread like a cancer into our society and finally, reached domains that were free of it, like the nursing and medical professions. The Swahili word for corruption is "rushwa" was not heard so frequently during the early period of independence up to the 80s. It then got other names to justify it, like "a handshake" meaning a present or "ahsante" meaning thank you for good service.

The way and extent to which it has entrenched into our society makes it difficult to wipe it completely. However, the impact of corruption is immensely detrimental to our development. However it takes and at whatever cost and length, corruption has to be wiped out in our society. Wiping corruption is not the responsibility of the government, rather, it is for the whole society. There needs to be concerted efforts of all individuals, Government and Non-Government institutions and the donor community, the general public and the international community.

Information to the Public
The public needs to be protected from unfaithful health workers who have corruptive tendencies. They need to know what services are provided, by whom, where, the price, where to pay etc. They also need to know where they should go arid who they should consult when they have a problem. If a health worker solicits a bribe, they should feel safe and secure to report and see that action has been taken against the culprit. The public should feel themselves as masters rather than underdogs.

In order to be partners with the Government in combating corruption, the public needs to be informed. Information must be made available to the media and a partnership needs to be forged between government and the media on how best to disseminate information to the public. This information can be provided through various media like announcements, posters, newspapers and electronic media.

Citizens Charter
Citizens need to be educated on their fundamental rights, responsibilities and obligations.

External Evaluation of Health Services
Apart from internal assessment of health facilities through self assessment and assessment by supervisors from the higher levels, health facilities should be evaluated by others not directly attached to the sector, and of utmost importance, health services should be assessed by the clients who are the beneficiary of the service being provided. Facilities should be encouraged to solicit feed. back from clients on the service they provide. Supervisors should always make it a point to talk to clients and solicit their opinion on the quality of service being provided to them.

Increase budget to the Health Sector
The present Government efforts to allocate more funds to the health sector should be enhanced to reduce the widespread shortage of drugs and medical supplies to make it easy for people to get health services and remove the environment for soliciting and paying bribes.

Streamline Procedures and Increase efficiency
Innovative technology and management procedures should be improvised to enhance efficiency and reduce long queues in health facilities.

Proper Analysis of Corruption environment
Rather than just dealing with individuals who solicit and give bribe, we should concentrate on dealing with the different environments that provide incentives for corruption and address those.

Involvement of Professional Bodies
All professional bodies should be educated to realise that corruption is killing them as professionals and that their trade may ultimately cease to be recognised as a profession. A sense of professional self regulation should be instituted among the various professional bodies.

Procurement procedures
need to be looked into in order to institute effective and transparent systems and processes.

Corruption should be dealt with severely
Corruption is a criminal offence. Any incidence of corruption should be taken seriously and the culprits dealt with squarely in order to deter others from committing it. We should work towards Zero tolerance for corruption by strengthening community net-works against corruption.

  • Health personnel need to be educated on the vices of corruption and be reminded that they are servers and not masters. We have also got to eliminate the doing you a favour attitude among health personnel.
  • Train health personnel in order to boost up morale and increase competence and efficiency.
  • Health personnel should be paid a wage in line with what is expected of them, and good performance should be recognised and rewarded.

Above all, the international community has got a role to play in the fight against corruption in developing countries. We know that corruption is not just an internal issue involving developing countries, but rather it goes across the borders. Practices of foreign bodies, including donors and investors, fuel the extent of corruption especially in procurement.

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