The next day, 25th April, 2018, had the ACE team engage health sector policy makers in FCT and Enugu. We aimed at brainstorming practical and feasible interventions to curb corrupt practices identified the previous day.
Activities for the day started with opening remarks, introduction and housekeeping of which Prof Obinna facilitated the session. Dr. Pallavi presented the approach of ACE, pointed out reason why most anti-corruption strategies usually end up on paper and those implemented come out half-baked. She stated that sometimes corruption looks intractable in most sectors, hence the need for an evidence based approach is needed. The reason is that anti corruption strategies are majorly centered on the vertical approach which is more of a top-down approach. The system forces people into corruption. Successful anti-corruption countries however have incorporated not just the vertical approach but the horizontal approach as well. The combination of these approaches leads to a successful reduction of corruption in countries. The ACE approach attempts to look at new ways of doing things, considering feasibility and impact. Thus, the ACE approach argues in support of horizontal approach, given that it involves less of those at the apex of governance structure in countries. This way, actors are empowered with emphases on what they can do to reduce corruption.
Dr. Dina emphasized the need for the study because of the cancerous consequences of corruption and expressed optimism regarding the issue of corruption as addressable. At the end of the session, Mr. Lawal (ICPC) suggested that the project could be enriched with partnering with the ICPC because they have been doing a lot of systems research in the area of health, transportation, etc. They aim at identifying areas that are prone to corruption and advise the sector on what to do about it.
Dr. Eleanor gave a recap of the findings from the previous day’s workshop. She further informed the participants how ACE team successfully carried out a literature review that identified some types of corruption. Also during the workshop, participants were asked to write down the types of corruption based on the most impactful and feasible in studying. The identified types are as follow in hierarchy:
- Under the table payment
- Employment irregularities,
- Health financing
- Procurement related corruption
Based on the ranked items of corruption in the health sector, the policy makers were divided into groups to identify forms of corruption and proffer possible solutions for curbing corruption in health system.
Group A dealt on absenteeism and under-table-payments
Group B dealt on employment related corruption and health financing
Group C dealt on procurement related corruption and pharmaceuticals.
KEY POINTS EMERGING FROM GROUP DISCUSSION.
Absenteeism should be conceptualized following variables that inspire absenteeism. It was viewed ranging from:
- Not coming to work at all
- Not coming to work early
- Coming to work and leaving before the appropriate time
- Coming to work and not doing the work at all
Desire to make more money, absence of enforcement of rules and regulations to check this, private practice, cultural factors of keeping up with status (this is very peculiar to senior consultants who would have to help junior workers and relatives around financially), location (not being at proxy to the facility), lack of maternity cover in the sense that women give birth and are much more involved in family care.
The group did not consider getting jobs away from main jobs a corrupt practice as long as it is outside official work hours. However, contract jobs for health workers was strongly discouraged as they might return from the contract jobs and get tired to deliver competently in their base facilities.
At the Primary Health Centers, the drivers of absenteeism were listed to be lack of supervision, lack of motivation in terms of salaries, lack of consumables and equipment, poor attitude to work culture, location (not being at proxy to the facility), lack of demand of health care at that level (underutilization of PHC facility), lack of maternity cover in the sense that women give birth and are much more involved in family care.
- Clock-in/clock-out system: This should be managed by the Human Relations Dept or related department.
- Payment of salaries should be result based (work output). This might be little difficult because of the political atmosphere of Nigeria and work output in our context would be hardly be measured.
- Enforcing and maintaining sanctions and rewards appropriately as part of monitoring systems.
- Provision of accommodation for staff.
- Encourage Public-Private/Private-Public partnership. A patient from private hospital could be treated in a public hospital with well spelt out modalities for payment to the private and public agency. This should be properly monitored to avoid abuse.
- Provision of transportation for health workers
- Contractual flexibility, though with efficient monitoring.
- Equipping the public hospitals to curb work frustrations which de-motivate health workers.
Basically, this means taking payments that should otherwise be paid to the government, extra or illegal payment that comes for services at every point in the health facility. It also includes private sales of consumables which is called “parallel sales of drugs”. Participants argued that this kind of payment cuts across the health system but more at secondary and primary healthcare centers. Participants consensually said that most healthcare professionals are involved in this.
Among the drivers include, need for money, patients not knowing their rights or ignorance, frequent stock outs, patients soliciting informal assistance from health workers, and inadequate staffing.
- Allowing patients to switch consultants and teams would help reduce under-the-table-payments; this will help whenever a patient notices irregularities.
- Decentralization of costing and dispensing consumables.
- Sensitization of the patients and those at the revenue controlling departments on the actual cost of services, through measures of print media and electronic media where applicable
- Effective Leadership to ensure enforcement of rules, regulations and legalities where appropriate, as this will be great in enabling monitoring and supervision
- Inter-professional checks and balances would help for monitoring and enforcement
- Establishing credible and reliable reporting platforms with patients being aware of the right channel for reporting.
- Sensitizing health workers to ensure they have clarity about rules, regulations and disciplinary procedures
- Carry out regular medical audits to achieve balance between number of patients who utilize a facility and financial records.
Participants agreed that under-the-table-payments affect the revenue base of the facility and ultimately the government. Revenue controlling department as well as the government will express intents in order to curb this particular irregularity.
- Corruption related procurement and pharmaceutical
This includes supply of commodities to where they are not needed, whereas those who need it, don’t get it, even when the commodities are available. The drivers are: procurement laws not practiced; complexities and even wastages in procurement of drugs; lack of proper consultation in the central stores; pushing out what is not needed; medical sale representatives bribing doctors so they can sell their drugs, and doctors prescribing more of a particular drug because of returns or gains from the pharmaceutical companies who give them kickbacks. The key players are the sale representatives, doctors, auditors and pharmacists. The implication is the actual cost to the system is high since the patients are the ones that pay for the expense of the drug because of the benefits people fight to be in procurement unit. There is logistics problem in the system and there is no proper reporting.
- Provision of essential medicine list at all levels
- Incentivizing DFR
- Multiple simultaneous submission
- Use of tendering boxes (limited access)
- Feedback for stock in stock out ascending through levels
- Daily reconciliations
- Institutionalize training and knowledge/skill transfer
- Training and of health workers working in pharmaceutical sections or drug stores. Also institutionalize knowledge transfer to reduce the monopoly of people in the procurement
- Introduce and use of ICT is important to enable us monitor the process.
- Committees should be set up for making decisions on drugs usage and supply.
- Advertisement of drugs needed in a hospital should be made public to ensure competitiveness involving more pharmaceutical companies thus reducing prices and transparency in the selection process. Collection box is provided, the envelope for tendering should be dropped in a box and ensured that it is not opened until the day that they would all be attended to by a committee.
- Adherence to procurement act because it eliminates the process of corruption. Violations should be reported and therefore should followed prosecutions.
- The whistle-blower policy is not fully institutionalized. There should be proper data management practices. It would help spot the points the drugs are there and where it would be followed to next.
- Health Employment related corruption
There is corruption in employment process/cycle. These include:
- Advertisement: People are employed without advertising the job.
- Short listing candidates for employment: Real employees have been taken. Short listing and conducting the interview is only formality. What causes this is favouritism.
- Inappropriate deployment
- Internship: Letters coming from powerful members of the society like politicians. Sometimes their aides always use their letter headed paper to employ their people.
- Under staffing/Ghost workers: Engaging more staff but only few comes to work on daily basis and all are paid. Salaries of ghost workers are shared by the cartel (team of leaders) to cover their tracks of corruption.
- Not matching the right person to the right job.
- Private sector corruption: engaging low qualified health personnel to carry out responsibilities beyond them because they do not have the capacity or limited knowledge
- Deployment of staff : Not deploying appropriate health personnel based on need but of interest.
Causes of corruption
- Weak system: Where individuals are powerful than the law or government.
- Lack of finance. (Low money allocated for health in the budget and non-predictability of the release of funds).
- There is wavier for advertisement by the federal government ( presently functional) to ensure all government jobs are properly advertised.
- Ensure due process is followed in the recruitment process
- Appropriate sanction for offender (trace it down to its root)- Critical Incidence analysis
- Institute transparency in all stages of employment ( publicly televised)
- Deployment should strictly base on specific roles and responsibilities of personnel.
- Support in-house training and mentorship of young health workers
- Roles of regulatory bodies is very critical in curbing corruption
- Conduct quarterly unannounced staff audit using different strategies.
- Use of electronic payment system (linking BVN to payment process)
Corruption in health care financing
- Irregular payment of funds by HMOs to NHIS or health providers (fee for service)
- Services being paid for and authorized by HMO but not given to the patients but billed by the health providers and paid by NHIS.
- Splitting of bills by health providers and patient especially for insurance patients
- Fake patients been recorded by health providers sent to HMOs for payment
- Non update of enrolee dropouts from a hospital
- Hospitals deny patients of health services because capitation fee was delayed.
- Stock out recorded by the health providers whereas it’s not supposed to be so. They will hoard the drugs and still send bills to NHIS
- Denial referral services to patients
- Overbilling of patients
- Unnecessary investigations (imaging, tests, x-rays) are requested for the patient to ensure money comes in. Sometimes investigations are not carried out but bills are sent to NHIS for payment.
- Splitting of bills between health providers and patients
- Fake receipts issued to patients
- Non- release of money allocated to health by the government at all tiers (Federal -15% allocated to health is not distributed), State and LGAs – Local Govt Chairman has no appropriate planning, not considering other factors – manpower, needs,) . This is because of lack of interest in health of the head of the office. Money is used in other sectors like education or road construction or infrastructural upgrade.
- Institute patient service mechanism through electronic
- Patients must always sign the bills which provides details of services provided at the facility before bills are sent to HMO
- Provide suggestion boxes and hot lines for reporting and feedbacks from patients in NHIS accredited hospitals. (Currently functional)
- NHIS should regularly update and accredit health facilities before engaging them. (Currently functional)
- Improvement in the regulation of NHIS system i.e. removal of some layers of NHIS system (like HMOs). This can help to reduce corruption in the process of NHIS.
- Prices of health services should be made public (by pasting on the walls of health facilities) to the patients.
- Provide incentives to the best performed facilities (motivation to others).
Compiled by the ACE Team