Health corruption: a chronic-degenerative illness in the public health sector

By Alejandro Gonzalez-Aquines

When you think about health corruption, some of the first things that might come to your mind could be bribery or lobbying. However, as a medical student in Mexico, I witnessed how health corruption is present in our everyday practice. For instance, staff from public clinics and hospitals would steal medicines and medical supplies for their personal use or to employ them in their private institutions; this affected all patients, including children whose parents were consequently forced to buy rehydration solutions while not having more than 5 USD to get them. Also, patients’ relatives would face the need to sell their properties to afford an urgent surgery in a private clinic because the waiting list in public institutions was more than 6 months long. Patients even died as a consequence of their lack of resources to fund the treatment that was supposed to be provided by the public healthcare system.

Corruption is defined as the ‘abuse of entrusted power for private gain’ and is present worldwide. The public health sector is particularly vulnerable due to the high number of intermediaries to provide health care; thus, the chances of funds misappropriation arise. For example, building a hospital requires large amounts of money and involves different sectors, such as the construction industry (to design and build the hospital), bioengineering industry (to acquire the hospital equipment) and pharmaceutical industry (to get the required medicines). Governmental authorities are responsible for the regulation of these activities, and hence play an essential role in ensuring an appropriate use of the resources. Therefore, there is a need of effective strategies and policies to tackle health corruption.

Over 95% of the member countries of the Organisation for Economic Co-operation for Development (OECD) have defined procedures to report corruption; however, the repercussions of corruption vary considerably across regions and countries around the world. Impunity is defined as the exemption from punishment or escape from fines and is the reason behind the lack of legal repercussions if acting corruptly. While in some countries, like Slovenia or Croatia, those accused of acting illegally present to courts to issue a conviction; in other countries impunity eludes criminals to be condemned. According to the Global Impunity Index measured by the University of the Americas (UDLA, its Spanish acronym), the countries with the highest impunity worldwide are in Latin America, and among these countries, Mexico represents the country with the 4th highest impunity.

Countries by Corruption Perceptions Index score (2020). By JackintheBox

To understand health corruption in Mexico, we need to look at the structure of its healthcare system, which is divided into public and private sectors. The private sector has grown considerably in the last decades, becoming the country with the highest ratio of private to public sector facilities across OECD countries. On the other hand, the public sector is fragmented into more than 5 institutions providing public health care. Each public institution has its own procedures to acquire medical equipment, devices, and drugs. Also, each of them is responsible for hiring their own suppliers, therefore leading to easier pathways for corrupt practices.

Just from 2010 to 2019, more than 4 billion Mexican pesos (approx. USD 178 million or 157 million euros) deviated from the public funding destined for health care. What is most concerning is that the stolen money was originally directed to the poorest States in Mexico: Chiapas, Oaxaca, and the State of Mexico where 76%, 66% and 49% of the population, respectively, are classified as living in poverty. Sadly, it is unknown what was the final destination of this amount of money, but it is likely that it ended up in illicit enrichment of public authorities. As a consequence, and in order to reduce the number of corrupt practices, the Mexican Congress approved a reform to consider corruption as a severe crime. This has led to several ongoing investigations to identify those responsible for deviating the money and recover the stolen amounts.

In addition to the amount described beforehand, the Mexican Government revealed that only in 2017, more than 93 billion Mexican pesos (yes, ninety-three billion Mexican pesos; approx. USD 4.1 billion or 3.6 billion euros) ‘vanished’ from the public funds and went to ‘shell companies’ (defined as companies or corporations with no physical presence which are used for deviation of public funding and tax evasion). After looking at these numbers, it is unavoidable to think how this money could have instead been utilised in healthcare. How many patients and their families could have prevented to go into poverty because of out-of-pocket payments (direct payments made by individuals to health care providers at the time of service use)? How many lives would have been saved? In a country where 52.9 million people (41.9% of the population) live in poverty, deviating health funding for private gain sentences patients to a further progression of their diseases.

Like a chronic-degenerative illness, health corruption weakens health systems steadily. This leaves a fragile and unprepared health system to face public health challenges, such as the increasing burden of non-communicable diseases, the persisting infectious diseases (tuberculosis, HIV/AIDS, malaria, etc) and pandemics brought by novel contagions like the COVID-19. The real question is: how are we, future public and global health professionals, preparing to tackle health corruption?

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