Beyond Politics and Fraud Investigation: Corruption as a Public Health Issue

A Strategic Imperative

I have recently been appointed as a Commissioner on the Lancet Commission on Anti-Corruption in Health. For me, the Commission represents an opportunity to shift how we conceptualize corruption in healthcare, with a new focus on tackling corruption as a public health problem.

Years ago, a colleague helped me recognize that corruption in health extends far beyond fraud control and auditing. It constitutes a systematic barrier preventing populations from accessing healthcare during their most vulnerable moments: medicines diverted from supply chains, salaries paid to fictitious healthworkers who can’t turn up to clinics, and families compelled to pay bribes for basic medical consultations.

These are not abstract governance failures. They represent structural impediments that deny essential healthcare to real people. This recognition led me to a critical conclusion: corruption in health should not be viewed solely as a political or compliance issue, but rather as a public health problem that requires public health tools to understand its causes and implement effective public health solutions.

Quantifying the Impact of corruption in health care

Recent modeling conducted by my colleague Bill Savedoff estimates that approximately 7% of global government health spending—equivalent to $441 billion annually—could be lost to corruption. Bill’s analysis further estimates that these losses contribute to 76 million lost disability-adjusted life years (DALYs), effectively causing 7.6 million people to lose 10 years of healthy life. These are significant costs and losses.

Beyond resource diversion, corruption also systematically erodes institutional trust. When populations lose confidence in health services, they tend to delay seeking care, question the quality of medications, and disregard public health guidance. Without trust, even adequately funded systems fail to achieve their intended results.

Reframing Anti-Corruption as Public Health Strategy

For too long, anti-corruption efforts in health have been treated as auxiliary functions: compliance exercises, often in response to donor requirements, or bureaucratic exercises. However, corruption directly undermines efforts to ensure universal access to healthcare without financial hardship.

This is why Anti-Corruption, Transparency, and Accountability (ACTA) must be recognized not as an end in itself, but as a fundamental public health strategy for improving population health outcomes.

When people hear “anti-corruption,” they often envision law enforcement actions or political investigations. In health policy, this framing proves counterproductive, as it politicises issues that can lead to policy inertia and gridlock.

The focus should not be punitive but institutional: building robust health systems that deliver services and products that populations require. ACTA is fundamentally about ensuring that:

• Salaries reach actual health workers who provide services • Government-procured medicines reach healthcare facilities • Patients access medical care without unofficial payments • Publicly funded equipment meets safety and reliability standards

ACTA is about making health systems effective, efficient, and fit for purpose.

An Institutional Approach to Prevention

Corruption thrives where institutions lack strength—where regulations are ambiguous, accountability mechanisms are absent, and services operate for narrow benefit. The primary solution is not investigative processes or high-profile prosecutions, but strong institutions that govern equitably and deliver services universally.

I argue that the most effective anti-corruption strategy is prevention through institutional design. This means embedding integrity mechanisms into reforms from the initiation stage, rather than adding anti-corruption components after problems emerge.

Integrity must be incorporated from policy inception:

• Health insurance schemes should feature transparent financial tracking systems • Personnel recruitment should utilize competitive hiring processes and digital payroll systems to prevent fictitious employees • Government procurement should include public contract disclosure requirements • Health information systems should provide citizen-accessible dashboards and complaint mechanisms

When integrity is systematically built into institutional frameworks, opportunities for corruption are substantially reduced.

Implementation Framework: Prevent, Detect, Respond

A practical approach to ACTA implementation follows a three-component cycle:

Prevention: Systematic Risk Mitigation

Prevention involves designing systems that minimize opportunities for resource diversion:

• Ukraine’s ProZorro online procurement system made all government contracts publicly accessible, generating billions in savings while increasing institutional trust • Malawi’s patient feedback mechanisms enabled service gap reporting, compelling systematic improvements • Brazil’s local health councils reviewed budgets and expenditures, creating oversight mechanisms that reduced resource diversion

Detection: Early Warning Systems

Effective systems require ongoing monitoring capabilities:

• India’s biometric attendance systems reduced fictitious personnel • Kenya’s audit processes linked to corrective action plans enabled facilities to address identified deficiencies • Protected reporting mechanisms encouraged staff disclosure without retaliation risks

Response: Corrective Action and Institutional Learning

When problems are identified, systems must respond effectively through both consequences and adaptive learning. Following procurement scandals during the COVID-19 pandemic have led to reforms designed to enhance competition and reliability in future contracting processes.

This prevention-detection-response cycle transforms ACTA from an abstract principle into a practical tool for strengthening health systems.

Implications for Universal Health Coverage

The global objective of universal health coverage—ensuring all people access needed care without financial hardship—is systematically undermined by corruption:

• Resource diversion from insurance schemes reduces coverage populations • Unofficial payment demands exclude the economically disadvantaged • Counterfeit medicines in supply chains compromise care safety • Unpaid personnel result in non-functional facilities

Conversely, when accountability and transparency are institutionally embedded:

• Supply chains function reliably • Health workers are compensated and present • Insurance funds achieve intended purposes • Populations trust and utilize systems

ACTA is therefore not peripheral but essential to achieving universal health coverage.

From Auxiliary Function to Core Public Health Strategy

ACTA is frequently marginalized because it is framed as enforcement, compliance, or external pressure. This creates defensive responses from policymakers concerned about institutional reputation.

The solution is integrating ACTA into core reform processes. When designing payment systems, the question becomes: how do we ensure financial transparency? For personnel reforms: how do we guarantee staff authenticity and presence? For procurement: how do we ensure competitive and fair processes? For health technology: how do we provide citizen transparency and voice?

When ACTA is treated as auxiliary, it struggles for resources and attention. When built into foundational design, it becomes an institutional strength.

Conclusion: Strong Institutions, Better Health

When I initially engaged with anti-corruption work, I approached it as a compliance issue. Experience has demonstrated a different reality: corruption is not only about resource waste or system dysfunction, but also about whether children receive the necessary medicines, whether health workers are adequately compensated for their work, and whether families can trust the health system.

ACTA must therefore be recognized not as policing or politics, but as a public health strategy focused on making health systems honest, reliable, and equitable.

The primary solution to corruption is not deterrence through punishment, but building strong institutions that serve entire populations rather than privileged minorities. Institutions that maintain medicine supplies, compensate health workers reliably, and treat every patient with dignity.

This approach fosters trust, promotes universal healthcare, and underscores why anti-corruption in healthcare must be recognized for what it fundamentally represents: a strategy to save lives and advance health equity.

Views my own

Bibliography

Corruption Impact and Modeling

Savedoff, William D. Research on corruption’s impact on global health spending. [Referenced modeling showing 7% of global government health spending ($441 billion annually) lost to corruption]

Ukraine ProZorro Procurement System

Open Contracting Partnership. “Ukraine’s open contracting impact.” March 4, 2024. https://www.open-contracting.org/impact-stories/impact-ukraine/

U.S. Strategy on Countering Corruption. Washington, DC: The White House, December 2021. [References ProZorro saving almost $6 billion in public funds since October 2017]

Yukins, Christopher, and Steven Kelman. “Overcoming Corruption and War -- Lessons from Ukraine’s ProZorro Procurement System.” Harvard Kennedy School, Mossavar-Rahmani Center for Business and Government, 2022. https://www.hks.harvard.edu/publications/overcoming-corruption-and-war-lessons-ukraines-prozorro

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Brazil Health Councils

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India Biometric Health Worker Attendance

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Republic Act No. 12009 (New Government Procurement Act). Philippines: Congress of the Philippines, enacted July 20, 2024.

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Malawi Health System and Accountability

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