A workshop held with ACE partners at the James Grant Centre of Excellence for Universal Health Coverage at BRAC University, the London School of Hygiene and Tropical Medicine and the team at SOAS, led to some fascinating discoveries about why irregularities occur in the practice of local healthcare delivery in Bangladesh, and what could be done about it. 

Mushtaq Khan and Pallavi Roy from the ACE research consortium discuss. This blog was first published on the World Bank’s People, Spaces, Deliberation site. 

It’s not often you get together the very people working on the frontline to sit down together and discuss why and how irregular practices occur in their sector – and what can be done about them. But that’s just what we did with a group of frontline health workers at a workshop in Bangladesh’s capital Dhaka in December 2017. We wanted to understand why corrupt and irregular practices occur in the health sector – what are the underlying incentives and processes? And what are some feasible and impactful ways to change these practices?

Many developing countries, including the three where our research consortium, the Anti-Corruption Evidence research consortium is working, Bangladesh, Nigeria and Tanzania, struggle to provide free or low-cost healthcare to all their citizens. Instead, citizens are often forced to buy services from the private sector at higher fees or worse, approach untrained or traditional healers. There is agreement in the literature that a large proportion of these inefficiencies occur due to corrupt practices (though there’s an active debate about whether using the c-word is helpful in this debate, which is why we talked about ‘irregularities’ during this workshop). Many of these practices are related to the way societies in developing countries are organized around patron-client relations, where tax resources are insufficient, and resources, jobs and promotions require lobbying powerful politicians.

Research by our partners at the BRAC James P. Grant School of Public Health, identified four key irregularities that created challenges for healthcare workers and their patients: absenteeism of doctors from their work, irregularities in the supply of medicines, the process of referrals (to private sector players or to tertiary hospitals from primary care centres) and informal payments for services that formally are free. The participants ranked absenteeism as the most pressing problem. One approach to this problem could be more top-down enforcement by the agencies that commission health services and regulate or punish non-compliance – controls or fines for healthcare workers who didn’t attend their surgeries. But would that really result in more consistent attendance and better outcomes for patients?

When developing countries attempt to address corruption and irregular practice using top-down or ‘vertical’ anti-corruption approaches, they usually do not work. We believe this is because they ignore the deeper causes of these problems. The enforcement of rules is necessary, but it only works if the rules being enforced are supported by many of those who are subject to them; in this case health sector professionals and administrators as well as patients. Without that, the incentive to support the enforcement of rules is simply not present and rule-breaking becomes the norm. Our approach is to identify the reasons that lie behind specific rule-violations, and to investigate whether feasible changes in incentives and institutions can result in better delivery outcomes, because frontline staff who deliver services will want to behave differently.

What better way to understand the pressures that create the conditions for rule-breaking than by asking those directly subject to those pressures? On absenteeism, the group of health workers felt that uncertain career paths, inadequate remuneration, staff shortages, security concerns for female staff and a biometric monitoring system that recorded staff clocking in and out, but not where or how they worked in the meantime, as root causes of the problem.

They suggested a better method of monitoring hours worked, with flexibility built in to reflect the varying and unpredictable demands on a medical practice, more trained support staff and for healthcare workers in remote areas to get priority for training, or a better posting next time. On informal payments, the workshop noted that good healthcare is about teamwork, so there is a need for a group incentive structure to avoid informal payments.

Perhaps not surprisingly, some of the issues highlighted as likely areas for policy initiative were very simple—like writing prescriptions more clearly so patients couldn’t be confused with the names of medicines or hiring more support workers to improve the health care facility environment. Other insights were quite complex, including the range of incentives and collusion that led to absenteeism of junior doctors assigned to small-town and rural postings.

The next question is what to do with these insights. The research project in Bangladesh, a partnership between the BRAC James P. Grant School of Public Health, the London School of Hygiene and Tropical Medicine and the team at SOAS, will in its next phase conduct in-depth interviews with key stakeholders and follow that up with a discrete choice experimentwhere alternate policy scenarios (based on our workshop results) will be presented to respondents to further assess the feasibility and impact of policy choices.

Corruption, irregularities and the everyday tragedy of poor access to healthcare and the damage that inflicts on peoples’ lives, are intractable, thorny problems. But that doesn’t mean there aren’t small shifts, supported by local players, that can make anti-corruption real, and result in meaningful improvements for workers and their patients.