The misappropriation of funds for health services, the theft of medicines, the distribution of out-of-date drugs and/or counterfeit products, plus extortion of ill people by health care providers, adds gravely to human misery. PTF focuses on supporting CSOs to have real impact by strengthening transparency and the public accountability of those most responsible for the provision and delivery of health services. Constructive engagement by CSOs with public authorities – at the local and the national levels – is essential to ensuring sustainable reforms.
PTF’s innovative approaches place citizens first. People seeking health services are best able to report on the inefficiency, waste and corruption that they confront. Ensuring that these citizens have the opportunity to voice their priorities and grievances is the most compelling means of promoting reforms. The lessons that PTF has learned are drawn from citizen monitoring of health services in over a dozen dedicated health projects in six countries over the past decade, as well as PTF’s broader project experiences.
PTF supported projects have monitored the provision of overall public health services at the local level, such as the procurement and provision of drugs to clinics. Projects have also empowered citizens to use hard evidence found through strategic monitoring to campaign for reforms and to constructively engage with health care providers. The lessons of experience that PTF has gained from its work in the health sector help to inform future projects by official donor agencies, philanthropic foundations and CSOs.
Drug Monitoring and Drug Trials
In the Philippines and Uganda, PTF has worked with local organizations to monitor the allocation and distribution of drugs; in the case of Philippines, drug procurement also formed part of the project. A PTF supported initiative in India focused on reducing corruption in clinical drug trials.
PTF partnered with the National Citizens’ Movement for Free Elections (NAMFREL) in two consecutive projects during the period 2008-2012 to monitor procurement and distribution of drugs, ultimately scaling up to work in 28 hospitals and centers. Following the training of volunteers and extensive consultation with hospital officials, PTF advisers worked with NAMFREL to create a grass-roots system of informed, motivated community volunteers. This cadre of volunteers was ultimately recognized as “official observers” in procurement and distribution processes, thereby strengthening the transparency of public bidding and the timely allocation and distribution of medicines. Their observations also provided valuable inputs to improving the warehousing of medicines.
PTF supported the Anti Corruption Coalition of Uganda (ACCU) in 2011-2012 to undertake a project aimed at reducing leakage of malaria medicines, a critical drug in this malaria-prevalent country, by monitoring the supply chain and surfacing issues through public accountability forums and dialogue with heath officials. As a result of the project’s successful efforts to ensure that drugs reach clinics in a timely manner and are not diverted once they arrive, clinics report that their stock of anti-malaria drugs now lasts 2-4 weeks, whereas drug stock-outs often occurred within a week of delivery in the past. Access to information as well as the relationship between citizens and clinic staff have both improved, with a side benefit of reduced absenteeism of staff and general improvements in patient care. A high-level Health Sector Anti-Corruption Working Group provides additional leverage upon and dialogue with government officials. The project is being scaled up via a PTF project just being launched to equip citizen monitors with SMS technology to expand reporting and follow-up capacity.
India has become a very large market for commercially funded human drug trials, and fatalities and other ill effects from rampant corruption in these trials have been significant. PTF provided support through two projects during the period 2009-2012 to Jananeethi, an NGO in Kerala State, that worked to ensure that institutions carrying out these trials comply strictly with global standards and practices. Through media campaigns, health watch committees, and dialogue with government and medical institutions, public awareness has risen significantly. An ethical standards handbook was released and its content incorporated into the curriculum of a regional medical college. Jananeethi continues to shine a national and even international spotlight on drug trials with the aim to further strengthen legislation to protect citizen participants.
Health Service Delivery at Hospitals and Clinics
PTF-supported projects in Nepal, India and Moldova have all strengthened citizen voice at facility level in terms of identifying abuses and putting pressure on government officials to correct them. The projects in Nepal and India established or strengthened existing village groups that could dialogue with health care providers and the media. Through these groups, citizens are no longer afraid to raise corruption issues, and have a mechanism to express their grievances to government officials, political parties and the press.
Through two projects during the period 2010-2013, PTF partnered with Samuhik Abhiyan to work with citizens, government, political leaders, the private sector and the media to strengthen awareness, create corruption monitoring committees (CMCs) and implement a number of instruments like citizen charters and score cards to monitor health service delivery. The project registered a 35% increase in health service attendance as a result of its work, and poor patients began receiving 85% of their free medicines. Ten corruption cases were identified by the CMCs, including malpractice in procurement and allocation of travel allowances, of which 6 have been settled—a remarkable achievement in the generally corrupt and slow moving judicial systems that characterize many developing countries.
This project undertaken with PTF support by the National Institute for Women of Moldova—Equality (NIWM) in 2010-2011 focused particularly on sensitizing health staff about unethical practices and instituting management enhancements such as establishment of a code of conduct and placement of an anti-corruption box in the target facilities for use by both citizens and staff. Beneficiary assessments conducted before and after project implementation revealed that while respondents believed that a “a high level of corruption” declined only marginally, from 96% to 83%, the percentage of respondents who personally confronted corruption fell remarkably, from 85% to 24%, and the percentage who had to give bribes to doctors dropped from 81% to 26%.
Experience in partnering with citizen organizations working in the health sector has yielded valuable lessons that PTF is applying across a range of programs, positioning it for successful design and implementation of health projects in the future. Some of these include the following:
- Raising public awareness of rights, particularly the costs of specific medicines and treatments, is a key first-step to ensuring these rights are appropriately fulfilled.
- Projects should be designed to cover a wide range of health care issues so that they are capable of hearing a wide variety of citizen voices and be responsive to their greatest concerns.
- Constructive engagement with authorities is the most effective way to resolve issues and achieve change.
- Advocacy is more powerful with partnerships between CSOs at the national level, who have access to decision-makers, and the local level, who can ensure that service delivery is supported by systemic or policy changes.
- Volunteer citizen committees, trained and supported by CSOs and NGOs, are powerful agents to identify corruption and push for improvements.
- Anti-corruption commissions and public service codes of conduct can be helpful in elevating corruption issues and strengthening accountability among service providers.
PTF is applying many of its lessons learned in health care projects in a new project – Citizens Action Platform (CAP).