Corruption - Plague of the Health System

These days, I am participating in a course on "Confronting Corruption" Let me share some of the reflections that I compiled for this course.

According to the “General Corruption Perception Index” Vietnam was at position 112 in 2011, better than 70 other countries including Russia, Bolivia, Bangladesh, Guatemala, Honduras, Philippines, Pakistan.That seems not too bad. But figures about the Vietnamese health system show that total funds for health come from out-of-pocket payments to over 50% (government budget accounts for about 30%, health insurance payments for the rest). And a large part of these OOP payments will be "informal payments", leading to inequality in access to health services and seriously overpriced services. 

Ever since I reading about this, I was wondering about the causes for such widespread corruption in the health sector. Low wages for health workers are one: Anybody who works in a government employment position is forced to find additional income. Government knows this and does not seem to care. But I think there are deeper, underlying traditional and cultural factors that are equally important. Culture and religion have formed people's habits and behavioural patterns over centuries, and they play an all-important role today.

In a recent study by Tuan Anh Nguyen, et al, UNSW School of Public Health, the authors suggest to differentiate between individual factors and systemic factors when trying to understand corruption. 

For me, the individual factors seem to sum up to a high level of expectation and motivation regarding good, or at least adequate payment for high levels of skill, reputation and personal involvement. The back side of this coin is easily described by a pun that was popular in East Germany before reunification: “As long as the government only pretends to pay me a salary, I will only pretend to work”. In other words: In the Vietnamese society of today, economic success and the possibility to participate in the massive consumerism, that has been promoted by government, has extreme importance. At the same time, old communist ideals about being a servant to the public, still provide the ideological basis for continuing to pay ridiculously low salaries to government officials – and health workers are almost all public officials or public servants. High expectations and high needs clash with low levels of income and official chances to fulfill these expectations, leading to a high level of frustration.

The second set of causes is summarized as systemic factors, I would say systemic shortcomings. All the aspects of poor governance are named, so are the the systemic problems in the health sector, which promote corruption in many ways. The most difficult part, which again is strongly related to the individual factors, is called socio-cultural factors here. One set of strong influences has been touched on already: The background of communist ideology. The second is culture,religion and tradition.

According to Segon&Booth¹, who quote Davis and Ruhe (2003), “corrupt practices increase when country culture characteristics are associated with high levels of power distance, masculinity, and

collectivism. This correlates with a Hofstede study on culture, accoring to which these traits and characteristics are more prevalent in the Asian countries (Hofstede, 1980). D’Souza, (2003) suggests that gift giving in Asian cultures is seen as an act of reciprocity, and an important process in the establishment of trusting relationships.” I believe that one important basis for such cultural understandings is religion, in Vietnam above all Confucianism. Of course Confucianism cannot be blamed as promoting corruption; primarily it is a religious philosophy that tells its followers to strive for and maintain especially standards of individual morals ² . However, more subtly, some of the aspects seem to make people vulnerable, especially to the sort of petty corruption which dominates the health sector in Vietnam. One is the notion, that personal morals are more important than society rules and laws. The second is that inherent striving for harmony has established the habit of offering and expecting gifts, and of creating networks of mutually indebted friends, indebted by gifts. The third is that a focus on personal moral and wellbeing makes people focus on their own individual and their families' thriving before caring about the situation of society at large. I can only take care of society if I take care of my family; and I can only take care of my family if I take care of myself first. And because individual moral standards are more important than society laws, one can even feel entitled to these actions; no feeling of guilt disturbs this conviction that one is doing the right thing when one is promoting individual and family/group wellbeing.

Both sets of influences come together in Vietnam, forming an unholy philosophical alliance to perpetuate and even justify corruption. As long as a large proportion of government officials' remuneration can be outsourced to direct user payments, the fiction of welfare-oriented, communist officials can be maintained. As long as personal networks are the texture of society, effective mechanisms of control will not really have a chance. And as long as it is religiously correct to value personal and family thriving higher than the wellbeing of society (and the strangers it consists of), all legal initiatives, which are being started following external demands by people “who do not have our culture”, will continue to be lip service, with no real impact on the way this society functions.

Of course, in health administration and policy, the obviously immoral effects of the current system, namely high prices and inequality of access, are increasingly discomforting. As a consequence some of the system factors are up for change. Hospital autonomy, user fees, output based funding were suggested and promoted as efforts to improve the situation. However, output-based funding and autonomy can be only be instrumental when trying to reduce costs. If a hospital's prosperity depends on reducing the costs of procured goods and services, there is a high incentive to use transparent bidding and true price negotiations to reach this goal. But is not clear whether this will translate into lower prices for patients, and how under-the-table payments can be reduced by these policies.

A strategy to combat corruption will have to tackle a number of causes simultaneously: Low wages, mismanagement, low effectivity of control mechanisms. But above all, a new ethics is needed, which does away with the old habit of trying to bribe the ancestors, the gods. anybody who can provide a scarce resource, by gifts, which are not really gifts. They are informal payments for expected services.

1International Review of Business Research Papers, Vol.6, No.1 February 2010, Pp.574-589, Managerial Perspectives of Bribery and Corruption in Vietnam, Dr Michael Segon* and Mr Chris Booth**

2New World Encyclopedia contributors, "Confucianism," New World Encyclopedia, , http://www.newworldencyclopedia.org/p/index.php?title=Confucianism&oldid=851939 (accessed May 18, 2012).