Lifting the lid on corruption to cure health systems

Corruption is one of the most important barriers to implementing universal health coverage around the world; imagine what that world would look like! The subject of corruption in global health is often muted and totally taboo for some to even think it. This podcast episode on corruption is opening up the discussion to a wider audience to understand the scale of the problem for health systems and to hold more people to account for their part in the resulting damage. 

For this Global Health Matters podcast episode, our host Dr Garry Aslanyan delves deep into the topic to uncover the sources, the offenders and the solutions from our panel of experts. Together they are able to define the subject matter, provide examples from around the globe and piece together the puzzle of how to solve this conundrum.  

• Monica Kirya – Senior Adviser, U4 Anti-Corruption Resource Centre  
• Patty Garcia – Former Minister of Health, Peru. Professor of Public Health, Cayetano Heredia University  
• Jonathan Cushing - Global Health Programme Director, Transparency International  

Related episode documents, transcripts and other information can be found on our website.

We are keen to engage with you, our listeners, at every step of the way – please feel free to suggest topics and questions to be discussed and share your feedback by dropping us a line at TDRpod@who.int.

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Disclaimer: The views, information, or opinions expressed during the Global Health Matters podcast series are solely those of the individuals involved and do not necessarily represent those of TDR or the World Health Organization  

All content © 2022 Global Health Matters. 

Transcript

Patty Garcia [00:00:00] For me, it means so many things and brings so many feelings. It's an open secret. It's systemic. It's spreading. It's an ignored pandemic. It's a violation of rights. It's deadly. It's inequity because affects the poor and most vulnerable people in our society and I think it's the biggest threat for the future of better health in the world.

Garry Aslanyan [00:00:29] Hello and welcome to the Global Health Matters podcast. As always, I'm your host Garry Aslanyan. Patty Garcia opened this episode by examining an important global health issue, namely, corruption. According to Transparency International, US$ 500 billion in public health spending is estimated to be lost globally every year due to corruption. It has been labelled the disease of the health system, hindering and preventing progress towards universal health coverage. So to unpack this highly complex issue, I'm joined by three guests who speak confidently and openly about this and shine light on some of the realities. Monica Kirya is a lawyer by background and the Senior Program Adviser at the U4 Anti-Corruption Resource Centre in Norway. Monica's work focuses on anti-corruption in public service delivery in the health sector and education sectors. Jonathan Cushing is Head of the Transparency International Health Program, which works alongside the global Transparency International movement to tackle areas of corruption in health systems, such as procurement, contracting and vaccine rollout. And finally, Patty Garcia is a professor at the School of Public Health at Cayetano Heredia University in Lima, Peru. Patty is the former Minister of Health in Peru, and she has become an influential voice on corruption within her own health system. Hi Monica. Hi Jonathan. Hi Patty.

Three guests [00:02:13] Hi Garry. Hello. Hey Garry.

Garry Aslanyan [00:02:15] Thanks everyone for joining me today. Let's get started with making sense of the topic we have at hand today. A question to each of you. If I say corruption in health, what comes to mind for you? Let's start, Monica, what about you?

Monica Kirya [00:02:31] Well, lots of things come to mind, but from the research that I've been part of, for me it's really about how corruption affects the lives of people who need health care and also how it affects health care workers. So it's not just something that is an abuse of power by people who have power, but it's really about the impact that corruption has on people's lives.

Garry Aslanyan [00:03:03] Jonathan, what about you?

Jonathan Cushing [00:03:05] As Monica says, it's about people not getting access to care and ultimately having poorer health outcomes. The other part to it is certainly when I started out in this world, corruption in health to me really meant that requests for bribes, petty bribery at the point of service delivery in health care centres. It's actually a lot more complex than that. There are corruption risks throughout health systems, and I think it's really important to recognize that it's not just about the case of the one bad apple in the basket, if you like, at a health centre, it's about weak systems and vulnerabilities, which results in people basically not getting the care they need and us not achieving SDG3 (Sustainable Development Goal).

Garry Aslanyan [00:03:40] Okay. And Patty, what about you?

Patty Garcia [00:03:43] For me, it means so many things and brings to me so many feelings. It's an open secret. It's systemic. It's spreading. It's an ignored pandemic. It's a violation of rights. It's deadly. It's inequity because it affects the poor and most vulnerable people in our societies and I think it is the biggest threat for the future of better health in the world.

Garry Aslanyan [00:04:09] Thanks for that, Patty. So I'm already excited because I'm sure we're going to have a great conversation. So, Jonathan, with so many pressing global health issues, your work is dedicated to fighting corruption in health. Why do you think we need to talk about corruption in global health?

Jonathan Cushing [00:04:25] Maybe I'm biased, but put it simply, if we don't tackle corruption in global health, we're never going to achieve universal health coverage, never going to achieve SDG3, and people aren't going to be able to access universal health care. So to why do we need to talk about it, I think there's many, many reasons. We've got to build systems that actually tackle the issue. We've also got to realize, sadly, over the last three years with the COVID pandemic, we've seen it. We've got to realize it takes place all over the world. Something happens here where I am in London, there have been instances, it's not just constrained to one country, one governance system, one typology. Every health system is vulnerable to corruption, and we've seen this throughout the COVID pandemic. We saw, looking way back to 2020, we could have analysed the PPE COVID response here in the UK (United Kingdom) to large levels of questionable contracts going out: £3.7 billion worth of contracts here in the UK that we thought needed further investigation; £1.6 billion worth of contracts, the PPE and emergency response that they'd given to people with political connections in the UK system. And at the same time, we were hearing reports of medical staff, clinicians complaining about the quality of PPE, not having the right PPE, personal protective equipment, when they needed it, where they needed it. So it was impacting on their ability to deliver in the overstretched system. And we've seen that kind of throughout the pandemic as well. We've looked also at the transparency of vaccine contracts. Zero point five percent (0.5%) of those contracts that we analysed have been released in an unredacted form, making it very difficult to actually hold power to account as we and others seek to do so. Say, what's going on here? What have you signed up to? And we've heard the stories of liens being placed on embassies in DC, and written as part of contracts and countries have had to change laws. It's really difficult to actually hold governments to account and we argue that the power balance shifted there. And we've seen other issues. TI did a survey in 2021 in the EU looking at corruption, not specifically linked to COVID, but there they found that 29% of people surveyed there across the EU reported using personal connections to access health services, 6% reported in the EU paying bribes. There are issues within systems around the world that really hamper access to care.

Garry Aslanyan [00:06:43] Monica, you've done research on corruption in Uganda, how does corruption affect the lives of Ugandans needing the health care and the health care services?

Monica Kirya [00:06:53] From my research, one of the biggest problems is that people simply can't access health services when they need them, as Jonathan has already said, and in this way, corruption is literally a matter of life and death. You can look at it from the perspective of an expectant mother in labour, or an accident victim bleeding profusely who can't access urgently needed health care simply because there are no doctors. Now, it's no secret that many developing countries have huge health worker to population ratios, but I think it's becoming increasingly clear that one of the reasons why there are no or very few doctors in public health facilities in Uganda, increasingly has to do with corruption. It became clear from the research I've done that medical graduates are having to pay huge bribes to district service commissions to be recruited. And this is severely affecting the recruitment and retention of health workers in Uganda. But I think that one of the most pertinent issues that we need to address is corruption in the recruitment of health workers and the fact that health workers aren't just perpetrators of corruption, it's very easy to see them on that side, but they're also victims of it. And I think we really need to urgently address this.

Garry Aslanyan [00:08:17] Very interesting. Thanks for that insight through your research, Monica. Patty, as the previous Minister of Health in Peru, you had your fair share of having to face complexity associated with identifying and addressing corruption in your health system. Would you mind sharing your experience with us?

Patty Garcia [00:08:40] Yes, of course. But actually, I would like to go even further. Since I was a medical student 30 years ago, I saw corruption related to medical practices. Thus, the fact that supplies were not available, corruption related to distribution of drugs, etc. But because at that point resources were scarce, probably it was not seen as a big issue because there was not much to steal. But when I became Minister of Health, I realized the magnitude of the problem, because there were more resources than ever before, and with more money, there is more corruption. I don't know what happened in Africa, but in Peru, for example, it's so incredible to see a hospital and surrounding the hospital, lots of private services that can serve the people that cannot get the services at the hospital. In Peru, for example, once I saw a paper clip inside an X-ray machine, the paper clip was used to damage the equipment at the public health centre, and that forced patients to pay for an x-ray in the private clinic in front of the health centre. So those kind of things are so unbelievably common. And when I was the Minister of Health and this was a big issue because I was really concerned about the lack of medications at the health centres, while I knew that we have had a very important process in which we bought medications for all the country. So we started an investigation and we found an illegal operation that was removing the drugs from storage and public hospital pharmacies and were placing them in private pharmacies. And I was working with the Ministry of Internal Affairs and with the police; it was like in the movies. So we were able to find that there were individuals that were called haladores or pullers that were conveniently placed outside the hospital pharmacies and were offering to take the patients where they could buy the medications at a reasonable price, the same medications that are supposed to be for free through the national insurance system. The operation was much more complex than I'm able to describe, really, and the idea was to try to find out who was at the top of the chain, not only at the bottom. The problem is that the investigation could not be completed. During my time as the Minister of Health. Although I tripled the average time of Ministers of Health in Peru, it was just 14 months, we couldn't complete it. And as soon as I left, the whole investigation was stopped and the problems are still ongoing.

Garry Aslanyan [00:11:28] Thank you for that, Patty, and thanks to all three of you for sharing reflections on what we mean. I feel like understanding and defining the corruption is not without its difficulties, and there seems to be a lack of clarity as when poor management becomes corruption, when abuse becomes a crime and the many associated factors influencing corruption. So perhaps let's scratch a little bit of the surface on that. Jonathan, Transparency International defines corruption as "the abuse of power for private gain", yet this definition is very broad. How does it get applied practically to help countries determine what is corruption and what isn't, if they were to use your definition?

Jonathan Cushing [00:12:17] I think sometimes in the work that we do as well, what we are trying to push in the global health world, so to speak, is that if we're going to tackle corruption, corruption is part of a bigger package of losses that happen. It's about loss from the system. And if we're talking about it, taking it from the health systems strengthening perspective, we really need to be talking about plugging the gaps, minimizing the losses throughout the system. And perhaps we in the corruption community need to do more about framing this in that way as well to get people on board. Corruption tends to be a kind of sensitive topic sometimes.

Garry Aslanyan [00:12:46] It really is linked to under-resourcing of the system, although your previous examples clearly came from well-resourced settings as well.

Jonathan Cushing [00:12:56] Yes, not always under-resourced systems, but it's about making the best out of the, well to take a step back on that, I think pretty much every health system in the world would argue that they're under-resourced. I can't think of a Minister of Health; in the UK they're saying that every system wants more resources into it, they're resource intensive. Every department of health wants more money. It's about stemming the losses and the wastage within systems. That's equally applicable from the UK to wherever. It's not necessarily about the level of resources.

Garry Aslanyan [00:13:28] So Patty, your examples when you referred to the situation in Peru show that it's the under-resourcing of it, and in preparation for this episode we looked at several articles that say that providers find creative ways to solve care delivery challenges, but obviously these creative ways have also been described as corruption. So having heard Jonathan's definition, or at least how sometimes we're trying to define, how does the functionality of health systems influence your understanding of corruption based on your experience?

Patty Garcia [00:14:05] I really don't think that corruption is related just to under-resourced systems. And what I was telling you is that if there is more resources, you may have more corruption. The health system is a very complex system. Within this web, you can find pockets of corruption, which I completely agree, in order to break this whole cycle, and one of the big issues is how can we assure accountability? So accountability is one thing that has not been taken into consideration with health several times because there is a power asymmetry between; it's like everybody wants to have health and probably in our countries what happened is also that the health providers or the people that are administrating health are supposed to be almost kind of like the gods because health is the most important thing we need, right, and we haven't worked very well about these issues of accountability, which are quite important. I really hate when people talk about terms of survival corruption. I think this is a way of justifying unjustifiable situations because even in very poor areas, you can find providers and health centres that are trying to do their best and using in the best way their resources, and you can compare those with other health centres or institutions that are in much better situation in which you know that things are not working well. So in other words, I really think that if you have a more functional health system with accountability and trying to break those dynamics of power and probably be more transparent, you have to work also in the society around because the big problem that we are facing is that we are normalizing what is happening. So is the function of the health system and the environment, the community, the providers everywhere within the system. With accountability, I think there might be a way of addressing this type of issues. And for me, when you are asking me about the understanding of corruption, the problem is that in societies where this is normalized, it's very difficult for people then to start discussing what is or not corruption. But we know that it is corruption because we're dealing and because it's making the health system less efficient and more people to suffer.

Garry Aslanyan [00:16:52] Jonathan?

Jonathan Cushing [00:16:53] I was actually going to agree with Patty. We've absolutely got to get away from this idea that corruption just happens in low-resource settings and low-resource systems. It happens everywhere. It may be more visible, as I said, the kind of, what we term the kind of petty bribery and things might be more visible than in some systems, but it happens everywhere. It's much more perhaps more complex, more hidden, the different power bases in some countries and in higher income countries. It happens. Until we address that, we're not going to get anywhere. Sadly, we still see this in the political declarations. We saw at the Summit for Democracy last year coming out, it was the focus was very much it's not corruption at home it's corruption overseas. It always happens and that's completely wrong. It happens here in London just as much as it does in, I don't know, any other capital city in the world.

Patty Garcia [00:17:40] And Jonathan, another thing that is I think it's quite important is that, I think we are not going to be able to fight corruption unless we realize that there are corruptors and corrupted. And several times, unfortunately, what we are seeing is that there are things that are coming from the north into our low- and middle-income countries promoting that greasing of the wheels of corruption within our countries. So I think that stigma that it's just the low- and middle-income countries that are the ones that are corrupt needs to be broken in order to, I mean, us as a global world to try to fight against this.

Jonathan Cushing [00:18:21] Absolutely. And as you said, the power dynamics in this, when we start talking about access to medicines, pharmaceuticals, etc., it is the corruptors and the corrupted in some cases who within it, we're not talking about individuals here, it's nation states who are having to kind of play into that game to get access to medicines or essential drugs. If I'm being critical, I sometimes feel this lip service paid to accountability is the fashionable word. As you say, there's still all too often this perception of the doctor or the medical system being the font of knowledge and not being able to challenge it. What do we need to do to actually build in accountability properly?

Patty Garcia [00:18:56] Maybe technologies can help us. Maybe technologies like electronic medical records could help us for this accountability about what people are doing, if they are seeing a patient or not. Absenteeism is a big issue, at least in my country. Productivity, too. And basically what is happening is that physicians will mark their attendance to the health centre and they will just go out and start seeing patients in the private sector. So I think accountability needs to be I mean it's a, you know it's quite interesting that it doesn't translate that well in Spanish, okay, and I think it's because we are, and especially in the health sector, we are not used to really counting what the people are doing at the health centres or what is going on, etc., etc. So accountability and transparency are quite important and I think using technology maybe is one of the ways in which we can work on this. And also, and this is something also that I think it's quite important, is the participation of the community. So we need to start working from the bottom up in order to fight corruption and we need to work in our societies too, because the normalization of these issues is the normalization and the fear. Since I have been one of the people that have been trying to fight against this in a very practical way, I never thought, I mean, people were telling me we are crazy, be careful because something could happen, and then don't you fear? And actually fear is another thing that is stopping us from saying the word, from trying to do things that are going to be important. Now I understand the fear because I'm seeing some consequences, but I think that maybe if we are more people discussing and trying to see what to do with corruption, fear also will dilute. 

Garry Aslanyan [00:20:56] Interesting, thanks. I think some definitional issues are emerging, so I'm very happy about this discussion and I'm sure our listeners are learning a lot as they go. Monica, let's come to you. What will you think from where you are in terms of the discussion around definition? How best to deal with that? Can it be defined locally? What other historical, political, cultural factors influence your understanding of corruption?

Monica Kirya [00:21:22] Garry, I do think that it's important that we have a global definition of corruption. It's a pity that right now the most popular one is TI's (Transparency International), the abuse of power, entrusted power, for private gain. Jonathan has already said a lot about some of the problems with that. And it's a big pity that the only international treaty we have on corruption, the United Nations Convention Against Corruption, doesn't actually define corruption. So that leaves all these grey areas and the fact that we are even having this debate. I mean, we've come together as a global and international community to define many other wrongs. We have defined racial discrimination, discrimination against women, slavery, torture, many other forms of suffering and injustice that we have defined. I've been listening to Jonathan and Patty and thinking, oh well, oh well, can we talk about health sector corruption without talking about political corruption generally? How is it that we expect health systems to be these islands of integrity in political systems that are generally corrupt? I think that when it comes to finding solutions and addressing corruption, then context specificity becomes very important because of these slight differences in countries, political economies and cultures and history. For example, we've talked a lot today about informal payments and petty bribery, which receive a lot of attention in the research and in the academic literature, not just in anti-corruption as a field, but also in the public health literature, to the extent that corruption is almost synonymous with bribery. I really take issue with this focus on bribery by frontline service workers because it takes attention away from higher, more complex forms of corruption, higher up in the system. And I'm talking here about grand corruption by politicians and senior public servants. I think that it's so easy to focus on what's going on in frontline service delivery because it's the most visible and because it's so much easier to go after corrupt health workers than it is to sanction prominent politicians and senior public officials. We have to take into account the fact that the way that politics works in many countries is inherently corrupt. So this is quite a pervasive problem, not just in low-income or low-resource settings, but all over the world. We have to take into account that when the system is rigged in that way, it then becomes much more difficult to have transparent and accountable systems lower down in public services, in the frontline where public officials interact with day-to-day citizens. So there are all these complex things going on. And the other thing you talked about, Jonathan and Patty, was the issue of low-resource settings and how these are not necessarily a barrier to delivering good public health services. And I agree. You can do a lot and a little can go a long way, but I also think that it's very important to bear in mind other forms of corruption in the global system, especially illicit financial flows and tax evasion, and those global systems that exist to take resources away from poor countries that produce mostly minerals and primary products. It's not by accident that some countries have low resources, low levels of resources, it's by design. It's built into the system and we need to take note of that, too.

Patty Garcia [00:25:26] Having agreed with Monica on most of the things, I disagree with the fact that we need to have certain definitions according to historical, political or cultural factors. I think there has to be some global standards that should be applied locally, too. And so that's the first thing. I don't think like absenteeism should be considered a normal thing or corruption in certain countries, and in certain countries should be considered corruption. I mean, that's definitely. Bribery is the same thing. Informal payments. Those are things that should not be happening, and we need to really agree on the issue that these are. 

Monica Kirya [00:26:21] I'm sorry if you misunderstood me.

Patty Garcia [00:26:23] Okay. I'm sorry. I thought that you were saying to consider it. OK, so maybe for everybody, there is not such a thing as things that are acceptable in some countries and not acceptable. And unfortunately even, and we were talking up different levels right, the foreign and the national, and let's also talk about the multinational international okay? Sometimes even funding agencies, in order to just be able to reach their goals, they accept things that should not be acceptable and even things that are simple, and I always give this example: there is an intervention that has to do with training professionals and training professionals are so overwhelmed that they are not coming for these trainings because they are not sure what it is. These agencies have started paying for health workers to come to the trainings. But that has started a really vicious circle because if there is payment the people that are supposed to come to the trainings are not the ones that are coming and that promotes, again, corruption within the high or middle levels. And although these agencies know about it, they continue this cycle because the only thing that they are seeing is, maybe we can get our goals or the intervention done or the programme filled. So it is a very complex issue, but I think we need to agree that it can go at these different levels, but we need to start tackling it at some point. If we just wait until all the politicians and all the systems get better, it's going to be very difficult. So that's what I was talking about, my bottom up approach.

Garry Aslanyan [00:28:04] So let's try and see how we can tackle some parts of it. You've mentioned communities, societies, civil society, engagement, etc. already. Jonathan, Transparency International works actively with communities, with civil societies, are there any innovative strategies that you've seen emerging from grassroots that you could shed some light on?

Jonathan Cushing [00:28:25] Yeah, I think there's a bit of a common theme running through this. Some of the most promising and actually the most sustainable approaches are those that come from the bottom up. I think one of the clear lines is that if you impose things from the top down, actually there's very little interest and lip service is really just paid to it. Some of the work that the Transparency International's been doing has been really about trying to bridge that divide and break that barrier, if you like, between the health service providers and communities. They've done quite a bit of work with communities and providers on trying to get communities to be able to access data, access information, so getting information put out there and working with communities to build up the understanding of that. And actually it's not a great effort. Communities really understand this. If you looked at your budgeting, procurement monitoring, they understand this stuff, they just haven't been given the access to the data. And it's been really positive. It started out in some settings perhaps as a kind of more of an interrogation of district health officials to understand why have you done this, this and this. But it actually progressed to something that's much more conducive where communities are working with the district health authorities to say, actually, we're going to continue to monitor, rectify decisions, but we also want to have a voice in shaping what the district health services are doing. Where are those priorities? Where are you budgeting? This goes beyond just corruption and corruption monitoring to actually allow systems to have a voice. The other thing is, you don't need to be tech heavy. There's a tendency to kind of say, let's design a massive website and some I don't know, some great tech thing, but the simple act of actually just putting the information out there can start the debate. Hosting tenders, posting information on the noticeboard outside a health facility can actually go a long way to opening up and making things more transparent. The third thing, we've done a lot of work around procurement and of non-procurement, is realizing that sometimes the private sector can be an ally in this as well. There are allies in government as well. But bringing people together to actually kind of start to unpick procurement systems, explain how they work, is often really effective. But in the private sector there are some that obviously have vested interests in the systems works in such a way that benefit those. There's a huge amount of people who want to enter in a bid on things in a transparent manner, get the private sector involved, kind of on get work with them to help them understand how to enter into contracting processes. And there's interest that is this business interest and that can have a knock-on effect as well.

Garry Aslanyan [00:30:40] Thanks for those examples. Patty, if you were to give advice to another health leader just like you were, or you are, what approaches or tools can leaders in the health system adopt to reduce the risk and impact of corruption?

Patty Garcia [00:30:59] As a Minister of Health, and after I was like shocked about what I was seeing, I decided to implement, for example, a platform for active surveillance. So a reporting system of situations of corruption with a very effective system to investigate and address those issues. So that's a relatively simple thing and good also, decreases the likelihood of people to keep doing things that they are not supposed to do. I completely agree about the transparency of data, but if you see, for example, in Peru, you can find the budget of every single health centre. So it's not only at the level of the health centre, everywhere. But what happens is that although it's transparent, it's cryptic because it's difficult to understand and difficult to find. So I think there is a need of making these more open to the citizens to understand what that means. Even people within the ministries of health, sometimes they don't understand what the budget means. And I found that in one big hospital there was a huge budget just to buy bread, which didn't make any sense. I mean, we started to analyse, for example, what was happening with medications that were very expensive, anaesthetics, for example, and comparing that with the number of surgeries that were happening, and we realized that they didn't match and something was going on. However, I have to tell you, and now not with this hat of Minister of Health, but with my hat of researcher. One of the issues that I was able to see also is that in Peru, although we are collecting data, there are no plans of how to use the data to prevent or detect corruption situations. So it's not only the fact of collecting the data, but having plans for that. And the other issue is that we still need to understand what works and how to overcome implementation challenges when you want to establish some of these different strategies. And that's why one of the things that I truly think we need is we need to have more research to be able to design and test these anti-corruption interventions and see what works and what doesn't to have better recommendations. 

Garry Aslanyan [00:33:30] Those are great ideas, Patty, thanks for that. Monica, what about you? What recommendations for anti-corruption efforts do you have?

Monica Kirya [00:33:38] I completely agree with everything Jonathan and Patty have said. I think that we do have some idea of what works in certain contexts, but we don't have enough evidence of how it could work in other contexts. And also a lot of anti-corruption measures that are implemented in the health sector don't have good monitoring and evaluation mechanisms built into them so that we know what the results were. So I do completely agree with Patty that that's very urgent. Also, Jonathan said quite a lot about the importance of transparency, accountability, community monitoring, participatory budgeting and how all these kinds of simple mechanisms that aren't necessarily tech heavy can go a long way. And again, this is where the context specificity comes in, because each country will need to adapt all the methods that we have that we know could work and see how it could work in their own context. I also think that it's important for the global health community to think about corruption in other sectors, not just health, because of course, corruption in other sectors can have negative effects for public health, which is one of the main things we saw from the COVID-19 pandemic, which may have been due to corruption in natural resource management, illegal wildlife trafficking, and all the circumstances that may have led the virus to jump from wild animals to humanity. Corruption may have been involved. We are still not entirely sure. And Jonathan already said how corruption, whatever, prolonged the pandemic in many ways. So it's a matter of global health security, and the global health community really needs to prioritize it and realize the urgency of finding global solutions to these problems.

Garry Aslanyan [00:35:40] So an amazing amount of information and amazing discussions so far, thanks all three. Nearing the end, I'd like to maybe go round one last time and ask a final question of you all. We see that corruption erodes trust in systems, in societies, in people, leading to bad health outcomes and unattainable health indicators. We are not making as much progress as we could. How, despite these challenges, do you find passion in doing this kind of work? And what would you share with our audience in terms of what your passion comes from and how do you see us all achieving these goals we have, despite the work that we're doing in, and you are doing around, this topic. Maybe I can start with Patty.

Patty Garcia [00:36:32] First of all, I agree with Monica. When I started talking about corruption in 2017 or so, people were afraid of the C word. Still, WHO has been using the word governance instead of corruption. So I'm happy that now we are bringing the word, and this will bring the elephant in the room and we confront it. We are not going to be able to do anything. So there are advances and that's good. We know that we need to do something. But we need to think about corruption as a disease of our health systems, and as we approach diseases, we need to find ways of preventing and curing. So we need to look for vaccines and ways of doing this. I think we really need not only recommendations but rigorous research methods to prove or disprove that a strategy works. And we need the participation of researchers from several disciplines and multiple approaches and the commitment of funders supporting serious research. I think that's the only way we are going to be able to really go forward on the efforts that countries have. I'm an optimist. I think we can do it. I think we are starting to talk about it, and that's a big step. But we need to understand what works and what doesn't and how to do it well. There is data that shows that all the money that we lose because of corruption could be enough to have universal health care for the whole world. So come on. And this is for me a call to researchers and to funders to start working together to have better data. I think we need policies that are based on evidence, and we don't have enough evidence of what works on how to ease corruption. So we need to keep working.

Garry Aslanyan [00:38:24] Thank you. Jonathan?

Jonathan Cushing [00:38:27] I think, first of all, I was going to say perhaps we shouldn't be as pessimistic about the world and about health systems. There is still trust in health systems. People do trust health systems. What needs to be done, I think, and how do we achieve health outcomes? I think to me transparency is really critical and transparency from the top down. I know we've been talking a lot about bottom up approaches, but we need to have honest leadership and the tone has got to be set from the top, be that at the country, but ultimately within the global leadership, the global power mechanisms. As Patty and Monica are saying, there's been progress here about getting corruption recognized in the global health community, people are talking about it now, but we need to have the leadership, the key global health players, ministers of health and executives within governments in countries actually leading by example on this, being transparent, not being corrupt, but also adopting that culture of transparency and accountability throughout their systems. Sharing data, sharing information. Patty said we need to collect more data. There is data out there in a lot of cases, and in some contexts it's not available. We need to get that out there. I think that's my key call is transparency and leadership. We need to have integral leaders. Leaders who are leaders with integrity.

Garry Aslanyan [00:39:42] Thank you. Monica, your last thoughts?

Monica Kirya [00:39:44] I would definitely follow on from Jonathan there and agree that honest leadership is important. And speaking as someone who is a citizen of Uganda, speaking from my perspective as a sub-Saharan African, I think the evidence shows that there's very low trust in public institutions in much of sub-Saharan Africa. That's from Afrobarometer data, which shows that people don't trust politicians and people don't trust public servants. Unfortunately, the survey doesn't really ask about health systems and health institutions, but if they are lumped together with public servants, then the survey results are quite dismal. But the picture isn't entirely gloomy because in sub-Saharan Africa people do trust certain types of leaders. For instance, they trust religious leaders quite a lot, and they also trust their traditional leaders a lot and they trust NGO officials, which is good news for Jonathan, I suppose. But I think that since we know who people trust, it's important that governments find ways of working with those trusted leaders, you know, religious leaders, traditional leaders and NGOs, to design systems and deliver the services that people need. I think that once that people see that governments are working in their interests, working for the many and not for the few, we'll be able to restore the trust that's been lost and we'll be able to make some progress. And I agree with Patty that we can't afford to be pessimistic. We can't just give up, you know, we've got to keep on hoping and we've got to find points in the system and entry points where we can leverage what's good and what's working already and where there is trust, and build on that and make progress from there.

Garry Aslanyan [00:41:37] Thank you, Monica, Jonathan and Patty for joining us today. And good luck with all of the work that you're doing. See you around.

Jonathan Cushing [00:41:48] Thanks, Garry.

Monica Kirya [00:41:49] Thank you.

Patty Garcia [00:41:49] Thank you so much.

Garry Aslanyan [00:41:53] As we just heard, corruption is not an issue that can be overcome through simple solutions and strategies. This complex issue requires a deep understanding of the inner workings of health systems. There are actors, as well as a sensitivity to underlying social and political dynamics of different country contexts. Addressing this complex challenge is not one that brave global health researchers, practitioners and leaders, like Monica, Jonathan and Patty, shy away from. They emphasized the need for global momentum to cure and prevent this health system disease, such that no patient is denied the quality of care they require. Remember, there is additional information and reading available for you on this topic on our webpage. You will find the key articles and reports shared by our guests.

Listener, Meru Sheel [00:42:55] Thanks for inviting me to share some thoughts about the Global Health Matters podcast. It's a podcast that I really enjoy listening to for several reasons. The first one being that you often touch on topics that are really important and involve modern day conversations in global health. The narrative storytelling idea of these complex global health problems is just really important and also beautifully done. My most recent favourite podcast episode was the one on the Health Journey of Refugees and Migrants. The discussion around what it involves to improve health outcomes for refugee and migrant populations, why countries should be doing more work and better work in achieving that was just so enlightening. The insights shared by Reem Mussa were just fantastic, so thank you for bringing together all these amazing speakers and I look forward to future episodes.

Garry Aslanyan [00:43:50] Thank you for your feedback, Meru, all the way from Australia. We want to thank you, our listeners, again for your support. It's been exciting to see our listenership continue to grow every month and we love hearing reflections from you on our episodes. We hope you will tune in to our next podcast in the series or take some time to discover past episodes available on our podcast channel. On behalf of all of us at the Global Health Matters podcast, until next time.

Elisabetta Dessi [00:44:21] Global Health Matters is produced by TDR, an infectious diseases research programme based at the World Health Organization. Garry Aslanyan, Lindi Van Niekerk and Maki Kitamura are the content producers and Obadiah George is the technical producer. This podcast was also made possible with the support of Chris Coze, Elizabetta Dessi, Izabela Suder-Dayao, Noreen O'Gallagher and Chembe Collaborative. The goal of Global Health Matters is to produce a forum for sharing perspectives on key issues affecting global health research. Send us your comments and suggestions by email or voice message to TDRpod@who.int, and be sure to download and subscribe wherever you get your podcasts. Thank you for listening.