Sectoral Perspectives on Corruption in Kenya:

The Case of the Public Health Care Delivery

A Research Proposal

Research & Policy Department

Preventive Services Directorate

July 2007

1.0 INTRODUCTION

1.1 BACKGROUND

The economic development of any given country depends on the health

status of its citizens. The importance of health as a vehicle for economic

growth and poverty reduction is reflected as key development target in the

Millennium Development Goals (MDGs). Three out of the eight MDGs are

directly related to health hence underscoring the importance of health care in

any nation’s development process. The MDGs include: reduced child

mortality; improved maternal health and the fight against HIV/AIDS, malaria

and other diseases. One additional goal relates to access to affordable drugs

in the developing countries. The challenge to implement the MDGs is real as

the end of the implementation period draws nearer. The challenge to realise

these goals is greater for Kenya as she contends with two fundamental

questions, namely; (i) Where does Kenya stand in regard to the realization of

these goals?; and (ii) What are some of the challenges that Kenya faces

today in meeting these targets? The MDGs Status Report 2006 indicates that

Sub-Sahara Africa and Kenya included is lagging behind in implementing

programmes targeting these goals. Even though some progress has been

made in combating HIV/AIDS, the pace of implementation is slow due to poor

governance, marked corruption and poor economic policy choices among

other reasons.

The above factors have also compromised the provision of adequate

healthcare in Sub-Saharan Africa in general and Kenya in particular. Globally

corruption continues to pose serious challenges in the provision of

healthcare. It compromises the quality, effectiveness and equity in service

delivery while raising the cost of discharging the same. Health care provision

depends on a combination of financial and other resources, supplies and the

delivery of services in an efficient manner countrywide. This calls for a health

care system that is entrenched on transparency, accountability and integrity

at all levels of service delivery. Ineffective and inefficient health care systems

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that are deficient in transparency and accountability lend room to corrupt

practices. It is important to note that corruption in the health care sector is

not exclusive to any particular type of the health care system. It occurs in all

systems, whether public or private, well funded or poorly funded, and

technically simple or sophisticated.

The Global Corruption Report, 2006 indicates that every year more than US $

3.1trillion is spend worldwide on health services with the bulk of the financing

by the governments. These large flows of funds are an attractive target for

abuse. The MDGs Status Report for Kenya , 2005, indicates that the Kenya

government increased the overall funding for health care in the financial year

(FY) 2005/006 by 30%,, increasing the sector’s share as a percentage of total

government expenditure from 8.6% in FY2004/2005 to 9.9% in the FY

2005/2006. The Report further indicates that 20% of LATF funds are to be

spent on core poverty programmes which are essentially MDGs- related

programmes. A recent government survey of the CDF funds indicates that

over 60% of this fund on average is spent on health, water and education in a

given constituency at any one time.

The National Anti-Corruption Plan, (2006) identifies corruption as a major

contributor to the decline in economic growth, deterioration of infrastructure,

inadequate health care facilities and drugs, run down public institutions,

increased poverty incidences among others. The Plan further states that

corruption emanates from two basic conditions namely: erosion and

distortion of values and existence of opportunities.

In order to mitigate the impact of corruption in the provision of healthcare,

Kenya like any other developing country needs to design appropriate

prevention programmes and also put in place relevant statutes for monitoring

the success of these programmes and other public investment programmes

targeted to the sector. It is also important to measure the quality and access

of the health care on a continuous basis. To be able to achieve all the

objectives, broad and appropriate systems must be developed and

implemented. A survey targeting both the healthcare providers and the

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healthcare seekers as the key respondents is one such system that will allow

these objectives to be met.

1.2 Statement of the Problem

The findings of the National Corruption Perception Survey (2006) indicate

that 22.9% of the respondents ranked the health facilities as the third most

corruption prone areas in their locality. Consequently, 41.3% believe that the

Ministry of health is the second most corrupt ministry and a further 27.5%

perceive the government hospitals as the fourth most corrupt institution.

Furthermore, The Examination Report of Kenyatta national Hospital 1

established weakness in the key operational areas of the biggest referral

hospital. Subsequent Examinations within the health sector2 also confirmed

discrepancies in the procurement of pharmaceuticals and non

pharmaceuticals and general malpractices in the institutional operations.

Reports by other institutions indicate the same concerns. The Transparency

International report, 20053 on corruption and in Kenya’s National Aids Control

Council, NACC, revealed that for years high level public officers had grossly

abused their office. The funds squandered may seem petty when juxtaposed

with the colossal funding that the health sector attracts, yet when

consolidated and if spent effectively could have meaningful impact on the

lives of many Kenyans.

Fighting corruption is a constant concern for donors and governments

worldwide. Efforts towards improving service delivery like health care

provision often fall short of the agenda in improving peoples lives. This may

be attributed to the fact that governments, donors and philanthropists

underestimate the challenges of governance and corruption in healthcare

1 Examination Report , 2003:The Management of Kenyatta National Hospital; Anti- corruption Police Unit 2Corruption Risk Assessment Report, 2005; Procurement and Distribution of Drugs and Other medical Supplies by the Ministry of Health and Kenya Medical Supplies Agency3 This is a working paper on corruption and HIV/AIDS

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delivery. The rush to endorse MDGs and translate these goals into real

programmes has largely overlooked the limited ability of institutions to

deliver. The need to identify and address corruption and weak governance is

often lost in the commitment to raise funds and expand services. Corruption

in the health care industry takes a serious toll both in monetary terms and

human suffering. Corrupt practices in the health sector include: informal

payment, fraudulent procurement and billing, inappropriate influence on the

regulatory process, selling expired drugs in altered package, absenteeism

among other malpractices, undermine the quality of health care and

medication with dire consequences.

Determining whether public investments in health care are reaching their

target population requires knowing which outcomes to monitor. Traditional

measures such as the infant mortality rate are poor reflections of the health

sector performance because they are too general and because of the tenuous

link between health inputs and health status at high levels of infant mortality.

To compensate for poor data and the difficulty of measuring the impact in

health care delivery, indirect measures of performance can be used. The

more complex and important measures of health system performance

include: as staff availability; availability and quality of drugs and medical

supplies; functioning equipment, quality of construction and general

infrastructure.

These factors, Savedoff and Hussmann, 2006, state make the health sector is

the most complex sector in the society. They further explain that it is

characterised by a large number of dispersed actors, asymmetric information

and has specific mix of uncertainty. This is complicated by the fact that

patients are not in a position to shop around for the best price and quality

when they are ignorant of the costs, alternatives and precise nature of their

needs. The three features bedevilling the sector: uncertainty, asymmetric

information and the large number of actors help in propagation of corruption

and make it difficult to detect, punish and deter the malfeasance.

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Additionally, government regulation in the pharmaceutical industry while

essential to safeguard the citizens against sub–standard drugs and unfairly

priced goods makes this sector particularly prone to corruption. If regulators

are subject to pressure from commercial groups, health objectives can be

compromised. Due to the unpredictability of the health needs, governments

are unable to plan effectively for future medical needs which diminishes their

ability to resist offers of medicine at inflated prices or in excess quantities

and to detect corruption in such transactions.

The Kenya Government recognizes the role of healthcare in the economic

development and therefore allocated KSh. 33 Billion towards the health

sector in the current financial year, 2006-2007. This huge investment outlay

necessitates interventions to improve planning and reporting including the

integration of financial data and service utilization statistics to enhance

transparency and focus attention on areas most vulnerable to abuse. Further,

the Global Corruption Report (2006) cites Kenya’s health care system as

lacking accountability mechanisms resulting to abuse and misappropriation

of the funds meant to alleviate disease. Some of the areas or processes cited

in the Report as vulnerable to corruption are: construction and rehabilitation

of health facilities: purchase of equipment and supplies including drugs;

distribution and use of drugs and supplies in service delivery; regulation of

quality in products, services, facilities and professionals; medical research

and provision of services by frontline health worker.4

This findings call for intervention measures and an urgent assessment of

existing anti-corruption initiatives within the public health care sector. The

increased attention to corruption in the health care sector has elicited

questions that have aroused the concern of anti- corruption advocates: which

areas and processes are vulnerable to corruption; what types of corrupt

practices are prevalent; what is the cause of the malfeasance in the sector;

how effective are the existing strategies and interventions; and what new

policy and strategy interventions need to put in place to combat the vice?

1.3 Objectives of the Study

4 Taryn Vian, Sectoral Perspectives on Corruption: Corruption and the Health Sector(2002)

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The main objective of this study is to assess the magnitude, nature and

impact of corruption in the Kenya’s public health care sector and the

healthcare systems. The specific objectives are to:

i. Identify the areas and processes that are vulnerable to corruption;

ii. Establish the types of corrupt practices in the various processes in the

health care system;

iii. Identify the causes of corruption in the sector;

iv. Determine the impact of corruption in the provision of healthcare;

v. Establishment of the effectiveness of the existing anti-corruption

strategies and other interventions; and

vi. Propose anti-corruption policies and strategies for the public health

care sector;

1.4 Scope and Rationale of the study

The Study seeks to explore the policy, legal and institutional frameworks

within the health sector and how they impact on the state of corruption and

governance. Thus areas of special focus will include corruption in

procurement of drugs and equipment, including construction; corruption

affecting provider –patient interaction, and financing within the public health

sector.

The study seeks to integrate anti-corruption strategies in the health sector with the overall

anti-corruption strategies at the national level. The paper intends to provide a benchmark

study for further research in this area.

2.0 KENYA’S PUBLIC HEALTH CARE SYSTEM

The health sector comprises the public system, with major players including

the Ministry of Health, (MoH) and Parastatal organizations and the private

sector, which includes private for profit, Non-Governmental Organizations,

NGO and Faith Based Organizations, FBOs, facilities. The health services are

provided through a network of over 47000 health facilities countrywide, with

the public sector accounting for about 51% of these facilities.

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The public health systems consist of the following levels of health facilities:

i. National referral hospitals are the apex of the health care system,

providing sophisticated diagnostic, therapeutic and rehabilitative

services. The two are Kenyatta national Hospital and Moi referral

hospital.

ii. Provincial hospitals, which act as referral hospitals to the district

hospitals.

iii. District Hospitals which concentrate on the delivery of health care

services and generate their own expenditure plans and budget

requirements based on the guidelines from headquarters through the

provinces.

iv. Health Centers provide ambulatory health services. They generally

offer preventive and curative services that are inmost cases adapted

to the local needs.

v. Dispensaries are meant to be system’s first line of contact with

patients, but in some areas, health centers or even hospitals are

effectively the first points of contact. They provide wider coverage for

preventive and curative services, mostly adapted to needs.

In 1994, the Government of Kenya approved the Kenya Health Policy

Framework (KHPF) as a blue print for developing and managing health

services. It spells out the long term strategic objectives and the agenda for

Kenya’s health sector. The Ministry of Health, (MoH), established the Health

Sector Reform Secretariat (HSRS) in 1996 to spearhead and oversee the

implementation process. The above policy initiatives were aimed at

responding to the following constraints: decline in health sector expenditure,

inefficient utilization of resources, centralized decision making, and

inequitable management information systems, outdated laws, inadequate

management skills, worsening poverty levels, increasing burden of disease

and the rapid population growth. The first National Health Sector Strategic

Plan (NHSSP-1) for the periods 1999-2004, was a follow up to the Ministry of

Health’s efforts to translate the policy objectives into implementation

programmes.

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An evaluation of the NHSSP-1 by a team of independent consultants revealed

that the overall implementation of the NHSSP-1 did not lead to the

transformation of the healthcare system and promotion of socio economic

development as envisaged in the plan. The failures were attributed to the

lack of well articulated, prioritized strategic plan; weak management systems

and low personnel morale at all levels among others. Poor management

systems and low morale are breeding grounds for corruption and corrupt

practices.

In renewed effort to improve the health service delivery, the MoH and

stakeholders reviewed the NHSSP-1 service delivery system in order to devise

a new strategy for making health care more effective and accessible to

people. These efforts led to the formulation of the Second Health Sector

Strategic Plan (NHSSP-II): 2005-2010 which puts more emphasis on

promotion of individual health as opposed to disease burden.

Adequate resources are critical to sustainable provision of health services.

The Kenya policy framework of 1994 identified several methods of health

services financing. These included; taxation, user fees, donor funds and

health insurance. These methods have since evolved into important

mechanisms for funding health services in the country. These methods ought

to reflect the cost and quality of service provision as well as the ability of the

population to pay.

In view of the myriad inflows of funding and players in the sector, proper

policies, guidelines and regulations should be put in place to manage and

monitor the funds so as to ensure that they are utilized for the intended

purpose, enhancing public health care delivery.

3.0 LITERATURE REVIEW

3.1 Conceptual Review

A study by Norberg(2006) confirmed that on a macroeconomic level,

corruption limits economic growth , since private firms perceive corruption as

a sort of ‘tax’ that can be avoided by investing in less corrupt countries. In

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turn, the lower economic growth results in less government revenue available

for investment, including investment in the health sector. Corruption also

affects government choices in how to invest revenue. Within the healthcare

sector, investments may also tend to favour construction of hospitals and

purchase of expensive, high tech equipment over primary health care

programmes such as immunization and family planning, for the same reason.

Subsequently, the growth, governance and corruption literature (Elliot, 1997;

Transparency international, 2005; World Bank, 1997; Economic Commission

for Africa, 2005) largely ignores governance when it comes to public policies

in the social sectors. However, efficiency in resource use would suggest the

need to consider such themes.

Furthermore, most developing countries depend heavily on public

intervention rather than regulation, hence the predominance of public health

care systems in these countries. A limitation in assessing existing health

care systems is the lack of any single measure of what constitutes a

functioning system. For developing countries, systems differ and information

on comparable indicators simply does not exist.

Lewis (2006) formulated the production function of a health care framework

representing the core of public health care systems embodying capital, labor

and governance. A simple representation is as follows:

Health outcomes= (L, K, G)

Where governance, (G) represents some measure of institutional quality of

governance, increase in the labor, (L) and capital, (K) can improve outcomes;

(G) may dampen or enhance these effects.

Labor encompasses management, physicians, nurses and other medical staff.

Capital is made of infrastructure, equipment and other fixed assets, as well

as financing: government transfers for local purchase, in–kind provision of

drugs and supplies, and third party and consumer payment.

Lewis (2006) further affirms that, while straight forward in concept, the

production function is far from simple and the market failures identified

above plague both private and public systems (principal agent and

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information asymmetry problems) , which undermine incentives and limit the

extent of accountability.

Multiple institutions collect indicators of governance. Kaufmann, Kraay and

Mastruzzi

(2005) have broken them down to six dimensions of governance; voice and

accountability; political stability and lack of violence; government

effectiveness; regulatory quality; rule of law ; and, control of corruption – all

of which affect the environment within which health care services function.

Accordingly, the costs for the official are not the only factor affecting his/her

decision to limit access to users. His/her potential benefits also play a role; by

limiting access to service, the public official can extract additional rent from

users who need the services he /she provides. Thus the presence of

corruption can translate into a more limited access to services desired.

Kaufmann et al, 2005, postulate a model that aims to explain the degree of

accessibility to a public service by the governance and corruption

characteristics of the public agency providing it:

Accessibility of public service=f (governance characteristic) = f (citizen voice,

quality of rules, audit mechanisms, effectiveness, resources, meritocracy,

mission, service performance, wage satisfaction, corruption)

3.2 Empirical Review

The evidence on the link between institutions and health largely relies on

analyzing the cross–country relationships between corruption and health

outcome measures. With evidence from 89 countries for 1985 and 1987

Gupta, Davoodi and Tiongson (2002) show corruption indicators negatively

associated with child and infant mortality, the likelihood of unattended birth,

immunization and low- birth weight. The correlation in explaining the same

health outcomes is reduced once factors such as mother’s education, public

health spending, education and urbanization are controlled.

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In measuring the impact of corruption on the effectiveness of health

spending, Rajkumar and Swarrop (2002) analyze data for the 1990 and 1997

controlling for GDP per capita, female educational attainment, ethno-

linguistic fractionalization, urbanization among other factors, and find that

the effectiveness of public health spending in reducing child mortality hinges

on the integrity rating, with higher integrity associated with reduced

mortality.

At a sectoral level, a number of surveys on medical personnel in Latin

America public hospitals provide a sense of the kinds and frequency of

corruption in facilities as surveys indicate corrupt practices, which by their

nature are not typically visible. Perceptions may be the only alternative in

instances where hard data is either unobtainable or unreliable; moreover,

corruption in general does not lend itself to straight forward data collection. A

review of research in Eastern Europe and Central Asia found evidence that

corruption in the form of informal payments for care reduces access to

services, especially the poor and causes delays in care seeking behaviour.

Health reforms involve changing government institutions and policies in

purposeful, fundamental and sustained ways.5

Savedoff (1998) confirmed that when combined with differing interests

among health sector actors, asymmetric information leads to a series of

problems that are analyzed within the framework of “principal-agent

relationship” iIn such as a framework the principal hires an agent to perform

some function. When an agent has interest that differ from those of the

principal and when the principal can not get complete information about the

agents output, it is difficult to find contracts that are optimal. These two

characteristics –diverging interest and incomplete information – are inherent

and widespread in the health sector. The principal agent problem s in the

health care sector have mainly been analyzed in terms of their impact on

5 Peter A Berman & Thomas LJ Bossert, ‘ A Decade of health sector Reform In Developing Countries: What have we learned’ ( Boston, MA; Data for Decision making Project , Harvard School of Public Health, 2000)

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health system efficiency, these same problems increase opportunities for

corruption. Savedoff (1998) further concurs that the difficulty of fully

monitoring the actions of doctors, hospitals, pharmaceutical companies and

regulators makes it hard to hold them accountable for the results of their

actions.

Akunyili (2006) established that unregulated medicines which are of sub-

therapeutic value can contribute to the development of drug resistant

organisms and increase pandemic disease spread. Additionally, corruption

could also lead to shortages of drugs available in government facilities, due

to theft and diversion to private pharmacies. Kassirer (2005) states those

promotional activities and other interactions between pharmaceutical

companies and physician, if not tightly regulated, can influence physicians to

engage in unethical practices. Wazana (2000) showed that these interactions

can lead to non –rational prescribing and increased costs with little or no

additional benefits.

Ensor (1997) availed evidence on corruption in the health systems with direct

public provision as being largely focused on informal, or illegal, payments for

services or transition economies. This form of corruption has a particularly

negative impact on access to care for the poor when they can not afford

these payments.

Dr. S Kumar (2003) affirms that the medical education system is to blame for

failing emphasis adequately on the humane aspects and also offering

insufficient training in managerial roles essential for success in the

hierarchical healthcare system.

4.0 METHODOLOGY

4.1 Research Design

The study will involve desks research where relevant and related

literature will be reviewed. In addition, quantitative and qualitative data

will be collected form identified respondents and key informants within

the health care sector and related sectors. A semi structured

questionnaire and discussion guide will be designed to gather relevant

information from identified service providers and seekers.

The study will therefore:

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i. Review policy, statutes and related documents to establish the

channels, types, causes of corruption and the policies and

regulation governing the sector and affiliate sectors.

ii. Analyse and synthesize information from the three diagnostic

surveys by KACC; Examination and Assessments reports on KEMSA,

Kenyatta National Hospital and the KACC and the Advisory Report

2006 on the Moi Referral Hospital.

iii. Incorporate interviews with consumers, providers, key informants

and other stakeholders within the public healthcare sector to

enhance the study.

4.2 Targeted Respondents

Key informants from the below listed organizations will be targeted.

Respondents Type of information Method of data

collection

1. KEMSA

2. NACC

1. Quantitative and

quantitative data on

types, causes, impact

1. Semi-structured

questionnaire

through face to

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3. KEMRI

4. Pharmacy & Poisons

Board

5. Ministry of Health

(officials of key

departments)

6. Government Hospitals

(Referral institutions,

provincial hospitals,

districts &

dispensaries)

7. National Hospital

Insurance Fund, (NHIF)

8. Private Healthcare

providers Medical

Insurance providers

9. Suppliers of non-

pharmaceutical

products

and areas prone to

corruption

2. Status of reforms on

harmonization of

rules, regulations and

policies in the health

care industry

face interview

In-depth

interviews

Review of

statutes, policies,

regulations &

other documents

2. Analysis of

relevant cases

10.Medical Educational

institutions(Universitie

s & KMTC)

End-users of public health

care services

3. Aspects of the

training to aspiring

medical personnel

4.3 Research Instruments and Data processing

An instrument will be developed to guide the review of documents including

relevant statutes, policies and regulations. For the qualitative data, a

discussion guide will be developed for each category of participants

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(providers and healthcare seekers). Discussions and interviews will also be

conducted with key informants.

The study tools will be pre-tested to ensure consistency, language

appropriateness, flow and sequence of questions, length of interview, and

clarity of questions, ethical considerations and general appropriateness.

Comments from the pre-test will be incorporated before proceeding with the

assignment.

An appropriate package will be utilized to analyze the data gathered.

5.0 IMPLEMENTATION PLAN AND BUDGET

In addition to rigorous desk research, the study will involve interviews with

the various stakeholders, key informants and consumers of the health

services. Therefore, the team will need transport, stationery, telephone

and night out allowance to facilitate the exercise. Provided below is the

budget for the study.

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Activity Output TimeframeFY2007/08

July Aug Sep OctW1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3

1. Development & approval of proposal

Approved proposal

2. Generation of field tools & logistics

1. Field questionnaire2. key informant guide

3.Field work Sector wide interview and data collection

4. Data processing Draft report5. Draft Report Report for comments6. Final Report Report for approval for

dissemination7.Publication & Dissemination of the report( Workshop)

Final Research paper published & dissemination to stakeholders

5.1 Implementation Schedule:

5.2 The budget

Due to lack of consensus on scope of the study, I have not adjusted the budget. Some members insist it should be more of a desk study with key informants involvement only. Kindly advice.

14. BudgetCost Item Quantity Day

sUnit Cost/Rate

Total (Kshs)

Preparatory

Research Instruments (Printing & Photocopying)

2500   20 50,000.00

Training and pre-testing workshop

       

Lunches and Teas (Field team including Commission staff)

35 5 1000 175,000.00

RA’s training allowance & transport 25 5 500 62,500.00

Sub-Total  287,500.00

FieldworkResearch Assistants (RAs) fee & Subsistence

25 14 3500 1,225,000.00

Field Supervisors (KACC Staff) - Per diem

6 14 5200 436,800.00

Drivers’ night out allowances 6 14 3500 294,000.00

Fuel Expenses 6 14 1000 84,000.00

Telephone expenses 6 14 500 42,000.00

Telephone expenses 31 14 100 43,400.00

Sub-Total   2,125,200.00

Data management

Data Coding & Entry Clerks' fee 10 15 2000 300,000.00

Data entry Supervisors fee 2 15 4000 120,000.00

CBS Entry Team 10 15 2000 126,000.00 Sub-Total       720,000.0

0Dissemination Costs

Printing 3000 1 350 1,050,000.00

Publicity/Advertisements      

Distribution (postage etc) 50 1 200 10,000.00

Hire of venues 100 1 1000 100,000.00

Lunches, Teas and snacks 100 1 1000 100,000.00

Sub-Total     1,260,000

.00 Grand Total

   

4,392,700.00

6.0 References

1. Akunyili D., The fight against counterfeit drugs in Nigeria, part 1.5 in Transparency International’s Global Corruption Report 2006.

2. Berman P., & Bossert L.J T, ‘ A Decade of health sector Reform I Developing Countries: What have we learned’ ( Boston, MA; Data for Decision making Project , Harvard School of Public Health, 2000)

3. Ensor T., ‘What is the Role of State Health Care in Asian Transition economies?, Health Economics 6 (5), 1997

4. Examination Report, 2005; procurement and Distribution of Drugs and Other medical Supplies by the Ministry of Health and Kenya Medical Supplies Agency

5. Examination Report , 2003:The Management of Kenyatta National Hospital; Anti- corruption Police Unit

6. Gupta S., Davoodi HR, Tiongson E, Corruption and the provision of health Care and Education Services, Governance, Corruption and Economic Performance, Washington , DC : International Monetary Fund, 2002.

7. Kassirer J., The Corrupting influence of money in Medicine, part 1.5 in Transparency international’s Global Corruption Report 2006.

8. Kauffman D, Montoriol –Garriga J and Recanatini F. “How Does Corruption Affect Public Service Delivery? Micro- Evidence from Service Users and Public officals in Peru.

9. Lewis M, Governance and Corruption in Public health care systems (Centre for Global Development, 2006).

10. Lewis M., ‘Tackling Health care corruption and governance woes in Developing countries, CGD brief , working paper 78, Washington DC.2006

11. Ministry of Planning & National Development(Kenya) and United nations Development in partnership with UNDP, Kenya and the government of Finland, MDGs Status Report for Kenya, 2005

12. Savedoff D W, The Characteristics of Corruption in Different Health Systems, 2003, World Health organization , p6

13. Savedoff D. W., (ed), ‘Social services Viewed through New lenses’, Organization matters: Agency problems in health and education in Latin America ( Washington DC : IADB, 1998

14.Sparrow, M. K. "Corruption in Health Care Systems: The U.S. Experience." Global Corruption Report 2006: Special Focus - Corruption and Health. Ed. Transparency International. Pluto Press, 2006, 16-22.

15.UN Department of Economic and Social Affairs, Statistics Division, ‘ Millennium Development Goals: 2005 progress report’ NY: UN DESA, 2005

i

7.0 Appendix7.1 Proposed tools

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16.Vian T, Corruption and the health Sector, 2002, UAID and Management Systems International ( MSI), p. 1, 2-3,28

17.Wazana A., Physicians and the pharmaceutical Industry: is a gift ever just a gift?, Journal of the American Medical Association,2000, 283:373-380

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