Why would a doctor take a bribe?

Earlier this month, Transparency International released the Global Corruption Barometer (GCB) — Africa report, which surveyed more than 47,000 citizens from 35 countries in Africa about their views on and experiences of corruption, including in the health care system.

The research revealed that 14 per cent of citizens who accessed health care services paid bribes to health care workers in the last year.

Although this is a relatively low bribery rate compared to other public services, like police services (28 per cent) and utilities (23 per cent), it still means a good portion of the population in these countries pay bribes, give gifts or do favours in order to access the medical care they need.

However, bribery in the health care system varies from country to country. For example, the bribery rate for health care services is very low in Botswana (1 per cent) and Mauritius (2 per cent), but very high in Sierra Leone (50 per cent) and the Democratic Republic of Congo (43 per cent).

While ordinary bribery contributes to a cycle of corruption that often harms the most vulnerable citizens, it is important to understand that not all informal payments are illegal, corrupt or even harmful.

The term, ‘informal payment’, encapsulates an entire spectrum of payment in the health care system. At one end, a patient may give flowers to a doctor after successful treatment, while at the other, a doctor may withhold life-saving medical care unless a patient pays a large amount of cash up front.

In between these extremes, there are many shades of grey. Generally speaking, informal payments are more likely to constitute corruption and bribery if they are made prior to any medical procedure, if the health care provider proactively asks for them, or if they involve cash or expensive items.

But for some, even grey areas may pose an impossible choice: pay a bribe or go without treatment.

In Zimbabwe 60 per cent of citizens think corruption increased in the previous 12 months. However, the bribery rate for health care services is just 4 per cent. Despite this, women still have to pay bribes for the medical care they need, including prenatal care.

In some cases, pregnant mothers like Shona from Zimbabwe, are turned away from clinics unless they pay additional “consultation fees” for health services that are supposed to be free.

In Kenya, where the bribery rate for health centres is 18 per cent, pregnant mothers like, Anne, face a choice between spending two-thirds of their monthly salary to access better care or risk stillbirth.

Or parents who, like Kamal, had to choose between waiting months or paying a bribe of a third or more of his salary to ensure his daughter could access a brain scan.

In countries where corruption is common, from the highest to lowest levels of government, officials across the corruption food chain siphon off funds from top to bottom, leaving inadequate resources to deliver much needed health services.

Health care workers operating in underfunded health systems experience poor infrastructure, inadequate supplies and equipment, and dissatisfaction among patients.

It’s no wonder that some health workers, who are chronically underpaid and overworked, sometimes turn to bribery to support themselves and their families.

Some studies show the prevalence of bribery increases in areas where the health system pays low salaries, suggesting that increases in salaries could potentially decrease bribery.

However, some studies also show that without appropriate supplementary approaches, such increases may be ineffective, and in some cases, actually increase levels of bribery.

Underfunded health systems can be plagued by infrastructural decay, inadequate supply of equipment and lack of satisfaction from patients. At the same time health providers themselves can be overworked and paid sporadically. Research highlights that poor working conditions can affect health care workers and make them more receptive to bribes.

In other cases, where there is a general acceptance of bribery for medical care, some patients even offer bribes unprompted by health care workers.

Bribery in the health system exists for many reasons: a lack of institutional capacity, a lack of punishment or sanctions, as well as poor working conditions and low salaries.

Studying bribery from all angles can help practitioners better understand existing drivers of bribery in the health care system and promote effective anti-corruption efforts in response.