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Defining Corruption: cultural aspects in health workers: ethical aspects and dimensions Global Gerecht Gesund Defining Corruption: cultural aspects in health workers: ethical aspects and dimensions Global Gerecht Gesund Berlin, September 17, 2010 Sylvia Sax, RN BSN MPH Doctoral Student Institute Public Health, University of Heidelberg

Pakistan: Country Profile Multiethnic & linguistic diversity 4 provinces & 2 territories Population ~ Pakistan: Country Profile Multiethnic & linguistic diversity 4 provinces & 2 territories Population ~ 145 million History: Rich cultural heritage + natural & human resources Productive agriculture sector Strategic trade location Per capita income: US$ 420 -460 Literacy rate: 38. 9% Population doubling time: 25 years Expenditure on health: 0. 7% GNP 70 -80 -% of health expenditure is on human resources Area 796, 096 sq Km

Research Case Study of North West Frontier Province, Pakistan (Khyber Pakhtoonkhwa) Health Services Quality Research Case Study of North West Frontier Province, Pakistan (Khyber Pakhtoonkhwa) Health Services Quality Contextual factors that influence mechanisms for quality improvement Qualitative and Quantitative methods

Nurses station in a district hospital Dust at base of tap No soap No Nurses station in a district hospital Dust at base of tap No soap No hand towels No guideline for washing hands No water

Key Health System Issues Critical shortage of health service providers But not sure of Key Health System Issues Critical shortage of health service providers But not sure of the numbers (3 doctors/1 nurse) External and internal brain drain (rural & donor) Urban/rural discrepencies Increasing reliance on paramedicals and ‚ward boys‘ Weak regulatory framework Limited registration of health facilities and providers with lack of regulatory mechanisms Professional groups weak influence on members Corruption Political interference in transfers and postings Private medical schools proliferating without transparent processes

The darker the red – the higher the corruption perception index The darker the red – the higher the corruption perception index

Ease of Corruption in the Health Sector Uncertainty about what services should be delivered Ease of Corruption in the Health Sector Uncertainty about what services should be delivered and at what level of quality Involvement of private and public actors like payers, providers, suppliers, consumers, and regulators Asymmetric information among different actors and their individual interests Extent to which private providers are entrusted with important public roles Adapted from Savedoff 2006

Corruption The abuse of entrusted power for private gain (Transparency International) according to rule- Corruption The abuse of entrusted power for private gain (Transparency International) according to rule- corruption where payments/bribe is paid to receive preferential treatment for something that the bribe receiver is required to do by law. Against the rule- where a bribe is paid to obtain services that the bribe receiver is prohibited from providing. IMF and World Bank define corruption as misuse or abuse of public force (office) for private gain

Sifarish In our research we consistently heard about the practice of Sifarish (patronage, nepotism, Sifarish In our research we consistently heard about the practice of Sifarish (patronage, nepotism, favouratism) Most interviewees identified Sifarish as a system, with specific practices which are not described or prescribed Those who reported on Sifarish usually described harmful results of the practice

Culture and Corruption Variations of levels of Corruption may be due in part to Culture and Corruption Variations of levels of Corruption may be due in part to variations in the social norms and preferences that have been internalized by the citizens of that country ( Barr & Serra 2006)

Sifarish – a moral system? It is a moral system which is accepted and Sifarish – a moral system? It is a moral system which is accepted and those participating are often not aware of the practice Morality can be defined as: a system of rules for guiding human conduct, and principles for evaluating those rules. Individual acts within a cultural and social system

If Sifarish is not recognized as part of the moral fabric of the cultural If Sifarish is not recognized as part of the moral fabric of the cultural system and understood as such -then, how can we develop tools which will maximize accountability and transparency?

What can we do? 1. Recognize that it is a social norm, a pattern What can we do? 1. Recognize that it is a social norm, a pattern in society and not simply an individual act 2. Include transparent discussion of the different kinds of acts and their results 3. Discuss the concept of harm to society and encourage research on not only corruption but also related topics such as Sifarish

Shukriya. . Thank you Shukriya. . Thank you

Selected References Barr A. & Serra D. 2006 Culture and Corruption. Global Poverty Research Selected References Barr A. & Serra D. 2006 Culture and Corruption. Global Poverty Research Group http: // www. gprg. org, accessed on 21 June, 2010 Nichtar, S. 2007 Corruption: the need-greed equation. News International, Islamabad, December 09. Savedoff WD. 2006. The causes of corruption in the health sector: a focus on health care systems. In: Transparency International. Global Corruption Report 2006: Special focus on corruption and health. London: Pluto Press. Taryn Vian, 2008, Review of corruption in the health sector: theory, methods and interventions. Health Policy and Planning, Vol. 23, pp 83 -94. Taryn Vian, 2002, Corruption and Health care Sector. Transparency international: Sectoral prospective of corruption, pp 1 -35 Transparency International : http: //www. transparency. org/ accessed on 19 th February 2010