Understanding and eliminating health sector corruption impeding UHC at district level in Nigeria and Malawi: institutions, individuals and incentives

Weak accountability and corruption (the abuse of entrusted power for private gain) threatens health in LMICs, especially among the poor. Evidence shows that corruption remains pervasive, harms health and access to care, and is a major barrier to achieving Universal Health Coverage. The health sector is consistently rated as among the most corrupt. Unaccountable and corrupt practice undermines the trust underpinning effective, equitable, and responsive health care and has a major impact on health outcomes. Corruption is often seen as an intractable problem-with limited evidence on successful strategies to address it.

Most approaches to weak accountability and corruption have seen these as a failure of management, a result of poorly governed and financed systems or reflecting social norms. Many interventions seek to improve law, policy, accountability and transparency. We argue that these can be more effectively addressed through a) understanding the main types of corruption manifest in the provision of care at district and local level (e.g.informal payments, absenteeism, leakage of health commodities, inappropriate referrals), b) the individual and organisational characteristics that drive it, and c) the underlying power structures. Thus, research must explore how formal structures (policy and its implementation) interplay with informal social, economic and political structures (local elites and kinship networks) to shape everyday practice within the health system. With this knowledge, it is possible to identify pragmatic strategies ('openings') to address corruption that takes into account their fit within the broader organisational and political distribution of power. Drawing on health systems research, anthropology, and political economy, our hypothesis is that measures based on a detailed understanding of the intersections between formal and informal structures, incentives and networks can inform the design of contextually appropriate interventions to tackle corruption in public health systems.

The study will take place in Nigeria and Malawi. Both have high levels of corruption and momentum-driven by political leaders and civil society-to tackle corrupt practice. We ask: how do health systems structures and practices, and informal socio-political and economic structures incentivise corruption at district level and how can these be overcome?

Our choice of methods reflects our intention to explore incidents of corruption in real time within frontline exchanges between provider and patients in district management structures and local community. We will develop novel and ethically robust approaches and methods: content analysis of policies and regulations, media (print and radio) relating to accountability/anti-corruption. Institutional ethnography in district health offices, primary, secondary and tertiary levels facilities, in-depth interviews with formal and informal political and health systems structures, focus group discussions and a household survey with service users, data from anonymous calls/ messages by individuals reporting corruption cases. The analysis will also draw on political economy, with analysis of actors, their power and their informal networks, on systems theory, especially complexity, and will involve co-production workshops and policy dialogues to interpret and validate findings. In Nigeria we will work in the Enugu state in the south and in the Kano state in the north and, and within each, urban and rural areas, and in Malawi we will select up to 4 districts. These will be selected to represent diverse populations, needs, outcomes, level of resources and institutional strength.

We will engage at all health system levels-with community organisations, districts/ state, as well as national authorities, to promote anti-corruption action. We will build a community of practice, share knowledge and support researchers and implementers in LMICs-linked to global anti-corruption initiatives.

Weak accountability and corruption in public health systems (abuse of entrusted power for private gain) are widely acknowledged as impeding access to health care, yet empirical research on the drivers and potential solutions is limited. To design contextually appropriate interventions to tackle these, we will explore the most prevalent/harmful corruption practices at district and local level; individual and organisational characteristics that drive these, and critically, how formal structures (policies, enforcement) interplay with informal social, economic and political structures (local elites and kinship networks) to shape everyday practice within the health system. We will then identify pragmatic strategies ('openings') to address corruption within the broader organisational and political distribution of power.

The district will be the unit of analysis. In Nigeria research will be in 3 urban and 3 rural Local Government Authorities in Enugu(S) and Kano(N) States, and in Malawi, in 2 districts in the South, 2 in the Central region. We ask: how do health systems structures and practices, and informal socio-political and economic structures incentivise corruption at district level and how can these be overcome?

We will develop novel and ethically robust approaches and methods: content analysis of policies, regulations, media; institutional ethnography; interviews; a household survey with users (2 districts); crowdsourcing of corruption cases. Analysis will also draw on: political economy, analysing actors, their power and their informal networks; systems theory, especially complexity; and involves local and national co-production and policy engagement workshops to interpret and validate findings and formulate actions. Engaging at all levels of the health system we will promote anti-corruption action by building a community of practice, sharing knowledge and supporting researchers and implementers in LMICs-linked to new global accountability initiatives.

This project builds on previous work to understand the nature and drivers of weak accountability and corruption in health systems and identify plausible strategies to address them. We have extensive experience with policy engagement, knowledge brokering, and the role of cognitive biases. Impact will be achieved through:

Changing mindsets. We will challenge the idea that corruption is inevitable. We will convey the message that greater accountability can tackle corruption, inspiring new ideas about what is possible. We will identify those who will benefit from anti-corruption measures and are ready to call for them, creating momentum for change, with charismatic community champions playing a key role. Some are already vocal on social media in Nigeria but we will seek to create new (virtual) networks. We will seek spaces at different levels of the health systems and community structures-allowing for conflicting views and innovative ideas applicable to particular contexts. We will emphasise openness, lack of blame, naming the real (often structural) causes of poor accountability and corruption, and novel (blue sky) solutions. Our aim is to impact on international debates and those in communities of practice (through co-production workshops), partnering with NGOs in this field; use virtual platforms & media to reach policy makers in LMICs.

Changing policies. Lasting impact will require changes to legal and regulatory frameworks, understanding how existing rules and procedures can impede rather than facilitate responses to weak accountability and corruption. We will position anti-corruption efforts centrally within discourses on health systems strengthening and governance, building on existing initiatives on whistleblowing, audits, and reporting, now officially mandated by the governments in Nigeria, and Malawi. We will engage with diverse stakeholders through formal policy dialogues but also informal discussions and fora (including during fieldwork). Impact will be at State level (in Nigeria) and district level (Malawi) but will also engage policy-making processes nationally. We will focus first on the districts where we work but gradually involving key actors from other districts.

Changing practice. The process of changing everyday practice begins through an understanding the structural, social, and cultural political drivers of poor accountability and corruption, identifying practical ways they can be addressed. We will focus at district level, working with key actors (health system leaders, managers and civil society representatives) to co-create pragmatic, locally-relevant solutions that attract support from key stakeholders and can be implemented at district level. We will focus on corrupt practices that can be addressed with existing institutional/ social resources, capacities, and power structures. We will seek to influence policy and programmatic efforts by governments, international agencies and donors-in study countries and across LMIC where an impetus for improving governance is emerging.

Creating and supporting networks and collectives. In Nigeria and Malawi we will link with national initiatives to tackle corruption and promote accountability, working with health systems leaders, civil society and communities. We will move beyond creating 'talk shops' to understand the relative strengths of each actor and the incentives they face as we support collaboration and action. We will involve actors that are influential within informal structures; many may not previously have participated in formal agenda setting. Recognizing context-specificities of the problems and policy, we will work at state/district and national level. Impact will be sought at the global level by engaging with initiatives such as the Global Network for Anti-Corruption, Transparency and Accountability in Health Systems and the Health Systems Governance Collaborative.