News article 24 Jul 2017

Revolutions in the economics of health systems

iHEA conference

The 12th International Health Economics Association (iHEA) Congress, held at the Boston University from 8th to 11th July 2017, was an excellent opportunity for global experts in health economics to share ideas. Dr Thidar Pyone, from CMNH, attended the event. 

The theme of this year’s congress was “Revolutions in the Economics of Health Systems”. The congress was unique as it covered a range of topics in health economics including health systems and policy research. Many health economists, health system researchers and policy makers from across the globe presented their cutting-edge research and exchanged ideas with the dynamic groups of people in attendance.

Our session covered a wide range of topics on governance and health system corruption with the aim further the discussion about how empirical research on health sector corruption can (1) elucidate the effect of corruption on health sector performance and (2) guide countries toward better anti-corruption strategies. In my own session, “Health sector corruption: measurement, policy and strategy”, focused on the control of corruption chaired by William Savedoff, a Senior Fellow, from the Centre for Global Development.

Presentations started with Professor Taryn Vian from the Boston University. She discussed on whether public-private partnership (PPP) model for hospital governance and management could reduce corruption or not. She used her own “Corruption in the Health Sector framework” using qualitative research methods to compare themes related to corruption between the two hospitals: government-run hospital and PPP model hospital. The findings suggest that corrupt practices which were described at the government-run hospital (i.e. theft, absenteeism, and shirking) were absent in the PPP hospital. In the PPP hospital, anti-corruption levers (i.e. controls on discretion, transparency, accountability, and detection and enforcement) were described in four management sub-systems: human resources, facility and equipment management, drug supply, and security.

Dr Gerard La Forgia, a Chief Technical Officer of Aceso Global, presented de facto institutional and governance arrangements of human resource management (HRM) in the public sector of India. The study focused on four HRM subsystems: postings, transfers, promotions and disciplinary practices from the perspective of front-line workers—physicians working in rural healthcare facilities operated by two state governments. The findings suggest that an institutional environment in which formal rules of accountability are trumped by a parallel set of accountabilities. Using a mixed methods approach, the author presented how these systems appear so entrenched that HRM reforms have borne no significant effect.

Then, I presented findings from my PhD research which was conducted as part of the programme of work called “Making it Happen” in Kenya funded by DFID. The programme was coordinated by our centre, the CMNH at the Liverpool School of Tropical Medicine (LSTM). I have used the institutional framing of governance to explore how a health facility isgoverned, including the rules (both formal and informal) that determine its accountability, its ability to control of corruption, and the transparency of its operation.iHEA conference

Our study elucidates just how governance arrangements differ with the functionality of a health facility. It shows that staff respond to problems with formal institutions by creating informal arrangements that sometimes circumvent and sometimes support the goals of the formal system. It demonstrates that fully functional (FF) facilities have accountability mechanisms that they self-enforce. By contrast, not fully functional (NFF) facilities lack both self-enforcement and effective 3rd party enforcement mechanisms. Furthermore, norms and practices for controlling corruption are clear in FF facilities but confused in NFF facilities. Other institutional factors that might have explained the difference between FF and NFF do not seem to be significant.

Finally, Dr William Savedoff presented a review of four cases of global aid involving the World Bank, USAID, the Global Fund, and European donors. The presentation focused regarding the severity of abuses, the quality of evidence, the responses of funders and recipients, and the impact on health and institutions. The presenter highlighted that, from a funder’s perspective, the main way to address the dynamics of the scandal cycle is to make sure that the decision of whether to disrupt health aid is influenced as much by program results as by the amount and character of corruption.

During the lively discussion, the audience provided interesting inputs ranging from specific presentations related questions to the threshold of corruption in the global health aid. Summing up the discussion, Dr William Savedoff contrasted two key approaches to measuring corruption in our presentations: one being the direct measurement of the corruption and the other indirectly through the performance of the hospitals, inefficiency of the hospital management and governance.

It is time to brainstorm on new research approaches and opportunities for understanding and addressing health sector corruption to enhance good governance.

About the author

Dr Thidar Pyone is a Clinical Research Associate at the Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine with interest in health system governance, health system and policy research and public health evaluation.