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A Sick South Asia: The price of Corruption

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Forget stock markets and GDP trends; there’s another annual report that genuinely reveals the health of a nation: Transparency International’s Corruption Perception Index (CPI). This year, the news for South Asia isn’t pretty. While the numbers don’t directly measure coughs or broken bones, they paint a chilling picture of a region struggling with a disease that eats away at its very well-being – corruption.

Across the board, South Asia scores below the global average, like a student consistently failing basic integrity tests. Only Bhutan and Maldives show signs of improvement, but what about the rest? Stagnant or slipping backwards. Afghanistan languishes at the bottom, Sri Lanka takes a worrying dip, and even giants like India and Pakistan fail to impress.

But why should we care about greased palms and shady deals when discussing health? Because corruption is a silent killer. It diverts lifesaving funds from hospitals, fuels the spread of counterfeit drugs, and silences voices that could expose public health failures. The lower the CPI score, the harder it becomes to guarantee equal access to quality healthcare, a fundamental human right that shouldn’t be a luxury. The CPI is a wake-up call that the fight for a healthier South Asia starts with tackling the rot at its core.

Consider how public health budgets for lifesaving medications and equipment are diverted to enrich corrupt individuals, a harsh reality in many South Asian countries. In 2022, Pakistan’s Anti-Corruption Establishment (ACE) registered a Rs 800 million embezzlement case against seven doctors and four other officials of the Mayo Hospital for a nefarious scheme, purchasing substandard items at inflated prices, effectively playing with people’s lives.

Meanwhile, a few days ago, in India, the Central Bureau of Investigation (CBI) arrested two of its own officers investigating alleged irregularities in Madhya Pradesh nursing colleges. These officers are accused of setting up a cartel that would collect bribes from college officials in exchange for overlooking issues and granting clean chits. The fake nursing college scandal in Madhya Pradesh, India, undermines public health by potentially graduating unqualified nurses who could put patients at risk, raising concerns about the broader prevalence of such institutions nationwide.

When COVID-19 first arrived in adjacent Bangladesh, doctors worried about the inadequate quality of personal protective equipment. There have also been instances of healthcare establishments providing fraudulent COVID-19 test results at a hefty cost. They went even further, charging a premium for Covid-19 treatment, which the hospital should have provided for free and reimbursed by the government. Instead, it did both.

Transparency International’s 2020 report on Pakistan paints a grim picture, highlighting the widespread practice of bribery for essential services like prenatal care and surgery. In this environment, the poor and marginalized, who are already struggling to make ends meet, are often left with no choice but to forego treatment, perpetuating a vicious cycle of illness and despair.

The Criminal Investigations Department (CID) arrested Sri Lanka’s former health minister and current environment minister in February 2024 for spending $465,00 on lifesaving medications that failed quality tests. Sri Lanka’s National Medicines Regulatory Authority (NMRA) claimed that falsified paperwork was utilized to get this batch of low-quality human immunoglobin, a lifesaving treatment for severe antibody deficiency. In the middle of last year, hospitals complained about patients’ drug reactions.

The ‘Pradhan Mantri Jan Arogya Yojana’ health insurance scheme, a source of hope for India’s low-income families, was rocked by allegations in 2021. Private hospitals entrusted with critical care have been accused of inflating bills, performing unnecessary surgeries, and even refusing to treat those who are eligible. This breach of trust may have diverted significant funds to provide a lifeline for the underprivileged. While investigations continue, the possibility of large-scale corruption casts a cloud of suspicion over this critical program.

Nepal’s Omni scandal during COVID-19 starkly illustrates the insidious reach of corruption in South Asian healthcare. Amidst the pandemic’s urgency, a dubious contract inflated prices and awarded medical supply procurement to a politically connected company (OBCI) lacking relevant experience. This case exposes the nexus between politics, business, and bureaucrats, where public health takes a backseat to self-interest, jeopardizing lives during a crisis.

Looking beyond our immediate borders, the Maldives, despite its idyllic image, is not immune to healthcare corruption. A 2019 Transparency Maldives report found evidence of bribery in procuring medical equipment and pharmaceuticals, raising concerns about the quality and accessibility of care. Similarly, Myanmar faces significant challenges. A United Nations report in 2021 highlighted inadequate healthcare infrastructure and a shortage of qualified personnel, exacerbated by potential systemic corruption.

In Ghana, over 80 children tragically lost their lives after consuming cough syrup imported from India, a grim result of systemic regulatory failures and corruption. This incident underscores the severe consequences of compromised safety standards in pharmaceutical exports, driven by the prioritization of profit over human lives. The Ghana scandal highlights the global ramifications of health sector corruption, demonstrating that lapses in regulatory oversight can have deadly international repercussions.

This discussion paints a bleak picture of how deeply corruption pervades South Asia’s health systems, with disastrous consequences for public health. This begs the question: can we remain silent in the face of such widespread suffering? Given the lacklustre and haphazard efforts of governments in this region to address corruption in meaningful ways, two key actors have a moral obligation to raise their voices and help tackle this issue head-on: WHO and UN agencies.

As the world’s leading authority on public health, the World Health Organization (WHO) cannot ignore the insidious link between corruption and poor health outcomes. Its regional and country offices must become vocal supporters of clean and transparent healthcare systems. Issuing strong statements is a powerful way to effect change. The WHO Director-General and regional directors should publicly condemn corruption in health, emphasizing its negative impact on populations. They can set the tone for prioritizing integrity and accountability in healthcare systems by stating their position clearly. Since WHO leadership now makes statements on ongoing wars and conflicts, corruption should no longer be taboo.

WHO’s ambivalence on corruption and reluctance to highlight how privatization of health services harms public health outcomes has not helped either. The evidence for this correlation has long been available, but there has been no effective advocacy by the global custodian of health. South Asian lawmakers and their families frequently own private hospitals, medical colleges, nursing homes, and schools. It is clear where they would stand in the privatization of health debate. WHO should advocate, in particular, with those international finance institutions constantly pushing for lower public-sector health spending and see privatization as the first line of treatment for failing healthcare systems.WHO enters into three to five-year country cooperation agreements with host governments to outline the agreed-upon work plan. Corruption in the healthcare sector should be a vital component of this agreement with allocated funds. Without this, the WHO becomes an accomplice to local politicians who steal donated money.

Thorough country-focused research and reports showing the quantifiable effects of corruption on health outcomes are another essential strategy for fighting health corruption. Data encourages decision-makers to act, especially when it comes to citizen health. Rather than adding to its already overburdened issue list, the WHO should work closely with organizations like Transparency International and the Boston University School of Public Health, which have specialized expertise and credibility in this field. In such partnerships, the WHOcan help develop clear policies, implement effective oversight mechanisms, and promote transparency in health procurement and resource allocation.

Supporting whistleblower protection within WHO, specifically its regional and country offices worldwide, is a critical aspect of combating corruption in health. WHO employees and collaborators who witness corruption firsthand should have safe and confidential channels to report it without fear of retaliation. The WHO can help expose corruption, hold wrongdoers accountable, and improve healthcare delivery by creating an environment where whistleblowers feel empowered and protected.

Development agencies, the United Nations, and international donors are critical players because they provide the financial and technical support required to drive country-level development efforts. However, due to the pervasive influence of corruption, these organizations frequently face obstacles in their efforts. To effectively address this issue, they must take proactive measures and make more intentional decisions. First, they should include corruption assessments in their country reports. This allows them to understand better the scope and nature of corruption in each country, which is critical when developing effective anti-corruption strategies. Recent UN country reports rarely mention the words “corruption” and “misgovernance.” Second, donors should tie aid to demonstrable anti-corruption efforts. Third, they should help civil society organizations (CSOs) combat corruption. CSOs play an essential role in holding governments and other institutions accountable, and they require financial and technical resources to do so effectively.

Corruption is a human invention; it can be dealt with, even in South Asia!

Published in print on 05 June 2024  in The Annapurna Express

Dr Sunoor Verma is the President of The Himalayan Dialogues and an international leadership communication expert. More on www.sunoor.net

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#Afghanistan #Bhutan #Bangladesh #Maldives #Myanmar #Nepal #Pakistan #SriLanka #India #Corruption #Health #WHO #UN #South Asia #Transparency #GobalHealth #GlobalHealthDiplomacy

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The art of making a massive health impact.

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public health communication multi-stakeholder engagement singapore

A call to active lifestyle by Singapore health authorities.

How can a small island nation with a multi-ethnic and multilingual citizenry and four official languages become a global champion in health communication? The answer is to use scientific evidence effectively, to be proactive in responding to evolving trends, to employ many communication channels, and to tailor messages to diverse audiences. And the country with this extraordinary feat will be 58 on August 9, 2023. It’s #Singapore!

Singapore’s demographics are rapidly shifting, posing significant challenges for the country’s health systems. The population is ageing, with the median age anticipated to reach 49 by 2030, as is the proportion of people suffering from chronic diseases. While many chronic diseases can be avoided or delayed, they are expensive to treat when they do develop. Singapore has a higher suicide rate than many other countries, and mental illness is stigmatized. Similarly, the prevalence of obesity rates in Singapore is rising, especially among children and adolescents. And Singapore is addressing all these head-on.

During my visits to Singapore, I can’t help but see behaviour change signals everywhere, some subtle and some direct. Singapore’s health authorities appear to be working on a war footing to confront emerging health concerns by investing in exceptional health communication.

As a strategy and leadership communication professional, I consider Singapore’s approach to be an accurate implementation of “Health is a Human Right” and “Health in All Policies.”

When I decipher Singapore’s magical public health communication formula, I discover the following precious principles:

One, Audience: Understanding your audience is essential to any public health communication strategy. Who are you targeting? What are their concerns? What drives them? After knowing your audience, you may personalize your message. However, this requires leaving your cosy offices and connecting with people in their homes or workplaces. Public health authorities must likewise give up the idea that they know what’s best for people.

Two, Relevance: your message should address your audience’s worries. They should care about it and recognize how it affects them. In contrast to Singapore, which determines its agenda with limited foreign intervention, low-income countries frequently follow the priorities of their international donors.

Third, Credibility: your message should be founded on solid evidence and originate from a reliable source. As in Singapore, this is made possible by multi-sectoral collaboration. Four, Engagement: your message should be engaging and thought-provoking to captivate your audience. It should inspire curiosity and action. Five, Simple messaging: Your message should be easy to understand and avoid jargon and technical terminology.

Singapore’s health communication formula also includes using a variety of mediums to engage people, such as print, television, radio, social media, and public events. Use humour and storytelling to connect with your audience. Track your public health communication campaign’s performance to see what works and what doesn’t, as this helps campaigns improve over time.

Feedback on health messaging is critical to improve campaigns.

Collecting feedback from audiences on health messaging is critical to improving campaigns.

Singapore has many public health successes. Singaporeans’ rising Type Two Diabetes rate prompted the 2016 “War on Diabetes” campaign. The 2015 “National Steps Challenge” to promote physical activity saw fivefold participation by 2018. The government has created an extensive initiative to support firms of all sizes in obesity prevention and management, chronic illness management, mental health, and smoking cessation.

Singapore’s health initiatives’ interconnectedness is their beauty. The government works with the urban planning sector to design localities that encourage physical activity; with the transportation sector to promote public transportation and make it easier for people to walk, cycle, and use active modes of transportation; with the education sector to promote health education in schools and create a healthy school environment; and with the workplace sector to encourage healthy workplaces.

By linking its public health programs with other vital sectors, Singapore has created a more holistic approach to health promotion that benefits the entire population.

Understanding that communication is a means to an end is critical to Singapore’s health communication success.  Singapore’s health communication programmes are proactive, evidence-based and serve measurable health objectives—infrastructural investments back health campaigns. To give Singaporeans a place to exercise, relax, and mingle this “Planned City” features government-built 59 regional and 271 community parks. They usually have running, cycling, and inline skating paths that link to nearby parks. Parks have many outdoor workout stations. The government also provides healthcare subsidies. This guarantees quality health care for all.

Leadership by example is also a part of Singapore’s health communication strategy. It sends a strong message to the public that healthy living is essential when Singaporean leaders and top civil servants follow what they preach. This encourages better choices. Singapore’s leadership communication strategy frequently includes health and lifestyle messages, demonstrating their importance as a national priority.

What also helps is that Singapore has traditionally had stable governments with enough majority to expedite health-related legislation. The other significant and rare advantages that Singapore enjoys are – one, Singapore has a long history of electing highly educated and trained science political officials, due in part to the country’s emphasis on education and its commitment to developing a knowledge-based economy and two, the presence of an impressive number of self-made female professionals in high-decision making roles. This is recognized to lead to better representation of women’s interests, more diversity of thought, and more decisive leadership.

Why are so few Asian countries able to reproduce the basic recipe for effective health communication a la Singapore? Because corruption, nepotism, or political and bureaucratic greed come in the way.

Singapore’s public health ambassadors are chosen for their health advocacy, not political connections. Singapore’s health promotion platforms are not chosen for personal profit. Similarly, posters and brochures are printed in proportion to audience size instead of commission. Health authorities in many developing Asian nations have piles of obsolete printed material rotting in their warehouses.

Singapore’s performance suggests good governance and low corruption are necessary for effective health communication. Transparency International‘s Corruption Perceptions Index 2022 ranks Singapore fifth least corrupt country out of 180 nations. In 2023, the Chandler Institute of Governance ranked Singapore top in good governance, ahead of Switzerland, Finland, Denmark, Norway, Sweden, the Netherlands, Germany, the UK, and New Zealand.

International development and philanthropic health programmes in low-income countries need to learn from Singapore’s health communication excellence. In the absence of national-level good governance and the presence of high corruption perception among the population, investing in public health communications is bound to yield poor returns.

Donor funding for health communication is highly susceptible to corruption, causing anger over “failed” health promotion efforts and raising questions over donor credibility. So, unless international donor-development agencies want to mainly boost a country’s t-shirt, flex, and poster printing business or provide politicians with a health platform for self-promotion, the funding of health communication portfolios should be carefully reviewed.

Thank you, Singapore. Keep inspiring!

An abridged version of this article appears on page 4 in The Himalayan Times, Nepal, 9th August 2023.

Dr Sunoor Verma is a global health diplomat-practitioner specializing in strategic partnerships, high-level advocacy, and strategic leadership communication. He has supported the work of WHO, UNICEF, UNHCR, UNDP, ECMI and their leaders in building complex coalitions, communicating effectively and devising out-of-the-box solutions in development and humanitarian settings. He has also worked with Boston University, the University of Geneva and Cambridge University on programs that intertwine international relations, global health and conflict resolution.

 

Public Health debates we can ignore at our own peril

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public health

Global lessons learnt are not as valuable as we might think!

Having lived and worked in low-, middle- and high-income countries, I do not like sweeping ‘global lessons learnt’. The situational, cultural, and operational contexts based on countries’ income levels vary hugely. Moreover, the reports and recommendations from global apex bodies are often drafted by people from primarily high-income country experiences. Many of them may have never actually worked at the country level. Often their lexica are so watered down in assessments of low-income countries that severe reprimand ends up sounding like applause by publication. Without a scorecard system where each country would know where they need to improve to achieve standards, it is difficult to get a reality check. We, the low-income countries, have a choice to make. We can believe that we are high performers or quench our vanity, critically examine our performance, and take corrective measures.

The glaring gaps in public health that COVID-19 exposed

COVID-19 has exposed critical societal gaps across the globe. In the case of high-income-developed democracies, this means adjustments and fine-tuning. In the case of low-income countries, this has meant seeing a horrid picture in the mirror and the need for transformational change. So a natural enquiry would be-what has been happening in the business of Health Systems Strengthening over the years and billions of donated dollars later? We would have thought that SARS, Ebola, MERS, and ZIKA emergencies would have better prepared our health systems, but here we are.

This pandemic has opened some chronic societal wounds, especially in low-income countries. The top issue that warrants an urgent societal debate is what services are essential and must remain in the public domain and how we regulate the private sector. Many proponents for the rapid privatisation of public services in low-income countries are foreign experts. Their countries have achieved an equilibrium between top-notch public services and effective private-sector regulation.

Public Health, Corruption & Transparency

Corruption, lack of transparency, power asymmetry, and invisibility of women in decision-making all contribute to the complexity of public versus private debate in low-income countries. When lawmakers overtly or by proxy own significant numbers of private hospitals, mainstream media, and educational institutions, it becomes difficult to have an objective national debate. The COVID-19 pandemic has allowed us to rethink and reboot societal contracts. The pandemic struck when public trust in institutions- governmental, civil society, private sector, media, academia, and the judiciary was at the lowest after years of steady decline globally.

Public sector- the saviour during COVID-19

Suppose we reflect on the past two years of the pandemic in low-income countries. In that case, we will note that we turned to either the public sector organisation or the defence forces whenever we needed a timely nationwide response. For example, when students needed to be brought back from abroad in India, the then-national carrier Air India stepped up. When stranded migrant workers needed to return home, it was the Indian Railways that rose to the occasion. When liquid oxygen had to be mobilised, the public sector was at work again. Working around the clock to secure scarce supplies from other countries and securing evacuation permissions were diplomats who are public servants. On the borders, facilitating the movement of people, supporting testing, quarantine etc., were members of the border police, armed forces, and the police. Similar was the case with many countries in South and Southeast Asia.

Other rich countries, such as Germany and South Korea, responded robustly. Attribution to the ability of their governments to manage private-sector activity and essentially public ownership of critical health system elements. Their impressive testing capacity was thanks to public laboratories and the presence of industries that could supply the required safety equipment and chemicals.

The South and Southeast Asia neighbourhood

Some governments in Southeast Asia have managed to build public health systems that learn. So, lessons from SARS and Tsunami have fed into their preparedness systems, allowing them to respond efficiently and effectively. The city-state of Singapore has traditionally shown a proactive approach based on solid scenario planning and proactive public health communication. Within India, the response of the southern state of Kerala has stood out. Over the decades, Kerala has invested in health, education, and women’s empowerment. It has consistently adopted an evidence-based approach to decision-making on health matters. Theirs is a learning system that drew heavily on lessons from the NIPAH virus emergency not too long ago. Kerala has also avoided the black-and-white notion of Public or Private and established a successful public-private partnership model. The government of Vietnam efficiently diagnosed the regional situation and closed its borders. Similarly, they were swift in developing low-cost test kits.

Public Health and the private vs public discourse- an axis of national security too

The considerations that need to be at the centre of this post-COVID-19 public-private discourse are:

  • Re-evaluate and reign in the privatisation spree of health-related assets and services. Nurture back to health underperforming units through quick and transparent reform.
  • Two, Reboot and relaunch sensible and practical national health policies that serve the objective of achieving universal health coverage. These should not be a copy-paste of what middle- or high-income countries are doing but should be rooted in the realities of poverty, patriarchy, and emerging democracy.
  • Three, While the issue may appear to be of health, the scope of solution searching is well beyond the expertise or experience of health actors. The complexity of this matter warrants the leadership of the Ministries of Finance, Law, Commerce and Home. For example, supply chains, the rule of law during the lockdown, transportation of people, and labour issues related to health workers have solutions outside of health agencies’ remit.
  • Four, Governments must take the lead and regulate the private sector more effectively and transparently. While governing the somewhat more streamlined public sector may be more satisfying, the rapidly and wildly growing private sector needs aggressive regulation. In many low-income countries, this means enforcing the existing fantastic on-paper rules and not drafting new ones. Moreover, the hopelessness of data collection from private sector health providers, whether on testing, bed occupancy, oxygen availability, or mortality during COVID-19, has hampered many low-income countries’ effective and timely response.

Refocusing on the Health for All agenda

This public discourse requires us to open our eyes to what we witnessed in the last two years and set aside our ambition and vanity. Let us acknowledge the actual situation in our countries and not artificially push ourselves into a higher boxing category for mere prestige. Organic, home-grown solutions are needed now, not a collage of random international best practices. Instead of drawing lessons from countries in the region, we need to study states and provinces with similar challenges and partner with them. Cross-border areas should be of interest in standard solution searching.

Many glorious careers are built worldwide in the name of Health Systems Strengthening. However, COVID-19 has shown that not much strengthening may have happened. WHO’s “Health for All” agenda ought to remain our focus. However, the tools, processes and commitment need to be indigenous. Countries must bring their sharpest, most independent, and most fearless minds to this debate.

Let us not forget that health, education, and security are nation-building tools. Taxpayers will have little incentive to contribute their fair share if all these continue being disproportionately privatised. One can only imagine the threat to democracy this will pose.

About the Author

Dr Sunoor Verma is a global health practitioner. He has advised WHO, UNICEF, UNHCR, HUG-Geneva and Cambridge University on Strategy, Leadership Communication, Advocacy and Resource Mobilization. He is credited with setting up WHO’s communication portfolio from scratch in Nepal in the midst of COVID-19. He has set up and led the country and regional operations for the European Centre for Minority Issues in the Balkans. He has supported track two peace processes in Macedonia, Kosovo and Sri Lanka and emergency response to the Tsunami, Avian Influenza and COVID-19. He has taught Global Health at Boston University. He has curated partnership initiatives with Macedonia, Kosovo, Germany, Switzerland, Australia, and Nepal parliamentarians. He divides his time between the foothills of the Jura Mountains in France and Buddhanilkantha in Nepal.

Published in Nepal’s national daily Kantipur on 30 June 2022 in Nepali language. This is a translation with some additional text.