ESRC award team led by IDD's Nic Cheeseman

Contrary to expectations, bribery for health services in Uganda reduced dramatically from 2011 to 2015. According to the Global Corruption Barometer (GCB), almost half of all people who made contact with the health sector in Uganda in 2010 paid a bribe, but by 2015 the bribery rate among those who had made contact with the sector was just 25%. This is an almost unprecedented reduction, especially in such a short time frame.

Research from the University of Birmingham, University of Bristol, and University of Durham suggested that such a reduction was especially remarkable given that the bribery rates for all other sectors within the country had increased over the same period.  Based on how bribery rates for other sectors in the country had changed, the model used to identify the reduction predicted a less than 0.01% chance of health-related bribery reducing to the extent that it had in the sector.

The research conducted began with a novel methodology that uses simple regression analyses of sector-specific bribery rates, using the GCB, to identify potential ‘hidden’ positive outliers on bribery – sectors that outperform all other sectors in a country, including those that do so ‘against the odds’ in poor governance environments. The case was vetted by using a range of sources, including triangulation with Afrobarometer data, and included qualitative in-country fieldwork in three Ugandan provinces.

Why did bribery reduce in Uganda’s health sector ‘against the odds’?

The research points to an anti-corruption intervention that targeted bribery in the sector across the country: a newly created Health Monitoring Unit (HMU). Established by President Museveni in 2009, and led initially by his personal physician, the HMU is a highly visible institution with power to monitor and evaluate the performance of health facilities, including investigating instances of corruption. The HMU boasts an impressive list of achievements, such as recovering stolen medicines worth more than 30 billion Ugandan Shillings (USD84 million) and arresting over 600 healthcare workers and healthcare worker ‘imposters’. Of these, there have been over 100 convictions.

The most high-profile work of the Unit involves carrying out unannounced investigations at healthcare facilities. Based on a strategy of catching health workers ‘red handed’, and publicly ‘naming and shaming’ those that are caught, the HMU’s arrests of health workers are often accompanied by TV and radio coverage, shared widely on social media.  The health care workers interviewed in the research project, reported becoming more fearful of asking for or accepting bribes as a result of the HMU’s ‘name and shame’ approach in particular. This seems to have resulted in a dramatic shift in behaviour with regards to bribery. However, there is some evidence that bribery patterns are ‘reshaping’ rather than disappearing and that the approach may produce important unintended consequences.

Why this isn’t a clear success case & why this matters for anti-corruption interventions

The research suggests that while in the short-term the approach taken by the HMU seems to be delivering impressive results on reducing bribery, these results are likely to be unsustainable and need to be seen within the context of a corrupt and dysfunctional healthcare system. While it may be the case that the HMU disrupted bribery patterns, it has done little to address the perception that ‘informal payments’ are generally required to receive health care in a system grossly short of resources. The research project suggests that anti-corruption interventions need to address bribery’s underlying functions – such as low health worker salaries, for example – in order to achieve sustainable results.

The research also points to the need to consider other unintended consequences of the approach. In November 2017, for example, members of the Uganda Medical Association went on an unprecedented nation-wide strike that last over one month and brought the already weak health system to its knees. The strike was blamed in part on the HMU’s activities. As this research project – and research elsewhere – has found, staff morale is at an all-time low, with worrying potential impact on service delivery.

For frontline services, improved service delivery should be the goal, rather than simply reduced bribery. The approach taken by the HMU is not likely on its own to produce better service outcomes for patients.

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