Stakeholder Corruption: An Inexcusable & Unexamined Macro-threat to the Advancement of Global Health Governance

Introduction to the Problem of Global Health Governance Corruption

            The former United Nations Deputy Secretary-General Louise Frechette once proclaimed, “The solution lies not in turning one’s back on globalization, but in learning how to manage it.  In other words, there is a crying need for better global governance...” (World Health Organization, 2000). As the governance of global health issues shifts from a Westphalian to a post-Westphalian paradigm, in which both state and non-state actors respond to transnational health threats and opportunities, it has been increasingly salient to establish a unified understanding and vision of what global health governance exactly entails. The six dimensions of governance have been firmly established and applied to various international legal and business sectors: voice and accountability; political stability and lack of violence; institutional effectiveness; regulatory quality; rule of law; and control of corruption (Lewis, 2006). All of these indicators have been proven to influence the environment within which health care services function in both the developing and developed world, and yet governance indicators for global health have still not been adapted (Lewis, 2006). The integrity that global health governance is founded on is ensured by checks on the accountability and transparency of the thousands of governmental, private, and non-profit stakeholders that span the globe. Arguably the most inexcusable, preventable, and unexamined macro-threat to the state of global health governance has been the lack of legalistic mechanisms and socially just standards that hold these stakeholders accountable for the actions that both directly and indirectly influence the health of humanity. This most often results in rampant institutional corruption, or the exercise of public power for private incentives and gain. It has been noted that “bribes, corrupt officials, and mis-procurement undermine health care delivery in much the same way they do for police services, law courts, and customs whose functions become compromised by the culture of poor governance and corruption” (Lewis, 2006). Dr. Paul Farmer, MD, PhD, a world-renown Harvard physician and prophet of social justice, introduced the theory of “structural violence,” or the presence of powerful societal and governing forces that override individual knowledge and choice, and largely explains how institutionalized corruption has contributed to the widening gap in health inequities globally (Menon-Johansson, 2005). Craig N. Murphy further proposed that “contemporary global governance avoids attacking state sovereignty, favors piecemeal responses to crises, and has emerged at a time when creative intellectual leadership was not matched by courageous political leadership” (2000). As Murphy illustrates, two of the weaknesses in global governance, the absence of challenging the actions of sovereign entities and lack of “courageous political leadership,” have bred widespread institutional corruption, whether or not it was intended.

            The chaos that cripples global health governance is largely due to the failure of governments, non-profit organizations, donor, and private corporations from clearly defining and aligning their goals, objectives, activities, roles, and responsibilities when addressing a specific global health issue (WHO, 2000). Furthermore, the lack of incentives for strong sectoral performance are especially undermined by ineffective management, weak productivity, and poor performance (Lewis, 2006). Measures to analyze the performance of global health’s governing stakeholders simply do not exist, such as hiring qualifications (Lewis, 2006). The absence of monitoring the institutional and sectoral policies and actions of stakeholders have largely escaped scrutiny and censure, most probably due to the stagnant paradigm that any form of public service is morally justified and welcome (Global Health Reporting, 2008). Each type of stakeholder succumbs to its unique obstacles and challenges in terms of corruption. First, whereas the introduction of the corporate world in the field of global health has garnered increased funding, research, and development, it has also brought forth increased corporate authority in global health policy-making through intimate collaboration with international bodies, such as the World Bank (WHO, 2000). This opens the door for unchecked corruption among corporate players and uncertainty of their incentive to promote health in the developing world, especially due to their primary focus on profits rather than health as their outcome objective (WHO, 2000). For example, the World Health Organization has expressed its worry over the tobacco companies’ active involvement in the formation of global tobacco regulation policies, and has warned national governments about the industry’s potentially insincere motives (Collin et al., 2002). Second, in terms of donors as significant stakeholders in global health, “perceptions are powerful factors in shaping behavior. If investors perceive corruption or patients perceive poor quality, it discourages private investment or health demand” (Lewis, 2006). Thus, respected institutions and politically stable governments that base their global health efforts on integrity and transparency are more attractive to private investors and donors. Third, numerous non-profit organizations serve as channels of advocacy and lobbying for certain global health issues often with narrow agendas, and thus possess the potential of supporting governments and private organizations that submit to their needs, but engage in corruption to achieve goal outside those of the non-profit organization’s focus (Thomas & Weber, 2004). Finally, numerous governments lack the skills and/ or incentive to provide effective stewardship over their countries’ health systems. Universities, non-profit organizations, and the local media in developing countries may lack the resources to serve as effective regulators over both their government officials (Global Health Reporting, 2008). It is of utmost importance to note that the absence of governing accountability at the highest levels trickle down to the micro-leadership level of health systems. For example, health professionals and administrators may succumb to under-the-table payments due to low pay, irregular salary payments, lack of government attention, and the need to keep services afloat (Lewis, 2006). Thus, vulnerable patients must pick up the financial slack of corrupt governments who prioritize their personal wealth over the well-being of their constituents (Lewis, 2006).

Evidence of the Association Between Stakeholder Corruption & Poor Global Health Outcomes

             Although the association between government corruption and health has not been studied nearly as robustly as health’s connection to other macro-deficiencies, such as the absence of medical technology in the developing world, it is still an evidence-based one that needs to be highlighted. “Only governments sensitive to the demands of their citizens appropriately respond to needs of their nation” (Menon-Johansson, 2005). The three most influential dimensions of governance related to a country’s public health profile were government effectiveness, the rule of law, and corruption (Menon-Johansson, 2005).  Researchers have discovered that as governments become more ethical, fewer of their nation’s women die in childbirth, more physicians exist per population, access to clean water improves, and life expectancy increases among adults (Menon-Johansson, 2005). Studies have also illustrated that government corruption practices are correlated with health outcomes of child and infant mortality, the likelihood of an attended birth, immunization coverage, and low birth weight (Menon-Johansson, 2005). Improvement in governance also elevates the country’s Gross Domestic Product (GDP), as well as higher investment in health and education, compared to the military (Menon-Johansson, 2005). In addition, the success of public health spending in reducing child mortality depends on a government’s integrity rating (1-5 range based on level of perceived corruption), with higher integrity associated with lower mortality rates (Lewis, 2006). The infectious disease profile of many developing countries is also influenced by their governing standards, as it has been proven that HIV prevalence decreases as the governance improves for each governance indicator (listed previously), as well as mean governance (Lewis, 2006). In terms of specific national governments, Slovakia, Tajikistan, Bangladesh, India, and Sri Lanka rank as possessing the highest association levels between a weakened health care system and corrupt government (Lewis, 2006). A comparative study in five South Asian countries (Bangladesh, India, Nepal, Pakistan, and Sri Lanka) found that in all but Sri Lanka, most health service payments were made under-the-table to submit to the demands from providers, and bribes were mandated in all five countries for admission to the hospital, to secure a hospital bed, and to purchase subsidized medications (Lewis, 2006).

            A more subtle, but nonetheless threatening, level of governing corruption exists among private foundations as well. An unintended form of corruption due to the absence of global health governance monitoring can be exemplified by the most highly regarded private foundation in the field of global health, the Bill & Melinda Gates Foundation. Besides serving as the largest private donor for global health initiatives, the foundation’s advisory board members are included in the decision-making processes of almost all major global health governing institutions, such as the Global Health Council. However, unlike institutions such as the World Health Organization, it is excused from any form of democratic or political accountability (Global Health Reporting, 2008). One of the foundation’s most criticized acts of contradiction in promoting and harming the public health of a country was its investment in the Italian petroleum company Eni (Piller et al., 2007). The foundation garners huge financial rewards from its investments in a company that has initiated an epidemic of adult bronchitis, childhood asthma, and blurred vision among children due to the fumes and soot from over 250 toxic chemicals that are released from its towers (Piller et al., 2007). It was discovered that the Gates Foundation contributed $218 million towards polio and measles immunization and research worldwide, but has invested $423 million in oil conglomerates such as Exxon Mobil Corporation and Chevron Corporation that causes pollution levels in developing countries that surpass standards set in affluent countries (Piller et al., 2007). Researchers also revealed that hundreds of investments by the Bill & Melinda Gates Foundation, totaling at least $8.7 billion (41% of its assets), have been entrusted to for-profit institutions that counter the foundation's socially just goals and philosophy (Piller et al., 2007).

Recommendations & Possible Solutions

            At the epicenter of devising a potential solution to the non-existent regulatory mechanism for global health governance is the principle that “global governance cannot replace the need for good governance in national societies. In fact, in the absence of quality local governance, global and regional arrangements are bound to fail or will have only limited effectiveness. In a way, governance has to be built from the ground up and then linked back to the local conditions” (Lewis, 2006). Thus, since few top-down approaches have proven to be effective in curbing stakeholder corruption levels in global health, the solution may lie in first assuring that corruption ceases at the micro-levels of a country’s health care system. Community-driven campaigns, social media efforts, and community-based organizational advocacy efforts must be implemented in order to hold governments and large institutions from slipping into intended and unintended forms of corruption and misalignment of actions with the needs of patients and communities. Only then do citizens possess the power to monitor its government and corporate capacity to implement sound policies, manage health resources, and provide services efficiently and ethically (Lewis, 2006). For sustainable change to take effect, international legal measures must be coupled with grassroots initiatives, which has been a largely unexplored area for the formation of ensuring governance standards are met by each country (Taylor & Bettcher, 2000).

Works Cited

Bulletin of the World Health Organization (2000). Global public-private partnerships: part II-what are the health issues for global governance?; 78(5).

Collin J, Lee K, Bissell K. (2002). The framework convention on tobacco control: the politics of global  health governance. Third World Quarterly; 23(2): 265-282.

Lewis, M. (2006). Governance and Corruption in Public Health Care Systems. Center for Global       Development; 78: 3-57.

Menon-Johansson, A.S. (2005). Good governance and good health: The role of societal structures in the  human immunodeficiency virus pandemic. BMC International Health & Human Rights; 5(4): 1-10.

Piller, C., Sanders, E., & Dixon, R. (2007). Dark cloud over good works of Gates Foundation. Los Angeles   Times. Retrieved March 28, 2009, from < style="mso-spacerun: yes" class="Apple-tab-span" style="white-space:pre"> gatesx07jan07,0,6827615.story>.

Taylor A.L., & Bettcher D.W. (2000). WHO Framework Convention on Tobacco Control: a global “good” for public health. Bulletin of the World Health Organization. 2000; 78(7): 920-929.

The Global Health Landscape (2008). Global Health Watch: An Alternative World Health Report. London: Zed Books; 210-239.

Thomas, C. & Weber, M. (2004). The politics of global health governance: Whatever happened to "health for all by the year 2000"? Global Governance: A Review of Multilateralism and International   Organizations; 10(2), 187-205.