Covid-19: an ongoing crisis

Covid-19 has reinforced vulnerabilities worldwide. It has threatened people’s health and well-being, shattered health systems, exacerbated poverty and inequality, limited children’s access to education, and negatively impacted economies.989c8c959ee4 Blindfolded by their lack of knowledge about this disease, governments’ efforts to contain Covid-19 once and for all have been limited at best.

Between January 2020 and October 2022, the pandemic illustrated the challenges of collective action by the global community to face common threats. These included the misuse, hoarding, and price gouging of vaccines, medical products, and equipment. The emergency, coupled with insatiable demand for these products and shortages, left supply chains vulnerable to abuse.6c37ba471d09 Advance-purchasing agreements for products such as personal protective equipment (PPE) and Covid-19 vaccines transferred risks from suppliers to buyers, contributing to overbuying and overpaying.6c6a98edbdd8 The Covax initiative, which engaged in pooled procurement to reduce costs and ensure equitable distribution of Covid-19-related products in low- and lower middle-income countries, had a limited impact because of a lack of timely financing.27fc6922d29c

When it came to Covid-19 vaccines, hoarding, wastage, and unnecessary boosting were common practices. By December 2021, around 20% of vaccine doses administered were boosters.20ed73957c70 By July 2022, only 58 countries had reached the World Health Organization’s (WHO) commitment to inoculate 70% of their population. In low-income countries, just 16% of eligible adults had completed two-course doses.6990e06e0d15 The distortions in the global supply of vaccines have been such that the WHO no longer expects countries to reach this commitment. Instead, it now calls for prioritising the vaccination of all health workers and people older than 60.30babf171fc9

At present, the world is facing other pressing challenges. The war in Ukraine has led to a large influx of Ukrainian refugees across Europe and impacted global food security, energy prices, and energy supply security.37168d971b30 Climate change has unleashed extreme weather events, with droughts and floods displacing millions of people and killing many others.a1e73318f578 Between these two emergencies, Covid-19 had killed more than 6 million people globally by October 20221fd591f4f651 and is evolving into more transmissible variants capable of evading the body’s immune response.d036dce5cbfe

The global response to Covid-19 is far from over. Just as the world transitions to accept Covid-19 as a long-term disease, the approach of the Access to COVID-19 Tools Accelerator (ACT-A), a multilateral initiative to address the Covid-19 pandemic, is also set to change. ACT-A will now place more attention on increasing procurement of and improving access to treatments. Procurement corruption, along with other forms of corruption such as diversion, theft, and the proliferation of substandard and falsified medical products, remains a latent risk.f5d841963b1e

Addressing corruption in pandemic and emergency contexts is vital to minimise losses and ensure that resources achieve their intended aims. Governments have allocated substantial resources to address the Covid-19 crisis and will continue to do so as the virus evolves and causes periodic flare-ups of infections and deaths. Additionally, diseases such as polio,c89f0b1188b4 tuberculosis,615ec658ef7a Ebola,2d9723ede041 and monkeypox847273bc763e have taken a greater toll on public health this year, requiring further funds. These resources have been and will continue to be susceptible to corruption, with deleterious effects on the world’s most vulnerable people. Documenting how and why Covid corruption happened, as well as assessing anti-corruption efforts during this crisis, should inform local, national, and global health decision-making for present and future health emergencies.

This report summarises research on Covid-19-related corruption in the health sector conducted by U4 between January 2020 and October 2022. It illustrates how corruption, including fraud,5e511f36558f materialised in Covid-19 responses. It also recounts the drivers of corruption, explains how Covid corruption impacted people, and elaborates on anti-corruption strategies deployed. The report concludes with lessons learned for minimising corruption during health crises.

Methods

The report is based on desk-based research. It summarises findings on Covid corruption trends, drivers of Covid corruption, the impact of Covid corruption on different population groups, and anti-corruption efforts during Covid-19. The sources are media articles, as well as reports from state and non-state institutions, from January 2020 to October 2022. Further research on this subject would benefit from stakeholder interviews and focus groups. Doing so may highlight the prevalence of additional corruption manifestations and drivers.

Trends and manifestations of Covid-19 corruption

While Covid corruption obstructed health systems across the world, it placed a heavier burden on the already-strained health systems in developing countries. Aid-recipient countries had chronic systemic weaknesses, which meant that they required ongoing financial and technical support.b6538885b4f7

Nonetheless, all countries – regardless of their income level – struggled to cope with increasing demand for quality health services and a limited supply of medical products, services, and personnel. The result was a wave of corruption-related incidents across all key building blocks of health systems: service delivery; health financing; governance and leadership; medical products, vaccines, and technologies; health management information systems; and human resources.

Petty corruption in service delivery

Between 2020 and 2022, countries from all income levels faced similar incidents of petty corruption:

1. Sales of falsified Covid test certificates were found in South Africa,14f179663158 Lesotho,a59b8266b946 the UK, France, and Spain.ddd324b75e05 There were also allegations of patients bribing healthcare staff to get falsified certificates in Singapore30961ea23817 and Australia.8620cadd5b50
2. Bribes and queue-jumping to access Covid-19 vaccines were widespread. In Lebanon, leaders were found bribing their constituents with free Covid-19 vaccines ahead of the 2022 elections.e438d17a1930 Queue-jumping from politicians, senior and high-level government officials, as well as wealthy individuals, happened in Malaysia,65be6c4319a4 the Philippines,896d8dcd2e8d Peru,3f423a4ded2d Argentina,3045de2a32e4 Spain,b81625d91fd8 Poland,fd5be9e27aae Canada,506258af214a and Ecuador.a1dbdfef6f1c
3. Price gouging and profiteering rose in critical times when Covid infections peaked. At its worst wave in 2021, India witnessed profiteering amid the oxygen crisis,5a788c8c4395 a rise in hefty feesb3a15f0c584c to access hospital beds, as well as artificial scarcity8e39351b9434 for such beds.In Peru, the police arrested several health workers, who charged up to US$21000 per bed for critically ill Covid patients in a state-run hospital.48101bf7d415
4. In Venezuela and Iran,9fb11c842851 the government’s slow and unclear rollout of vaccines left many desperate to get Covid-19 vaccines on the black market. In the Venezuelan state Lara, at least 2,000 people were inoculated with jabs made of boiled water, antibiotics, and analgesics, at a cost of US$100–450 each.7308871290dc

Procurement corruption and embezzlement affecting health financing

Procurement corruption prevailed as one of the most common types of Covid corruption. In Africa alone, approximately US$1.78 billion was allegedly spent and lost in corrupt procurement deals in Cameroon (333 million), Malawi (1.3 million), South Africa (910 million), Kenya (541 million), Nigeria (96,000), and Uganda (528,000).017468b4b1b8 In Malaysia, the Anti-Corruption Commission opened 25 investigations over alleged corruption in Covid-19-related procurements and the distribution of aid and stimulus packages during the pandemic.e12de2705416 In the UK, almost two-thirds of contracts related to the purchase of personal protective equipment (PPE) were awarded to firms that were part of a special ‘VIP lane’, without following due diligence.24f5a830ccb1 Transparency International Global Health uncovered 3.7 billion pounds worth of contracts warranting further investigation.1b904dd317fd

Corruption was also prevalent in the procurement of Covid vaccine doses. For example, Bangladeshi activists found large discrepancies in what the government was paying for the Sinopharm vaccine: a government committee approved the purchase of 15 million doses at US$10 per dose, but a separate order of 3.15 million doses cost the government US$100 per dose.2c29014d5605

Additionally, large amounts of Covid-19 funds were allegedly embezzled, mismanaged and/or not accounted for in several countries, including Afghanistan (US$27,000),dc91bfd3c869 the Democratic Republic of Congo (US$357 million of Covid funding awarded by the International Monetary Fund [IMF]),80a7de7e8889 and Cameroon (US$333 million).308fdc70f7b1

Grand corruption weakening health governance and leadership

State capture siphoned off much-needed resources from the Covid response. In Viet Nam, foreign ministry, tourism, air, medical, and manufacturing officials were arrested over allegations of multimillion dollars’ worth of corruption scandals and mismanagement of Covid funds. They charged astronomical fees for repatriation flights and pocketed almost US$240 million, fixed prices for emergency healthcare and equipment, and violated regulations on bidding.192b35782c3d In another case, the company Viet A was found to be exerting undue influence on policy decisions made by the Ministry of Health, central and local governments. They paid US$35 million in bribe ‘bonuses’ to health and hospital officials. In return, Viet A earned US$175 million in revenue from winning bids and selling overpriced Covid-19 testing kits.57ef12add91f

In Brazil, Covid corruption implicated members of Jair Bolsonaro’s administration (2019-2022) and key allies.a23b68529a02 The Senate inquiries uncovered officials from the Ministry of Health attempting to buy the Covaxin vaccine, which had not yet been approved by the Brazilian government, through intermediate buyers, at above-market prices. Additionally, the Ministry of Health’s previous head of logistics was found to be requesting a US$1 kickback on each AstraZeneca dose offered by US-based Davati Medical Supply, a company that did not represent AstraZeneca and could not deliver on the deal.3b55387c19fe

In several countries, former ministers of health and other high-level government officials were arrested because of their involvement in Covid-related grand corruption schemes:

• Kyrgyzstan’s minister of health was arrested for wasting US$18.8 million on the purchase of unnecessary Covid-19 vaccine doses. The payments were allegedly made to offshore accounts.a902f3e1ac32
• Zimbabwe’s minister of health was detained over corruption allegations in the procurement of Covid tests and medical equipment, amounting to US$60 million in 2020.76ac7e7c227c
• The minister of health from the Democratic Republic of Congo was placed under provisional arrest over alleged embezzlement of more than US$7 million destined for the Covid-19 response in 2020.3126e06d9a3c
• South Africa’s Gauteng health department chief financial officer faced a Special Tribunal hearing for her role in the procurement of PPE contracts, worth more than 42.8 million rand.ebd20e001b3a
• Bolivia’s minister of health was arrested over allegedly buying overpriced ventilators, each at a price of US$27,683 despite its real cost being US$10,312–11,941 in 2020.8081b1dddb5e
• The former Head of Inversión Estratégica de Honduras (INVEST-H), an organisation tasked with Covid-19 emergency procurement contracts, was sentenced to nearly 11 years in prison for wasting money purchasing overpriced and useless mobile hospitals.2e0bfefed039

Additionally, a recent study found that many Covid vaccine manufacturers engaged in state capture when they demanded indemnification from national governments in developing countries. This led to several low and middle-income countries (LMICs) changing their legislation to cater to manufacturers’ demands. The result was the stalling of vaccine access in these countries.ef093dc69c7b

Growing black markets, falsified medical products and lack of clinical trial transparency

Fake vaccination schemes and falsified vaccines and other medical products proliferated in black markets during the pandemic. Falsified versions of Covid-19 vaccines were found in Mexico, Poland,cb626860f29a Iran,11d2ec254ece India, and China.57c78843d888 Schemes to sell falsified records of Covid-19 vaccine status were discovered in Saudi Arabia,a100d6a69763 Canada,8f7df4473014 Hong Kong,ac44d3cbc99c Germany,bb8ca929c180 and the US.873b5d677cf0 Worldwide, there was a 257% increase in fake vaccination cards being sold online via the Telegram app, with this corresponding to the peak of Covid-19 cases due to the Delta variant.3db5babc18a6

Additionally, the manipulation of clinical trials for Covid-19 vaccines eroded public trust and endangered people’s access to safe and good-quality health products. A 2021 report from Transparency International analysed 85 registered clinical trials for Covid-19 vaccines and found that only 12% made their clinical trial protocols public. This meant that there was no information available on how the trials had been run.f3468f88f513 There is evidence that this lack of transparency provided room for malpractice. For instance, a whistleblower who was part of Pfizer’s clinical trials in Texas reported to the British Medical Journal (BMJ) that: ‘The company falsified data, unblinded patients, employed inadequately trained vaccinators, and was slow to follow up on adverse events reported in Pfizer’s pivotal phase III trial.’5e8c4906f209 In Peru, a Sinopharm’s clinical trial was suspended before its completion after allegations of queue-jumping by elite groups from the government, the Catholic Church, and the private sector came to light. The government confiscated all remaining doses, and several legitimate volunteers were ‘left in the dark’, unable to get a second dose or find out if their first dose had been a placebo. Unvaccinated volunteers were not given adequate follow-up and protection by the institutes conducting the trials, in an apparent breach of trial protocols.141903538d18

There was also evidence of duplication, weak clinical trial reporting and research waste in clinical trials focused on Covid-19 treatments. In the spring of 2020, about 247 clinical trials testing hydroxychloroquine’s potential to prevent or treat Covid-19 competed for the same patients. None of them managed to get a large, representative sample. Their lack of coordination contributed to statistically insignificant results, as well as duplication of research.929d953a0ead In the same year, a report of clinical trials for favipiravir, another drug tested for Covid-19 treatment, found that more than 85% of trials completed worldwide did not publish their results on trial registries.1acdbe10e460 This ‘prevented pooling of data and conducting meta-analysis to generate conclusive evidence to support recommendation of Favipiravir use in Covid-19 or know about its safety and efficacy profile’.847bb4c5731d By June 2020, 1,516 trials, which was 40% of a total of 3,754 completed trials on different drugs tested for Covid-19 treatment, had not made their results public, either on the trial registries or via academic outlets.8481d91c1371

The quality of some medical products for Covid-19 treatments was dubious, representing a health risk for different population groups. In 2020, an academic study highlighting the benefits of ivermectin – a drug used against parasites – in treating Covid-19 was taken down due to ethical concerns. Several paragraphs in the study were plagiarised, its raw data contradicted the study’s protocol on many occasions, and there were at least 79 patient records that were clones of other records.50ee03d07dfe In 2022, fake versions of Merck’s oral antiviral drug, molunpiravir, were found worldwide. Sellers in an online market website disclosed their ability to daily dispatch their falsified products to the US, Chile, Peru, Colombia, and Brazil.d523e0170e24

Data manipulation and misuse affecting health management information systems

Governments manipulating data on Covid-19 infections and death rates created a mismatch between reality and official accounts in several countries, including Brazil, India, the Philippines, Tanzania, Zambia,75dec20d59aa and Venezuela.a93bcb261643 This contributed to resource misallocations, worse spikes in infections, and increased mistrust in governments’ capacities to tackle the pandemic.

Covid-19 datasets could be shared and traded at large scale, increasing the risks of unscrupulous actors using this information for personal benefit and with no medical consideration.e777baf65896 In Latin America, the Covid-19 Observatory of AlSur Coalition found that most technological initiatives in 14 Latin American countries processed personal and sensitive data without a proper assessment of legality, necessity, and/or proportionality in their impact on human rights.89e2c11d58f4

Opacity and corruption in health workforce governance, recruitment, and management

A highly qualified, motivated, and supported health workforce is essential for an effective response to health emergencies. However, corruption in the health sector contributes to the recruitment of staff who are unqualified to respond to a crisis.dd6cdfab91bb Staff recruited through the back door are, in turn, less likely to report corruption and mismanagement. A study in Nigeria found that healthcare staff hired on unmeritorious grounds were unable to challenge hospital management when corrupt acts like PPE hoarding occurred during Covid-19.9686d5751a51

Corruption in the management of Covid funds and procurement of Covid-related medical products and equipment also had a detrimental impact on healthcare workers’ safety, morale, and ability to provide quality care. In Nigeria, doctors and nurses reported that allocated resources announced by the government never translated into improving their working conditions. As a result, many deliberately avoided treating Covid patients.f422b23e3f5b In Kenya, healthcare workers protested over the government’s failure to protect them. A 2020 investigation found the government had mismanaged US$70.4 million.5c0749d32137 Transparency International’s worldwide network of Advocacy and Legal Advice Centres (ALACs) received several complaints from healthcare workers based in the Democratic Republic of Congo and Venezuela for obliging them to work with little or no pay, and in Ireland over fears that their employers were not implementing sufficient safety measures.4617ae07c257

Health workers in these contexts might engage in ‘functional’ corruption to protect themselves and/or secure a minimum living wage. During Covid-19, corrupt acts ranged from stealing PPE and selling it on the black market for a profit, to asking for bribes from patients and illegal absenteeism. The theft of medical products from hospital facilities was heavily documented. In Uganda, the Kampala Capital City Authority was asked to account for 21,000 Covid vaccine doses that went missing.6c460a5de88e In Rwanda, eight health workers were arrested for allegations of stealing testing kits and Covid-19 vaccines.e9fd25a7aef1 In Ghana, hospital staff stole and sold personal protective equipment for personal profit.2577de78259a

Corruption drivers during Covid-19

Corruption drivers are critical gaps in national, regional, or international political, economic, and social settings, which enable corruption risks to manifest. The relative importance of these factors depends on the corruption problem in question.91c08fa53673

Economic drivers

Increased financing and limited absorption capacity

Emergency scenarios call for expedient government responses, which may come at the expense of transparency and accountability. Health procurement is an area particularly vulnerable to this. From the start of the outbreak, governments were pressured to respond. However, their limited capacity to manage large amounts of Covid-related funds led many of them to bypass normal procedures at times, relaxing regulatory, budgetary, and accounting safeguards. This increased the risks of diversion and mismanagement, and limited governments’ ability to negotiate prices with suppliers.175472079e4c Failures in ensuring procurement transparency enabled opportunities for undue influence, bribery, price gouging, and the proliferation of substandard and falsified medical products.bf7f8db673e8

Increased demand and limited supply

The pandemic increased the demand for acute and critical care, personal protective equipment, essential medicines, vaccines, ventilators, and diagnostics. Governments, however, struggled to meet these demands, especially at the start of the outbreak.5425b42f485e The pandemic also exposed health systems’ vulnerabilities that existed prior to the pandemic.7af64de7bf4c

As the global demand for medical products rose, supply chains struggled to deliver. For instance, the Covid-19 vaccine supply chain faced significant challenges due to a limited number of vaccine manufacturing companies, inappropriate coordination with local organisations, lack of vaccine monitoring bodies, difficulties in monitoring and controlling vaccine temperature, vaccination costs, and lack of financial support for vaccine purchase.b963f665c71c Desperation provided fertile ground for corruption: cases of overpriced medical services and equipment, bribery, vaccine queue-jumping, favouritism, and nepotism emerged as a result.5e11fa4deae3

Political /institutional drivers

Poor preparedness and planning

Covid-19 exposed serious vulnerabilities in pandemic preparedness and response plans. There was limited capacity to: properly conduct surveillance to detect pathogens and modelling to see how the virus spread; enhance public health guidance and communication; and develop therapies and vaccines.67cf3649d42b The successful implementation of Covid-19 vaccination campaigns depended on the resilience of countries’ supply chain systems. These systems needed to ensure ‘effective vaccine storage, handling, and stock management; rigorous temperature controls in the supply chain; and the maintenance of adequate logistics management information systems’.8770eae3675c Among the reasons why vaccination campaigns were slow to deliver in Sub-Saharan Africa was the region’s poor trade and logistics capacity. The short shelf-life of some vaccines meant that poor transport logistics could increase the risk of delivering unusable vaccines.5f6b81172115

Previous and endemic corruption contributed to weakening health systems’ preparedness for health emergencies. An exposé from an independent digital newspaper in Colombia, La Silla Vacía, revealed that the theft of US$6.7 million by a state official, which was destined to provide healthcare for an indigenous group before the pandemic, could have been used to buy between 241 and 322 intensive unit beds and ventilators during the pandemic.407d3a231529

Impunity trends

Lack of, or poor, accountability and poor enforcement measures enable an environment for uncontested impunity. In December 2021, Zimbabwe Anti-Corruption Commission expressed concerns about the slow pace of corruption cases in the justice delivery system.83a5fbaa2380 In March 2022, the Africa Criminal Justice Reform Unit reported that the number of corruption convictions against government officials in South Africa had more than halved. Among the cases with missing responses in 2020/21 financial year were 386 relating to Covid-19 procurement corruption.74976e46187d Although the National Prosecuting Authority (NPA) pointed to the Covid-19 restricted environment as the cause for slow progress, the Africa Criminal Justice Report still found worrying trends in the NPA’s performance: ‘a decline in overall throughput, a reliance on guilty pleas, a reliance on minor offenses to beef up numbers, and large numbers of cases processed through the unregulated alternative dispute resolution mechanisms’.6b9b2b2128c7

Lack of transparency

The lack of transparency along the vaccine value chain – in research and development, manufacturing, distribution, and contracting – is largely to blame for the unequal distribution of Covid-19 vaccines.e3b28f10c13e A 2022 external evaluation of ACT-A found that it compromised on accountability and transparency in its interventions. ACT-A failed at tracking and communicating results, as well as making decision-making, allocation of resources, and reporting transparent. Although data-tracking systems existed, they were set up in an ad hoc manner by different agencies.353f777ee00f

Similar patterns are found at the national level. In Ghana, Transparency International conducted a corruption risk assessment and found that real decision-making over Covid procurement contracts had been opaque.c1a6db577ac7 In Madagascar, the lack of legal frameworks for public financial management in emergency situations led to confusion about responsibilities and a lack of accountability.8d870c67a618

Breakdown of safeguarding systems

Without proper protection, potential whistleblowers are deterred from reporting mismanagement and wrongdoing. Whistleblowers can face reprimands in their workplaces, and sometimes loss of their livelihoods. In India, the Kerala Medical Service Corporation Limited sacked officials who reported fraud over emergency purchases at the beginning of the pandemic.9f5f57b81c2a Whistleblowers’ lives are also endangered, as the killing of Babita Deokaran shows. Ms Deokaran was the Gauteng health department finance manager, and her assassination was presumed to be the result of her involvement as a key whistleblower in an investigation of PPE fraud in South Africa.a24e6e933a10

Poor management of conflicts of interest

Having a conflict of interest is not an act of corruption. Not disclosing it and acting upon it for personal benefit is. In 2020, media reports from the UK denounced the government’s unwillingness to publish the conflicts of interest from advisers to the coronavirus Vaccine Taskforce. Many of them had financial interests in pharmaceutical companies receiving government contracts. For example, adviser John Bell had around 773,000 pounds sterling (£) worth of shares in Roche, which was the same pharmaceutical company that sold the government £13.5 million worth of antibody tests in May 2020.43f62ae80c69

Poor and unreliable data information systems

The scarcity of reliable information contributed to worsening Covid-19 corruption. An investigation found that reporting disincentives and a lack of consensus in all steps of data collection were among the reasons why China could manipulate its Covid data and claim a questionable low death toll – almost 62 times better than Australia’s by late 2021.812ff255051d

Social drivers

Constrained civic space during the pandemic

When the outbreak started, civil society organisations faced several challenges to hold governments accountable, monitor their performance, advocate for people’s rights, and promote citizen participation. Continuous lockdowns, social distancing, and other quarantine measures limited their ability to access information, and conduct community meetings, social audits, and group sessions.d086caaafb27

Civil society organisations and other non-state actors, such as the media, require free civic space to conduct their monitoring and reporting work. Yet, several governments extended executive powers, reducing the scope for bottom-up accountability. In 2021, 123 developing countries enforced 254 new legal frameworks related to Covid.5614d15cb116 These included measures that heightened repression and curtailed access to information laws.87b225b76ae9

Social pressures and desperation

In many countries, existing social pressures to respond to family and friends’ needs, coupled with the anxiety over poor pandemic preparedness and planning, served to justify different forms of corruption. These included favouritism in access to Covid treatments, nepotism in contracts, and vaccine queue-jumping of family and friends. For example, several doctors in Norway broke state guidelines to ration medicines and wrote prescriptions for families and friends at the start of the pandemic.eb851244c268

How Covid corruption impacted people

In both emergency and non-emergency scenarios, it is marginalised groups who struggle to access quality healthcare. These patterns have prevailed during Covid-19. In South Africa, for example, surveys conducted by the Human Sciences Research Council revealed that black South Africans and rural populations were less likely to be vaccinated than their white and urban counterparts. The reason was the lack of accessibility: vaccination sites were usually located in inaccessible locations for people living in rural areas or informal urban settlements, while government communications were mostly in English, despite it being a minority language. Information provided online also did not reach those without access to the internet and pop-up outreach units were inadequately publicised.19651cdd8d08

Inequality in healthcare access also left marginalised groups more vulnerable to Covid corruption. Their experiences included being victims of bribery, overcharging, sextortion,309d2d9c080b and having to make other informal payments in exchange for healthcare services, including Covid care.d225cb7af2d0 They also experienced having limited access to quality medicines and were more prone to acquiring substandard and falsified medical products on the black market.60351ecf9104 These experiences put a significant strain on their ability to exercise their right to health.651fd0648ab9

Covid corruption had an acute impact on women, because of gendered power differentials and the large role they play in providing care for their families. As patients and caregivers for infected family members, women had a higher likelihood of being the ones in contact with public service providers, making them more vulnerable to corruption. In Zimbabwe, women reported being sexually extorted to access water. In Nigeria, women were arrested and abused by the police over minor Covid-19 infractions.46f109fe196d In Mexico, half of the extortions women faced when trying to access public services during Covid-19 happened in the health sector.7ac2dbf28933

Additionally, women represent 70% of the workforce in the health sector. They also occupy a large share of the service industry and the informal economy.27860f7c4c78 Despite this, women were underrepresented in decision-making bodies.f8498d6c6135 Corruption also left a large proportion of women unable to protect themselves from Covid-19. With Covid funds mismanaged or embezzled, and procurement contracts for personal protective equipment rigged, many countries struggled to ensure a constant supply of high-quality equipment and medicines.

Women and their children’s healthcare needs also suffered because of Covid-19. The diversion of public resources away from services such as maternity and obstetric care, vaccination, and other forms of primary healthcare put their lives at risk and made them more vulnerable to corruption.9ed1cc739e0f While Zimbabwe’s health system struggled to cope with rising Covid-19 infections, pregnant women were being forced to bribe healthcare workers for delivering their babies.fa0abbb07f10

Strategies deployed to address Covid-19 corruption: what worked and what didn’t?

Between 2020 and 2022, there were several local, national, regional, and global efforts to address Covid corruption. This section assesses some anti-corruption initiatives identified across the health system building blocks.cba2414e2adf

Service delivery: tackling petty corruption with tech-based solutions

India experienced a rise in large fees and artificial scarcity of hospital beds during its worst wave in April 2021. In May 2021, technologists and bureaucrats from Bengaluru were tasked with transforming the Covid Hospital Bed Management System (CHBMS) into a unified dashboard to combine information on bed management, private hospitals’ information management systems, and information on oxygen and ambulance availability. The aim was to increase transparency and reduce the scope for fraud, including ‘bribe-for-bed’ scams.a9fbda623b27

By July 2021, the dashboard showed that 70% of the beds reserved for Covid patients were vacant. However, the numbers were not consistent with the actual figures on the ground, suggesting problems in maintaining real-time updates. Additionally, some healthcare institutions providing Covid care were absent from the dashboard and there were complaints about private healthcare providers denying Covid treatment.f6e0ea6940f1 A 2022 research study found that only 23 out of 36 subnational governments reported vacant bed availability. Without national guidelines, there was no accountability mechanism to ensure subnational governments provide granular reporting.9c19182ba241

The adoption of tech-based solutions to tackle petty corruption, such as bribes and theft, has increased in LMICs, and there are some excellent examples of innovation.b6d7c838eff4 Yet, their effectiveness depends on how their design responds to the problem at hand in a particular country context and if the technology is supported by measures that ensure digital insights are turned into action.5a09f11b4ff5 In the case of India, the lack of national guidelines and measures to secure real-time reporting and hold state governments accountable limited the dashboard’s potential to reduce bribe-for-bed scams.

Health financing: the role of civil society and financial management information systems in reducing corruption in procurement and overall spending

Anti-corruption interventions in health financing can benefit from bottom-up approaches. Civil society, for example, can play a complementary role as a watchdog to monitor procurement processes. In 2020, Argentina’s Transparency International Chapter, Poder Ciudadano, launched a Covid-19 Public Procurement Observatory, which made procurement contracts’ information available to the public.b0b126f4096a By October 2022, it had tracked more than 1,400 procurement deals worth US$185 million.6c85c3e86dcb The Observatory findings revealed a greater discretion in procurement processes, a lack of uniform criteria for the publication of information, and an overall disregard for minimum transparency requirements.05ae72d5db4b

While civil society can play an instrumental role in demanding more accountability of government expenditures, top-down approaches are also key for enhancing transparency. Several countries enhanced their institutional capacities to track Covid spending. Rwanda prepared specific Covid-19 codes to track expenditures along the spending chain within its comprehensive financial management information system (FMIS). Pakistan and Benin created additional information systems to complement their FMIS and better monitor their Covid-19 funds’ activities and spending.81998f6e1a11 Sierra Leone launched a Corona Virus Disease Response Transparency Task Force to secure integrity in the use of funds and conducted real-time audits of the emergency funding allocated to Covid-19.e78003f20b54

Sierra Leone Audit Service’s experience demonstrates that it is possible to enhance public health financing over time in fragile states.1877f35aad27 In both Ebola and Covid-19 health emergencies, the Audit Service has had the authority, supported by the constitution, to engage in real-time audits. This enabled the recovery of stolen assets post-Ebola, and the dissemination of key information on financial mismanagement – in collaboration with civil society – during Covid-19. By May 2022, the Anti-Corruption Commission had used the audit findings to start investigating allegations of corruption. While it is too early to assess the wider impact of Covid audits, what is clear is that Sierra Leone has provided its national supreme audit institution with a clear mandate and sufficient authority to conduct independent audits. The success of these audits has depended on whether the Audit Service approaches them with a flexible mindset, accommodating emergency settings and circumstances.57c76cee56ed

Health governance and leadership: enforcing the law to address state capture

In countries where investigation processes and law enforcement happen slowly and sporadically, grand corruption and state capture largely contribute to a culture of impunity. While enforcement measures can be as important as preventative ones to address grand corruption risks, they are not sufficient without an overhaul of the state’ modus operandi.

Throughout the Covid-19 pandemic, several former ministers of health and other high-level government officials were arrested (to see specific country examples, refer to the section on grand corruption). Their efficacy in deterring other state actors from engaging in corrupt acts, however, was limited in countries where endemic corruption had already weakened executive and judicial institutions. For example, after Zimbabwe’s former Minister of Health, Obadia Moyo, was sacked from office, charged, and detained over serious Covid corruption allegations in 2020, he was acquitted in 2021 on the basis that the allegations were imprecise.de4fcb63517b Journalists and political activists claimed that the case by the state was made deliberately weak to free Mr Moyo from any responsibility. This reflected the government’s adherence to a ‘catch-and-release’ policy – a clear representation of state capture.ff1505a34d0e

Addressing state capture requires substantial reforms across executive, legislative, and judicial powers, a better internal organisation of the political system, and accountability measures to be in place to regulate the relationship between state and business.f2f7d6324972 To date, no country has taken a comprehensive approach to dismantling state capture linked to Covid-19 beyond applying some sanctions.

Medical products, vaccines, and technologies: enhancing medical products’ quality across supply chains using blockchain

Corruption contributes to the proliferation of falsified medical products, which can happen when legitimate and licensed suppliers manufacture, distribute, and sell falsified medical products through legal channels. Emerging technologies, such as blockchain and artificial intelligence (AI), have been considered to enhance transparency and efficiency across supply chains, contributing to securing medical products’ quality.300f730259c7 At the start of the Covid-19 pandemic, South Korea piloted blockchain technologies for contract tracing; IBM developed the Rapid Supplier Connect platform based on blockchain technologies to help the US and Canadian governments identify trustworthy companies to deliver high-quality PPE equipment; and Estonia, Hungary, and Iceland used blockchain to host vaccination certificates as part of a pilot project initiated by Guardtime and AstraZeneca Estonia.1fbae5346da7

Despite its promising applications, blockchain’s potential as an anti-corruption tool during Covid-19 was limited. First, the pandemic was characterised by quick and shifting priorities, which truncated the rapid deployment of advanced technologies to monitor different supply chains, such as for PPE, vaccine distribution, vaccine certificates, and rapid antigen test kits, among others. Second, several countries did not meet all the key conditions needed to ensure that the use of blockchain technologies led to more transparent and accountable medical supply chains: political stability, collaboration among relevant interest groups, responsive legal frameworks, and technological capacity. Conducting a context-based analysis is a crucial step before using blockchain and other advanced technologies for anti-corruption purposes.6e6775fbe44a

HMIS: their role in enhancing decision-making

When they are well-established, health management information systems (HMISs) enable access to timely, relevant, and reliable information. This is essential for effective decision-making about health strategies, policies, and programmes. DHIS2, a free and open-source health data platform, is currently used in 73 low- and middle-income countries as their main HMIS.fb662dc47688

During Covid-19, more than 40 countries used DHIS2 for Covid-19 surveillance and 40 countries used it for Covid-19 vaccine delivery. For example, Sri Lanka used DHIS2 to track immunisations, monitor vaccine stocks by using aggregate data and to produce verifiable vaccination certificates. It also analysed immunisations and stock data on a joint dashboard to inform decision-making processes, enhancing accountability in the process.6537e5e88fa3

Nonetheless, using DHIS2 or another HMIS is no guarantee that data will not be misused or manipulated for private gain. There are several reasons why corruption may still happen. First, there could be political and administrative incentives to keep information undisclosed, reducing transparency and accountability. Also, in some countries, the limited pace of digitalisation of health data means that most data collection is recorded in papers, opening opportunities for data manipulation. Third, there may be a lack of or weak open data policies, which can nurture opacity, and, finally, shrinking progressive civic space may result in less access to information that can be used to hold governments accountable. Strong data governance is therefore crucial to ensure that data collection, management, and use are ethical and equitable, and help promote better decision-making.5a353a63f394

Human resources: rationing PPE to minimise opportunities for malfeasance

The research conducted here did not find any clear indication of preventive measures taken to actively deter corruption in the selection of healthcare personnel, improper use of medical equipment and products, bribes, and/or absenteeism during the Covid-19 pandemic. While some countries, such as Canada,3e7bdb3ba13b sought to reduce theft in healthcare facilities by rationing PPE equipment, this measure had a counterproductive effect: it put health workers’ lives at further risk.

Lessons from this pandemic to minimise corruption risks in other health emergencies

Covid-19 brought health systems to the brink of collapse, hurt economies, increased poverty, and inequality, and pushed back any substantial progress made to achieve the Sustainable Development Goals by 2030.

Since 2021, countries have met to discuss a global accord for pandemic preparedness. In its latest reunion in August 2022, Transparency International provided several recommendations on how to curb Covid corruption.f63c68d3f4db It also put out recommendations for the World Bank’s new Financial Intermediary Fund (FIF), which aims to kick-start the estimated US$10.5 billion per year needed to strengthen pandemic preparedness and response.cdd496195631 Additionally, the O’Neill Institute for National and Global Health Law and the Foundation for the National Institutes of Health convened leading authorities on international agreements in trade, regional integration, public health emergency preparedness, finance, biomedical science, climate change, maritime affairs, tobacco control and human rights, to discuss norm-setting and regime compliance modalities for the global accord.7e51e33b475f

Based on U4 and these organisations’ findings, this Issue compiles lessons learned from the Covid-19 pandemic. These should inform policymakers’ decisions on local, national, and global responses to health emergencies, either presently or in the future.

1. Transparency in decision-making during health crises is crucial at the district, national, and global levels.

This not only constitutes providing information to the public about the decisions made during an emergency, but also ensuring that this information is continuously updated, easily accessible and reflects the most critical societal needs. For this to happen, decision-making groups must be diverse, including representatives from those most affected by health crises, such as women.

2. Health emergencies-related anti-corruption initiatives should integrate a gender perspective.

Health emergencies affect men and women differently, and so does corruption. Efforts to enhance transparency, accountability, and integrity in health emergency responses will be most effective when a gender lens is applied in their design and implementation. For example, recognising women’s exposure to petty corruption in their interaction with public healthcare providers will lead to the design of anti-corruption measures that capture their experiences, such as gender-sensitive reporting tools. Information collected through this means can contribute to making providers more accountable for women’s needs.

3. Healthy financial accounts require reliable public financial management.

Governments require an arsenal of tools to guarantee the integrity of health emergency funds. These should include tracking of funds and dissemination of financial information to the public through user-friendly platforms; legislation in place to ensure due diligence, as well as reduce the scope for conflicts of interest to pervade the management and use of funds; free civic space so non-state actors such as civil society and the media can actively monitor spending and demand accountability in governments’ financial performance; and well-established government institutions that can keep spending in check.

As one of the most important financial institutions, supreme audit institutions should have strong legal mandates, independence to conduct audits on any topic and at any time – including real-time audits during health crises – and should count on strong leadership that can take their mandate forward. Donors and international organisations should leverage their influence to support the establishment and independent functioning of such institutions.

4. Civil society can still play its monitoring role when space is constrained physically and legally.

When confinements happen, free civic space is constrained, and legal tools for protecting whistleblowers and access to information fail to deliver, then civil society’s monitoring role can be enhanced through digital civic engagement. Development practitioners can support the establishment of digital accountability networks, which help increase awareness of corruption risks, build new alliances, and promote accountability initiatives.b725ca4b8849

Additionally, it is important that donors, governments, and multilateral organisations integrate community leaders into Covid-19 responses. As trusted members of the community, these leaders are in a better position to operate locally and ensure all resources are spent effectively. This will enhance public trust in governments’ pandemic preparedness and response plans.98c973a149e7 It is key to provide more training, support, and resources to these groups.

5. Strong data governance is essential for enhancing transparency, accountability, and integrity of data collected during health emergencies.

Donors, multilateral organisations, and governments involved in the collection, use and management of data during health emergencies should have well-established frameworks in place to guarantee the quality and protection of data in line with a human rights-based approach. This can be achieved by conducting assessments of the need, proportionality, and legality of collecting and using data to avoid impacting on people’s human rights to privacy and freedom of expression. There should also be agreements on how to share data between institutions (including standardised formats and public dissemination of aggregate data, such as data on vaccine rates in priority groups), and how to guarantee transparency and interoperability among their information systems. Doing so will help ensure data reliability, which can better inform decision-making processes.

6. There needs to be more attention to protecting health workers and addressing the drivers of functional corruption, as well as petty corruption engendered by social norms.

Social norms may play an ‘inverse’ accountability function, pressuring health workers to engage in different forms of corruption, such as favouritism, to avoid social exclusion. Creating and enforcing codes of conduct or integrity guidelines, without considering the informal rules that govern societies, will have limited value on changing behaviours.ac7c0ddb7962 It is important for practitioners and governments to complement conventional integrity measures with strategies that take social norms into account.

Additionally, careful consideration should be given to identifying what could drive health workers to engage in corruption, as well as prioritising their safety and well-being during health emergencies. Low salaries, lack of access to personal protective equipment, and long working hours with minimal support and in high-turnover environments may lead some health workers to consider engaging in bribes, malfeasance, and absenteeism to secure a living wage and protect themselves from falling ill. Interventions such as salary increases, safety reporting mechanisms, and spaces for civil society oversight can be effective anti-corruption measures in these contexts.

7. The private sector also engages in corruption, including state capture, procurement corruption, and lack of transparency in clinical trials. There should be tailored anti-corruption measures aimed at drug manufacturers and private healthcare providers.

Health emergencies increase drug manufacturers’ bargaining power vis-à-vis governments, especially during procurement and contracting processes. Legislation on beneficial ownership, access to information laws and due diligence should be in place to regulate public–private sector engagements. Governments may need to delay any processes related to these legislations to act more expediently. Where they do so, it is important that they clearly communicate the interim measures taken to secure the collection of key information about state–business relations, so it can be used for accountability purposes as soon as possible. Additionally, it is recommended that countries establish or, if they have them already, implement ‘sunshine laws’. These are legal frameworks to regulate pharmaceutical companies’ engagements with healthcare professionals to mitigate the risks of undue influence, collusion, bribery, and proliferation of low-quality or substandard medical products.

Governments, donors, and multilateral organisations, who are actively supporting or host pharmaceutical companies’ research on health emergencies-related drugs and treatments, should leverage their influence to ensure contract transparency, and that drug manufacturers make their clinical trial protocols public (ideally prior the recruitment of participants). Governments should revise clinical trial legislation to guarantee the public dissemination of clinical trial protocols in platforms that follow WHO standards.45e3c50f99e0

8. Mainstreaming anti-corruption during health emergencies requires an institutional commitment from governments to adhere to anti-corruption principles within national and global pandemic plans and policies, as well as context-driven measures in collaboration with all interest groups.

At present, there is no uniform approach to anti-corruption in the health sector among countries and international organisations. Transparency International has taken a step forward to enhance coherence in global approaches to health emergencies by recommending that the Global Pandemic Preparedness Accord includes the following measures: WHO guidance on publishing clinical trials, public release of full contracts for purchases of medical products within 90 days, mechanisms that support transparent procurement and data sharing (such as open procurement, beneficial ownership registries, live audits, vaccination progress of priority, and vulnerable groups), and gender-sensitive whistleblower mechanisms, along with whistleblower protection.62e642e7f1ba These measures should also be replicated in national pandemic preparedness plans and policies.

Additionally, governments, donors, and multilateral organisations that are engaged in pandemic responses should base their anti-corruption measures on a thorough reading of contextual capacities and identification of highest corruption risks.