On the 31st of December 2019, WHO’s Country Office in the People’s Republic of China picked up a media statement by the Wuhan Municipal Health Commission on emerging cases of “viral pneumonia.” Since then, the coronavirus SARS-COV-2, also known as Covid-19, has spread around the world, infecting more than 100 million people and claiming the lives of more than two million.

This pandemic has tested the resilience of global health systems. For countries with ill-equipped health systems, Covid-19 has brought them to the brink of collapse. Not only have they struggled to contain the pandemic’s infection rate and death toll, but many have experienced the disruption of other vital health services. 

In Asia, countries have struggled to control the spread of Covid-19 whilst simultaneously providing other services such as cancer care, which costs the lives of two million people annually. Meanwhile, Latin America and the Caribbean, the most unequal region and home to only 8.2 per cent of the world’s population, accounted for 28 per cent of all cases and 34 per cents of all deaths by October 2020. Most recently, the African Centre for Disease Control and Prevention has warned that, due to the new coronavirus variants in the continent, 21 of 55 countries are now reporting Covid-19 death rates above the current global average of 2.2 per cent.

The pandemic has served as a catalyst for corruption, which has also contributed to debilitating health systems. In the first ten months of the pandemic, more than 1800 people contacted Transparency International Advocacy and Legal Advice Centres to report Covid-19 related corruption. 

Previous corruption in health care systems also limited their capacity to respond to the outbreak. Nemexis, a Berlin-based anti-fraud consulting firm, surveyed 58 countries and found that corruption in healthcare services weakened healthcare delivery, contributing to Covid-19 deaths in every third country surveyed. 

Documented corrupt practices during Covid-19 include grand corruption schemes involving high-level politicians, petty corruption at the point of service delivery, and corruption in procurement and contracting processes. In addition, obscurity in the research and development (R&D), manufacture, purchasing, allocation, and distribution of Covid-vaccines has resulted in considerable research and financial waste, and contributed to perpetuating inequality. 

From the start of the outbreak, governments loosened their regulatory environment to expedite their Covid-19 responses. According to Devex, more than USD $20.7 trillion have been committed to combating the virus between 1 January 2020 and 31 January 2021. Corruption thrives in emergency scenarios characterised by fast responses, lax checks and balances, and ongoing funding. Experiences from other health crises, such as Ebola, corroborate this too.

As donors continue to release funds to tackle the pandemic, it is key to recognise the impact corruption has had on Covid-19 responses and will continue to have on health systems.

Grand corruption during Covid-19

The pandemic has led to a wave of corruption-related incidents perpetrated by high-level government officials from all over the world. While it is unclear how much exactly has been lost through grand corruption, worldwide evidence indicates that large-scale Covid corruption has created a significant dent in resources destined to the pandemic.

There are many examples of corruption during the pandemic, including:

• Zimbabwe’s Minister of Health was arrested over alleged corruption related to the awarding of a USD $60 million contract for Covid-19 supplies;
• Uganda’s ambassador and her deputy were found strategizing how to pocket money allocate for the Covid-19 response;
• Somalia took four high-level health officials to court over allegations for misappropriating pandemic relief funds;
• The head of Kenya Medical Supply Authority and other officials were suspended over suspicions of corruption in the procurement of personal protective equipment (PPE);
• The Philippine’s Senate held a hearing on PhilHealth executives’ mismanagement of Covid-19 funds;
• Indonesian Minister for Social Affairs was suspected of having pocketed USD $1.1. millions in funds relating to Covid-19 aid;
• Bolivia’s Minister of Health was detained for allegedly purchasing 179 unusable ventilators at twice their original price;
• Rio state Health Secretary and Governor in Brazil were charged of corruption for over alleged graft;
• Ministers and vice-ministers in Peru, Ecuador, Bolivia and Panama were implicated in corruption cases and forced to resign;
• High-level political leaders and wealthy individuals in Canada, Peru, Argentina, Spain, and Poland have jumped the queue to access Covid-19 vaccines;
• A ruling by the UK’s High Court found that the Health Secretary breached his legal obligations by not publishing Covid-19 contracts within the 30 days stipulated by law. 

Covid-19 related corruption in service delivery

At the beginning of the outbreak, U4 predicted that petty corruption was likely to be exacerbated. Low wages and poor working conditions may motivate health workers to engage in informal payments, overprescribing, favouritism, and nepotism. Patients could also engage in corruption—for instance, bribing officials to evade quarantine—and contribute to the spread of the virus. It was expected that petty corruption during the pandemic could lead to a poorer patient perception of public health services and reduce health seeking-behaviour. 

Last December, a report from Transparency International Health Initiative identified different forms of corruption manifestations at the point of service delivery in more than 30 countries, highlighting cases of informal payments; embezzlement and theft; absenteeism; corrupt activities in service provision, such as overcharging and false treatment reimbursement claims; favouritism and nepotism; and manipulation of data. 

Covid-19 related corruption in service delivery has had a dire effect on groups who are most reliant on health and other public services, such as women, poor people, and often people from migrant/ethnic backgrounds. Women, for example, who contribute US $3 trillion annually to global health and represent 70 per cent of the workforce, have rarely been involved in decision-making processes related to the pandemic. This has worsened their vulnerability to corruption, both as patients and as providers.

In general, corruption during the pandemic represents a real threat to Universal Health Coverage (UHC). Transparency International recently found a strong association between control of corruption, as measured by 2020 CPI, and Universal Health Coverage. Even after accounting for a country’s level of economic development, countries experiencing systematic corruption generally spend less on healthcare, reducing the quality and accessibility of health services. 

Procurement corruption and Covid-19

Corruption costs the health sector around 455 billion annually—6.19 per cent of total global health expenditure. A great proportion of these losses is attributed to corruption in procurement. According to the OECD, corruption and fraud syphon off 10 to 25 per cent of procurement budgets. 

The pandemic has amplified corruption pressures on healthcare procurement. Transparency International found that, during the first months of the pandemic, governments purchased some goods at 25 times the original price, and a survey run by the International Federation of Accountants confirmed evidence of fraud, corruption and mismanaged public money. The sense of urgency, coupled with the relaxation of checks and balances, increasing demand, and shortages of essential medicines, PPE, ventilators, and medicines caused a strain in global supply chains, making them vulnerable to corruption.

Experiences of corruption in Covid-19 related health care procurement has affected both developed and developing countries alike. Cases are found in the United States, United Kingdom, Italy, Bangladesh, Bosnia, Kenya, Paraguay, and Romania, among others. This has led to price gouging and the proliferation of falsified goods in many countries, in addition to the wastage of key resources for Covid-19 responses.

Recently, purchases of Covid-19 vaccines have opened another avenue for procurement corruption. Most countries around the world have issued direct contracts without competitive processes, whilst many pharmaceutical companies negotiate bilateral contracts with confidentiality clauses, giving them a veto right and removing any financial risk and liability. Indeed, the European Ombudsman is investigating the secrecy with which the EU executive is handling Covid-19 vaccine supply contracts. Yet, obscurity in these processes limits the detection of corrupt practices, which may range from government officials requesting kickbacks from suppliers; suppliers exploiting shortages and demanding higher prices; and suppliers engaging in collusion and bribes to win contracts; etc.

Serious consequences of procurement corruption are already emerging. Sharp differences in the prices of Sinovac Covid-19 vaccine in Southeast Asian countries such as the Philippines, Thailand, and India, point to corruption. So does the proliferation of a black market for substandard and falsified Covid-19 vaccines in Mexico, the Philippines and Nigeria, amongst other countries in Latin America, Africa, and Asia.

Corruption and Covid-19 vaccines 

In addition to procurement, the R&D, allocation and distribution of Covid-19 vaccines are equally vulnerable to corruption. As of 3 February, three quarters of all global doses were only in ten countries, and around nine out of ten countries beginning vaccination this month were high income or middle-income. Corruption in this context can easily perpetuate inequality in the access of Covid-19 vaccines. 

First of all, the fast pace of R&D, coupled with substantial investments and the urgent demand for a vaccine, have created opportunities for fast-tracking research processes with minimal transparency. For instance, the Coalition for Epidemic Preparedness Innovations (CEPI)—which is a publicly funded agency part of the COVAX Facility, the mechanism tasked to allocate vaccines equitably around the world—has been criticised for the lack of transparency in its grant agreements with Covid-19 vaccine developers. Despite US$1.4 billion donor funding going into CEPI to support research from Novavax, Moderna, Curevac, and AstraZeneca, among others, CEPI’s grant agreements have been negotiated in secrecy; and while CEPI’s vaccine-developers are required to allocate a part of their vaccines to COVAX at affordable prices, CEPI does little monitoring over how pharmaceutical companies’ bilateral deals with governments can affect their commitment to COVAX.

Any shortcut or obscurity in the R&D process, which includes the early research phase, the patent application, the preclinical testing phase, three phases of clinical trials, and the registration process, can result in corruption, significant health risks, and the loss of public confidence in the vaccine. For example, the lack of clinical trial transparency in the development of Russia’s Sputnik V, China’s Sinovac Biotech vaccine, Oxford-AstraZeneca’s vaccine, Pfizer’s vaccine, and India’s Covaxin, have raised concerns over their quality throughout 2020 and 2021. It has also resulted in duplication of research efforts and research waste in Europe, especially in Spain, which hosts the largest numbers of clinical trials.

As the world starts to roll out Covid-19 vaccination programmes, there are many corruption risks to monitor, such as theft and diversion; lack of compliance with allocation criteria; lack of timely information on vaccine shipment and availability; inadequate communications on safety and misinformation; inadequate adverse reaction monitoring and response; substandard quality of vaccine related materials; contract awards to politically favoured contractors; authorised fees demanded for vaccine administration; and jumping the queue involving bribes, nepotism, and politics.3 Indeed, line-cutting behaviour of high-level political leaders and wealthy individuals have happened in Canada, Peru, Argentina, Spain, and Poland, among others.

The distribution of vaccines under the WHO ACT-Accelerator framework, and its corresponding COVAX Facility, is also vulnerable to corruption. Under this framework for global collaboration, countries should receive doses for 3 per cent, then 20 per cent of their population, and then scale up to full coverage. Yet governments have a carte blanche to decide who and where the health workers and key at risk populations are. In Colombia, for example, several ID numbers from deceased people have been prioritised for vaccination in the online platform Mi Vacuna, raising fears of corruption infiltrating governments’ selection of priority groups and distribution of Covid-19 vaccines.

Moving forward

In non-emergency times, corruption in the health sector lowers public trust in health institutions, weakens health systems, and threatens progress on health outcomes. During health emergencies, such as Covid-19, corruption’s impact is amplified. Traditional anti-corruption responses are insufficient to tackle corruption risks during a pandemic. Here is a list of several anti-corruption measures, both short-term and long-term, for governments, donors, and development practitioners to consider: 

Short-term measures

1. Include anti-corruption and counter-fraud agencies on the national committee or taskforce: This is a key step to mainstreaming anti-corruption into the pandemic preparedness and response plan. 
2. Conduct a situation analysis and identify and assess corruption risks: once the risks are well-mapped, policymakers and practitioners can build mitigation measures that promote transparency, accountability and participation into the plan. 
3. Support civil society and promote multi-stakeholder participation: Development practitioners can support civil society by drawing upon the many existing – but untapped – resources to mobilise digital civic engagement. By establishing digital accountability networks, there is potential to increase awareness of corruption risks, build new alliances and promote accountability initiatives. Promoting gender parity, diversity and inclusivity in pandemic response teams is also a good idea, as this is known to have a positive effect on policy and organisational outcomes, including corruption control.
4. Commit to transparent funding: Donors, central and local government, NGOs and other stakeholders should always publish how much money they allocate to pandemic responses and for what use.
5. Commit to transparent and accountable procurement: This can be achieved through budget transparency, open contracting, and robust internal and external auditing. This is particularly relevant for the procurement of Covid-19 vaccines, as it is key to reduce the risk of purchases from illegitimate suppliers. 

Long-term measures

1. Mainstream anti-corruption into wider efforts to strengthen health systems: This entails integrating transparency, accountability, integrity, and multi-stakeholder participation measures, with a view to improving health outcomes. 
2. Invest in institutional strengthening: Focus on enhancing existing anti-corruption laws and policies, such as whistleblower protection and access to information laws, to ensure they advance civil society participation, uphold the rule of law, and strengthen the management of public affairs. 
3. Identify and protect vulnerable groups: Vulnerable individuals and communities are the hardest hit by corruption during the pandemic. Many of them struggle to access quality health services and need to be supported. Governments can make use of digital tools to overcome identification barriers and ensure the distribution of Covid-19 vaccines is done in a fair and equitable manner. 
4. Invest in monitoring and evaluation: In the aftermath of a pandemic, it is vital that the response is evaluated so that lessons can be learned for future pandemics. The evaluation should consider whether and how corruption hindered the pandemic response. It must also look at how transparency, accountability and participation were upheld or undermined. The evaluation should make recommendations for minimising corruption and upholding these principles in pandemic response implementation alongside public health-related ones.