determinants of corruption processes in public...

INTRODUCTION

Corruption has been known worldwide forthousands of years. The Arthashastra, an ancientIndian treatise more than 2000 years oldmentions bribery as a strategy of managingthe country [Grose, 2000]. Indeed, the wordbribe was not known at that time, but thesheer number of synonyms indicates that thephenomenon was remarkably widespread.For instance, while Queen Bona Sforzaalleged that A. Zebrzydowski bought hisbishopric, he calmly retorted that it was forsale. In turn, F. Birkowski, the successor ofP. Skarga, expressed his indignation sayingthat: corruption is a rather hideous name ofgifts which virtuous eyes should never see.

The turn of the 21st century brought a newoutlook on corruption, also in the field of healthcare. National perspectives have turned intoa global one, triggering measures at the inter-national level [Nowak, 2008]. The problemsof integrity, ethics, and morality have alwaysbeen considered in the context of public hospitals.Successful ethical management of public healthcare rests on integrity and sincerity [Su∏ek,Âwiniarski, 2001]. The process of providinghospital services to a considerable degree dependson the appropriate functioning of hospitalsand adherence to ethical standards.

The enacted laws defining normative patternsof behavior still leave some room for ethicalmodels in diagnostic and therapeutic processes.Obedience of the law is not enough in itself;the other necessary factor is the integrity of thestaff of public hospitals. This is due to the factthat medical professionals always operatein direct contact with patients, facing a rangeof requirements and ethical dilemmas. Theconducted survey shows that corruption pro-cesses have become an increasingly seriousproblem over time, and their escalation has beenobserved in both quantitative and qualitativeterms.

DEFINING CORRUPTION

Concepts such as corruption are not cate-gories that may be easily conceptualized.Indeed, there are many definitions and typesof corruption [Nowakowski, 2007]. Corruptionrefers to a certain syndrome, or a multi-dimensional and multi-faceted phenomenonthan cannot be defined unambiguously.Originally, corruption meant deteriorationand moral decay, and gradually the denotationof this term was extended to include briberyas a basic manifestation of corrupt behavior[P∏oskonka, 2003]. The essence of corruption

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Determinants of corruptions processes in public hospitals

Journal of Health Policy, Insurance and Management – Polityka Zdrowotna

DDEETTEERRMMIINNAANNTTSS OOFF CCOORRRRUUPPTTIIOONN PPRROOCCEESSSSEESS IINN PPUUBBLLIICC HHOOSSPPIITTAALLSS

Uwarunkowania procesów korupcyjnych w szpitalach publicznych

Benedykt Bober

STRESZCZENIE

Niniejsza praca przedstawia istot´ procesów korupcyjnych w szpitalach publicznych, rol´ etykioraz stanowienia prawa w procesie zapobiegania negatywnym skutkom spo∏eczno-ekonomicznym.Ukazana jest równie˝ rola organizacji pozarzàdowych, jako swoistego barometru spo∏ecznegow procesie kszta∏towania po˝àdanych postaw kadr medycznych.

S∏owa kluczowe: korupcja, s∏u˝ba zdrowia, opinie pacjentów, szpitale publiczne, prawo

Keywords: corruption, health care, patients’ opinions, public hospitals, law

processes is the use of public authority forprivate gain. However, it is found not onlyin the public sphere, as corrupt interactionsalso take place in the private sector [Nowak,2008]. Corruption, amongst others, is: promising,offering, giving, demanding, accepting by any person,directly or indirectly, of any undue financial,personal, or other gain for themselves or any otherperson, or accepting a proposition or promiseof such a gain in return for an act or omissionof an act in the performance of a public functionor in the course of a business activity. Morespecifically, in public hospitals corruption includesaccepting bribes by doctors, manipulation of infor-mation on drug trials, misappropriationof medicines and supplies, irregularities in pro-curement, and overbilling insurance companies[Act of June 9, 2006 on the Central Anti-Corruption Bureau].

According to the definition of TransparencyInternational [Global Corruption Report,2006], corruption is the abuse of entrustedpower for private gain. The World Bank,in turn, defines corruption as the exploitationof one’s office or position for gaining unduebenefits by:

• state capture – the illicit activity of peopleor interest groups (both in the publicand private sectors) aiming at passinglaws, regulations, strategic programs,and other policies to their advantageor

• administrative corruption – circumventingthe existing provisions, laws, and regu-lations by a public person to provideothers with benefits in return for the secretprovision of illegal private benefits to thatpublic person.

This distinction has important analyticaland practical implications in considering theeffectiveness of anti-corruption strategies.57

Many forms of corruption are associatedwith public hospitals; out of them the follo-wing were most frequently listed by respondents:

• bribery,• favoritism in awarding positions,

• deliberate and unlawful diverting of fundsand assets owned by public hospitals,

• partiality,• nepotism.The aim of the present paper was to find

out prosumers’ opinions on corruptionprocesses in public hospitals in Warmia andMazury Province, Pomeranian Province,and Greater Poland Province (A, B, and C).Moreover, also access to information and itsprocessing are very important. First, a lackof information may lead to poor quality of theprovided services, which increases the riskof corruption. Second, even if informationis available, it may be used by medical staffto change the effects of a given diagnosticor therapeutic process in a certain way or tojustify an effect which, in another situation, wouldhave to be acknowledged as ineffective.

The present paper used some of the researchmaterial obtained as part of the author’sown project. This made it possible to look atcorruption, not only as a criminal act fallingunder the Penal Code but also as a socialproblem having a number of determinants.Patients staying at the studied hospitals weregiven a questionnaire containing toolsexamining opinions on corruption processesin those hospitals. The questionnaire wasdeveloped by the author and the surveyinvolved 104 public hospitals in Provinces A,B, and C (20.43% of the total number of publichospitals) from January 2007 to December 2011.As a result, 900 electronic questionnaires wereobtained from each hospital, filled in by trainednurses upon patient discharges. The popu-lation under study, purposively sampled,amounted to n = 93,600 hospitalized anddischarged patients. The proportion ofhospitalized patients relative to the overallpopulation of the provinces amounted to 19.88%(7,003,180 people). The collected materialwas subjected to statistical analysis at a levelof significance of α = 0.05 to accomplish theobjectives of the study. Statistical informationis given in Tables 1–3 and Chart 1 and 2.

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57 European Commission Communication of May 28, 2003 on a comprehensive EU policy againstcorruption stresses that a distinction should be made between corruption in the narrower sense of criminallaw and corruption in social and economic sense.

The studied population was categorizedaccording to employment type, as well as gender,age, and education. In terms of gender, 69%(64,584) of respondents were female and31% (29,016) were male. Another criterionconsidered in the paper was employmentstructure: 72% (46,330) of females and 78%(22,747) of males worked in the servicesector, while 28% (18,254) of females and22% (6,269) of males worked in other

sectors. In terms of education, 18% (11,531)of females and 21% (6106) of males hadhigher education, 27% (17,638) of femalesand 31% (9,068) of males had secondaryeducation, 32% (20,404) of females and25% (7,134) of males had vocationaleducation, and 23% (15,011) of women and23% (6,708) of men had primary education.The mean age was 45.7 for females and 45.9for males.

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Table 1. Structure of the studied population – hospitalized and discharged patients

Source: Author’s survey conducted in 2007-2011

Chart 1. Number of patients relative to the population of provinces in 2007-2011


RESULTS AND DISCUSSION

The survey shows that the majority ofpatients responding to the questionnairewere treated at a public hospital once amonth (31,201 – 33.34% of the total numberof respondents) or every 6 months (21,984 –23.49%) (Table 2). The results of the surveyconducted in three provinces indicate that avast majority of the respondents (66.78%)have been asked by the medical staff to paya bribe for admission to hospital, treatment,surgical operation, or medical consultation(table 3). The majority of those surveyed(72.46%) thought that corruption in publichospitals is an important problem, while17.54% expressed the opinion that it was amarginal problem. Moreover, 88.86% of therespondents said that corruption was on theincrease (in 2007-2011) and 5.33% had noopinion on this issue.

Respondents were asked about the reasonsof bribe offers, with the most frequent answers(taking into consideration the “definitelyagree” and “somewhat agree” options) beingskipping the waiting list for admission to hos-pital or performing an operation (73%) andobtaining a sick leave or another medicalcertificate (61%). Moreover, respondents wereasked about the most efficient ways of fightingcorruption: in their opinion those weresevere punishment for offenders (54%) andcreating laws without loopholes. The formeroption was chosen by approximately halfof respondents. Severe punishment for offendersas an efficient way of fighting corruption wasmost frequently indicated by respondentsaged 40–49 (54%), those with primary edu-cation (57%) and vocational education (56%),as well as by those experiencing seriousor very serious financial difficulties (54%).On the other hand, for 42% of respondents,

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Table 2. Frequency of using hospital services


Table 3. Respondents’ opinions on corruption processes in public hospitals


the most effective way of fighting corruptionwas creating better laws without loopholesor inconsistencies. This way of fightingcorruption was favored by respondents aged30-39 (47%) and people with higher edu-cation (50%). Increasing internal controlsin public hospitals and strengthening the anti-corruption agencies was chosen by abouta quarter of respondents.

LEGAL ASPECTS OF CORRUPTIONIN THE STUDIED HOSPITALS

In the present discussion, it has been assumedthat the process of fighting corruptionrequires comprehensive policies concerningthe implementation of standards on effectivemanagement of the resources owned by thestudied public hospitals. Doctors workingboth in public and private health careinstitutions are persons performing publicfunctions [article 115 section 1 of the PenalCode; art. 17 section 1 of the Constitutionof Poland], whereas persons in managerialpositions (management staff) are generally notpublic officials, but may be deemed so if theirorganizations are financed with public funds[Supreme Court Resolution of June 20, 2001,No. I KZP 5/01]. In addition, the Ministerof Health and the officials and employeesof the Ministry of Health are also consideredpublic officials. The terms ethics and publicservice are ingrained in the medical profession,as doctors perform public services while beingsubjected to professional rules, deontology,and ethics. The Act on Chambers of Physiciansand Dentists of May 17, 1989 states thatMembers of the medical self-government aresubjected to professional liability before MedicalCourts for conduct contrary to the principlesof ethics and professional deontology, and forviolation of regulations on performing the medicalprofession. In the present paper, it has beenassumed that these procedures do not representa suitable way of fighting corruption on accountof the fact that such court cases are not heardby an independent body.

Abiding by EU laws in the area of anti-corruption activity [Nowak, 2004], Poland hasratified:

• Council of Europe Criminal Law Con-vention on Corruption,

• Council of Europe Civil Law Conventionon Corruption,

• Convention made on the basis of ArticleK.3 (2)(c) of the Treaty on EuropeanUnion, on the fight against corruptioninvolving officials of the EuropeanCommunities or officials of MemberStates of the European Union,

• United Nations Convention against Cor-ruption, which designated December 9as International Anti-Corruption Day[Nowak, 2004].58

In turn, in the Polish legal system cor-ruption is a criminal offence prosecutedex officio on the basis of the following articles:

• 228 section 1 of the Penal Code – passivebribery,

• 229 of the Penal Code – active bribery,• 230 and 230a of the Penal Code – influence

peddling,• 231 of the Penal Code – abuse of public

authority,• 296 of the Penal Code – breach of trust,

and• 115 of the Penal Code, section 4,

according to which financial or privateadvantage is an advantage both for oneselfor another person.

The phenomenon of corruption has alsobeen addressed by non-governmentalorganizations NGOs, such as TransparencyInternational Poland, the Stefan BatoryFoundation, the Helsinki Foundation forHuman Rights, and the Institute of PublicAffairs. NGOs, constituting the so-calledthird sector, play an important role in counter-acting corruption processes in public hospitals,as they:

• perform a monitoring function by analyzingthe legitimacy, purposefulness, effectiveness,and quality of services, as well as the scopeand objectives of public expenditure, andadherence to law,

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58 Resolution of the General Assembly of the United Nations No. 58/4 of October 2004 establishedDecember 9 as International Anti-Corruption Day.

• act as a barometer of social awareness –they play an educational role throughpublic awareness campaigns disseminatinginformation about the negative effectsof corruption,

• perform the role of experts (researchinstitutes) producing expert reports onthe phenomenon of corruption in publichospitals, and

• provide legal advice for victims (inter-ventions).

In the present discussion it has been assumedthat the activity of non-governmental organi-zations is one of the essential elementsof building civil society – a social barometerbeing an important factor reducing corruptionin public hospitals. Social monitoring is thebasis for a sense of security, equality beforelaw, and also integrity of the personnelemployed in public hospitals in the studiedprovinces (A, B, and C).

According to the author, problems ofmuch greater significance than the criminaloffences falling under Art. 228 of the PenalCode seem to be misuse of power and failing

to fulfill obligations (Art. 231 o the PenalCode), false statement of facts in officialdocuments (Art. 271 of the Penal Code),and involvement in a criminal organizationor association, which lie at the heart ofcorruption (Art. 258 of the Penal Code). Atotal of 14 cases of such offences surfaced inthe years 2007–2012 (chart 2.).

FIGHTING CORRUPTION IN PUBLIC HOSPITALS

Under the current legal system, publichospitals do not possess the competencesof law enforcement agencies in the areaof fighting corruption; instead they canmake use of available administrative andorganizational measures. Assessment of thescope of corruption processes is also difficultdue to the fact that corruption is dealt withby many governmental agencies, such as: theCentral Anti-Corruption Bureau (CBA,established by the Act of June 9, 2006), theInternal Security Agency (ABW, established

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Chart 2. Scale of criminal offences committed in 2007-2011

Source: Based on the author’s survey conducted from January 2007 to December 2011 and data from theMinistry of Interior and Administration and the Ministry of Health

by the Act of May 24, 2002), and the police(regulated by the Act of April 6, 1990).An essential role in the prevention and dis-closure of corruption processes is also playedby the tax audit authorities (regulated by thePublic Finance Act of August 27, 2009),introducing management control in publicsector entities including public hospitals,which is a mechanism ensuring the pursuitof their goals and tasks in a lawful, effective,and timely manner.

The implementation of qualitatively newmethods and tools such as, the identification,mapping, and monitoring of corruption pro-cesses gives the opportunity to react appro-priately, reducing the risk of corruption by:

• diagnosis of the current situation,• planning and implementation of anti-

corruption measures,• planning and implementation of a system

of monitoring corruption and monitoringthe implemented solutions.

The undertaken measures address the needsof the medical staff, prosumers, and the externalenvironment from the point of view of:

• the organization: answering the questionof how to redesign human resourcesmanagement and the processes adoptedin public hospitals to make themresistant to corruption;

• the staff: answering the question of whatconditions a doctor/a patient wouldexpect and what conditions couldbe provided by the public hospitalto eliminate corruption incentives;

• the consumer and the external environ-ment: answering the question of whatsolutions the customer would expectand what solutions the public hospital(health care) could provide to eliminateoffers of corruption.

The proposed measures are aimedat creating bilateral channels of communi-cation in the process of social enquiry andactivities performed within the frameworkof anti-corruption process in public hos-pitals [Bober, 2013]. Comprehensive riskmanagement in the studied hospitals at thetime of development of anti-corruptionmeasures ought to include also the identi-fication of risks to the selected processes

and repair/preventive measures. Since thebeginning of post-communist transformation(1989), public hospitals have sought to improvetheir functioning by:

• enhancing the quality of hospital services,increasing stakeholder satisfaction,and reducing the decision-making riskby implementing quality managementsystems (ISO), performance-basedbudgeting, TQM, and the balanced score-board,

• implementing the Common AssessmentFramework [Opolski, Modzelewski, 2009],and

• more effective management [Kjae, 2007].Analysis of the collected materials indicates

that this list is not closed since corruptionprocesses may appear in each hospital withvarying intensity.

CONCLUSION

The motivation for this paper was the un-acceptably high level of corruption in publichospitals, which have not developed sufficientsystemic mechanisms for detecting and re-acting to this harmful phenomenon. It wasalso assumed that corruption is commonplace,irrespective of religion, or social or moralstandards. Therefore, fighting corruption cannottake only one form or be limited in time.

The conducted survey confirmed notonly tacit consent for committing criminaloffences of corruption but also a lack of under-standing of the effects of their destructiveinfluence on the social and economic sphere.Institutional helplessness is accompaniedby insufficient social mobilization, leadingto a situation of rampant impunity. It is verydifficult, if not impossible, to counteract cor-ruption processes in public hospitals withoutthe involvement of medical staff. The obtainedresults became the basis for a classificationof the basic corruption-generating mechanismsin the analyzed hospitals; these include:

• discretionary conduct,• conflict of interests,• lack of transparency of procedures,

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• weakness of monitoring and supervisionsystems,

• accumulation of powers,• disregard for patients’ medical records.The issue of fighting corruption processes

in public hospitals effectively is a complexproblem. Due to the existing social andeconomic conditions, it is highly unlikelythat this harmful practice can be completelyeliminated. In the analyzed hospitals, thereare both hard forms of corruption linkedto spending public money and soft formsarising from weaknesses of their organizationaland functional structures, leading to ineffectivediagnostic and therapeutic procedures anda waste of hospital resources.

On the basis of the obtained results, onecan argue that public hospitals (managementstaff) are regarded as unprepared andineffective in fighting corruption processes.According to patients, the current legalsystem and the absence of tools in the formof adequate criminal sanctions provideincentives for potential offenders, ratherthan a solution to the problem (such as, e.g.,disclosure of data from public hospitalsor the health care system, which would helpto build confidence). The survey results alsoconfirm the importance of both social andeconomic conditions and the legal systemfor the occurrence of corruption processes.

RECOMMENDATIONS

The perception of public hospitals as rathercorrupt institutions (Poland is in 41st place59)has been confirmed by the results of the con-ducted survey, although it should be re-membered that corruption perceptions arebased on the patients’ experiences andbeliefs, whereas the number of revealedcriminal cases is evidence of the efficiencyof the existing preventive and correctivemeasures. While this might be mistaken foran increase in the crime rate, actually thistestifies to an increase in corruption detection.

Conditions for the ethical and effectivefunctioning of public hospitals (networks)include:

• free public health care offering a basicbasket of guaranteed health care services,

• prohibition of combining work in thepublic health care system with privatepractice,

• increased social involvement (in the formof non-governmental organizations)in the process of corruption preventionand eradication in public hospitals,

• market principles of funding public hos-pitals,

• increasing the patients’ awareness of thefact that medical personnel is paid forthe services they provide,

• regulations according to which doctorsbill the payer and the patients are awareof the costs incurred, and

• monitoring the legitimacy of waitinglists and the way in which they arecreated.

The implementation of the above solutionswould largely eliminate the phenomenonof corruption from public hospitals. In sum-mary, while the quality of prosumers’ livesis rising, there is an essential deficit of socialtrust and little cultural objection to corruptionand disrespect for public property. The levelof social trust remains very low despite thefact that trust in one’s family and friendsremains extremely high. Confidence in otherpeople, also in public institutions (hospitals),is significantly lower than that in one’s closestrelatives. [Solon-Lipiƒska, 2009] In thepresent paper it was also assumed that cor-ruption processes may be eliminated by creatinga free market (through selected marketmechanisms) for hospital services andestablishing networks of hospitals effectivelyusing their infrastructure and diagnostic andtherapeutic equipment.

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59 Transparency International – Corruption Perceptions Index (CPI) – a tool for assessing the level of corruptionin the public sphere in selected countries: 2006 – 163; 2007-2009 – 180; 2010 – 178.

LITERATURE

1. Bober B., Metody analizy i oceny uwarun-kowaƒ ryzyka decyzyjnego w zarzàdzaniuprocesem Êwiadczenia us∏ug w szpitalachpublicznych, Wyd. WSB, Poznaƒ 2013.

2. European Commission Communicationof 28 May 2003.

3. Grose T., Dzia∏ania antykorupcyjne w paƒ-stwach cz∏onkowskich OECD, Florenc 2000.

4. Kjaer A. M., Governance, Polity Press,Cambridge – Malden 2006.

5. Nowak C., Dostosowanie prawa polskiegodo instrumentów mi´dzynarodowych do-tyczàcych korupcji. Raport, Fundacja im.Stefana Batorego, Warsaw 2004.

6. Nowak C., Korupcja w Polskim prawiekarnym na tle uregulowaƒ mi´dzynarodo-wych, Warsaw 2008.

7. Nowakowski K., Poj´cie i typy korupcjiw naukach spo∏ecznych, Wyd. „Wroc∏awskieStudia Politologiczne” 8/2007.

8. Opolski K., Modzelewski P., ZarzàdzaniejakoÊcià w us∏ugach publicznych, CeDeWu,Warsaw 2009.

9. P∏oskonka J., Korupcja – zagro˝enia i metodyjej zwalczania. Empiryczne badania nad po-ziomem korupcji, „S∏u˝ba Cywilna” No 6,2003.

10. Resolution of the General Assembly of theUnited Nations No. 58/4 October 2004 onDecember 9 has been established as theDay of Anti-Corruption.

11. Sakowicz M., Modernizacja samorzàduterytorialnego w procesie integracji Polskiz Unià Europejskà, Oficyna WydawniczaSGH, Warsaw 2007.

12. Solon-Lipiƒski M., Indywidualna aktyw-noÊç obywatelska – postawy i ÊwiadomoÊçPolaków w okresie 2001–2008 w Êwietledost´pnych badaƒ, [in:] Zakorzenieniei uspo∏ecznienie dzia∏aƒ organizacji poza-rzàdowych, Gumkowska M., Herbst J.(eds.), Stowarzyszenie Klon/Jawor, Warsaw2009.

13. Su∏ek M., Âwiniarski J., Etyka jako filozofiadobrego dzia∏ania zawodowego, Warsaw2001.

14. Supreme Court Resolution on 20 June 2001,No. I KZP 5/01.

15. The Constitution of Poland of 2 April 1997(Journal of Laws, 1997 No. 78, item 483).

16. The Act of 24 May 2002 on the appointmentof The Internal Security Agency and ForeignIntelligence Agency (Journal of Laws 2010No 29, Item 154 with subsequent changes).

17. The Act of 27 August 2009 on public finances(Journal of Laws No. 157, item 1240 withsubsequent changes).

18. The Act of 2 December 2009 r. on MedicalChambers, (Journal of Laws 2009 No. 219item 1708).

19. The Act of 9 June 2006 on the appointmentof CBA (Journal of Laws, No. 104, item 708with subsequent changes).

20. The Act of 6 April 1990 on the Police (Journalof Laws 2007 No. 43).

21. Transparency International. Korupcja w systemieochrony zdrowia – Globalny Raport Korupcji2006.

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