advanced search

<< Back To Home

NEW THIS FRIDAY: TWO ON CORRUPTION

Thursday, 29th of August 2013

 

• TWO ON CORRUPTION
  
• CORRUPTION KILLS: ESTIMATING THE GLOBAL IMPACT OF CORRUPTION ON CHILDREN DEATHS

Hanf M, Van-Melle A, Fraisse F, Roger A, Carme B, Nacher M.

      PLoS One. 2011;6(11):e26990. Epub 2011 Nov 2.

Source

Centre dInvestigation Clinique Epidémiologie Clinique Antilles Guyane CIC-EC INSERM CIE 802, Cayenne General Hospital, Cayenne, French Guiana. matthieu@hanf.fr

Abstract below; full text is http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0026990

BACKGROUND:

Information on the global risk factors of children mortality is crucial to guide global efforts to improve survival. Corruption has been previously shown to significantly impact on child mortality. However no recent quantification of its current impact is available.

METHODS:

The impact of corruption was assessed through crude Pearsons correlation, univariate and multivariate linear models coupling national under-five mortality rates in 2008 to the national "perceived level of corruption" (CPI) and a large set of adjustment variables measured during the same period.

FINDINGS:

The final multivariable model (adjusted R(2)= 0.89) included the following significant variables: percentage of people with improved sanitation (p.value<0.001), logarithm of total health expenditure (p.value = 0.006), Corruption Perception Index (p.value<0.001), presence of an arid climate on the national territory (p = 0.006), and the dependency ratio (p.value<0.001). A decrease in CPI of one point (i.e. a more important perceived corruption) was associated with an increase in the log of national under-five mortality rate of 0.0644. According to this result, it could be roughly hypothesized that more than 140000 annual children deaths could be indirectly attributed to corruption.

INTERPRETATIONS:

Global response to children mortality must involve a necessary increase in funds available to develop water and sanitation access and purchase new methods for prevention, management, and treatment of major diseases drawing the global pattern of children deaths. However without paying regard to the anti-corruption mechanisms needed to ensure their proper use, it will also provide further opportunity for corruption. Policies and interventions supported by governments and donors must integrate initiatives that recognise how they are inter-related.

 

• COMBATTING CORRUPTION

 

Combating healthcare corruption and fraud with

improved global health governance

 

Tim K Mackey1,2,*

Email: tmackey@ucsd.edu

Bryan A Liang1,3,4

Email: baliang@alum.mit.edu

 

1 Institute of Health Law Studies, California Western School of Law, San Diego

Center for Patient Safety, University of California San Diego School of Medicine,

350 Cedar Street, San Diego, CA, 92101, USA

2 Joint Doctoral Program on Global Health, University of California San Diego-

San Diego State University, San Diego, CA, USA

3 San Diego Center for Patient Safety, University of California San Diego School

of Medicine, 350 Cedar Street, San Diego, CA 92101, USA

4 Department of Anesthesiology, University of California San Diego School of

Medicine, San Diego, CA, USA

* Corresponding author. Institute of Health Law Studies, California Western

School of Law, San Diego Center for Patient Safety, University of California San

Diego School of Medicine, 350 Cedar Street, San Diego, CA, 92101, USA

 

Best viewed at http://www.biomedcentral.com/content/pdf/1472-698X-12-23.pdf

 

Abstract

Corruption is a serious threat to global health outcomes, leading to financial waste and

adverse health consequences. Yet, forms of corruption impacting global health are endemic

worldwide in public and private sectors, and in developed and resource-poor settings alike.

Allegations of misuse of funds and fraud in global health initiatives also threaten future

investment. Current domestic and sectorial-level responses are fragmented and have been

criticized as ineffective. In order to address this issue, we propose a global health governance

framework calling for international recognition of “global health corruption” and

development of a treaty protocol to combat this crucial issue.

 

Correspondence

The impact of globalization on health has been marked by new and daunting challenges.

Though globalization has enabled advancements in trade, travel, and communications, it has

also facilitated rapid global spread of infectious diseases such as SARS and H1N1/A,

requiring a paradigm shift in global health governance. Yet, the next global pandemic is not

the only challenge facing global health. A more immediate threat is systemic global

healthcare corruption that adversely impacts both developed and resource-poor states.

As reported by Transparency International, the scale and scope of corruption impacting

health is immense. Exact numbers are elusive, but it is estimated billions of dollars are lost

annually due to corruption and fraud in a global health market estimated to be worth 10% of

global gross domestic product in 2009 [1-3]. Systematic corruption in health is also a barrier

in meeting the Millennium Development Goals as it weakens health systems and delivery [4].

It also disproportionately impacts the vulnerable, including negative health outcomes for

women and children [4].

 

Importantly, health corruption not only leads to financial waste of scarce resources, but also

has adverse impact on healthcare access, infrastructures, financing, and social determinants of

health. In addition, health corruption can severely compromise quality and coverage of

services, leading to price inflation for health service unit costs [5].

Indeed, health corruption at the domestic level represents a severe impediment to global

health efforts in resource-poor settings and transitional economies. Corruption can drain

resources from already impoverished and fragile health systems, precluding access to lifesaving treatment for vulnerable patient populations [4,6]. With surveys reporting that 80% of individuals in developing countries have experienced health sector corruption, these resourcepoor population are disproportionately impacted [4,7,8].

 

Recent scandals that have plagued global multilateral health programs have also raised

concerns regarding presence of corruption in global health. Allegations of corruption and

fraud in the Global Fund to Fight AIDS, Tuberculosis and Malaria (the “Global Fund”)

represent a serious threat to continued funding and support of global health initiatives. This is

particularly concerning given ongoing funding challenges arising from the recent global

economic crisis [9].

 

The confluence of domestic and international level health corruption impacting global

populations points to a lack of an international framework specifically addressing the wide

range of interrelated issues associated with health-related corruption. Improved global health

governance is an important first step. Reform to detect and eliminate forms of corruption that

impact health must be coordinated in order to ensure that health systems are protected and

that global health interventions meet their full potential.

 

Global Impact of Domestic Health Corruption

Corruption is defined as the “misuse of entrusted power for private gain” [10]. In the health

setting, it can encompass bribery of health professionals, regulators and public officials;

unethical research; diversion/theft of medicines and medical supplies; fraudulent or

overbilling for health services; absenteeism; informal payments; embezzlement; and

corruption in health procurement [4,10,11]. Though many of these activities are domesticallyfocused,they nevertheless impact global health outcomes. Domestic corruption may have global results due to interconnectedness of domestic and global health financing, a globalized drug supply chain, health worker migration, and shared global health security.

In combination with the reality that criminal activities can easily impact and move across

geopolitical borders affecting multiple states/organizations, health corruption presents

significant challenges for detection and enforcement. The broad infiltration of corruption,

diversity of illicit acts, and multitude of stakeholders involved (often with limited or indirect

accountability) adds to health system complexity, existing information asymmetry, and

uncertainty in health markets, with developing countries particularly vulnerable [4,10].

Beyond developing countries, domestic corruption is also endemic in developed and

emerging economies. For example, 5-10% of USA public sector health expenditures are lost

to fraudulent overbilling [2]. Recent reports in the USA of $4 billion in recoveries in

enforcement actions, a $163 million indictment against an organized crime enterprise for

fraudulent billing, and other cases highlight the near universality of domestic level health

corruption and fraud [12,13]. As well, 5% of the Cambodian health budget is lost to

corruption within the central government, and 56% of Russian Federation total health

expenditures are “informal” payments [2].

 

The global drug supply chain also provides an illustration of how lack of regulatory

harmonization can lead to forms of global health-related corruption [14,15]. Health systems

in developing regions and emerging markets that lack transparency, regulatory control, and

adequate law enforcement can result in public and private sector extortion and bribes that

enable production and sale of counterfeit drugs [14,15]. As a result, counterfeit medicines can

be exported to other global markets, resulting in documented patient death and morbidity,

pathogen resistance and decreasing drug effectiveness, waste in resources for pharmaceutical

products and services, and lack of safe access to essential drugs [14-16].

 

Note that health corruption also extends to legitimate corporate entities. For example,

corruption allegations against multinational pharmaceutical and medical device companies

such as Johnson & Johnson, Merck, Eli Lilly, and Medtronic have surfaced involving bribery

of physicians and health officials overseas. As pharmaceutical companies push to gain entry

into emerging markets, competition gives rise to corrupt practices and have been prosecuted

as potential violations under USA and UK foreign anti-bribery laws [17]. Reflecting this

trend, recently the worlds largest drug manufacturer, Pfizer, agreed to pay a fine of more

than $60 million to settle violations of USA anti-bribery laws for improper payments to

healthcare professionals in a number of countries including China, Russia, Bulgaria, Croatia,

Kazakhstan and Italy [18].

 

This broad spectrum of domestic level health corruption that has a global impact

encompasses countries at all levels of development, spans various types of illicit activities,

and includes both public and private actors.(See Figure 1) The broad scope of the problem

necessitates development of systems of international cooperation and governance in order to

mount a comprehensive solution.

 

Figure 1 Examples of health corruption types and scopes

Corruption in Global Health Interventions

Large scale, multilateral global health programs also present new opportunities for health

corruption. Alleged domestic corruption in developing countries receiving aid through the

multibillion-dollar Global Fund has recently shaken public trust in global health initiatives

and financing [19]. Yet these are not the first allegations of corruption in the Global Fund or

other multilateral global health projects.

 

For example, corruption was discovered in 2008 in five multimillion-dollar health projects

financed by the World Bank in India. The program was aimed at combating tuberculosis,

malaria and HIV/AIDS. Investigation uncovered procurement corruption, including bidrigging and bribery [20]. Further, investigators discovered substandard HIV/AIDS testing

kits, which may have produced incorrect results and exacerbated disease spread [20]. Yet,

Indian public officials have expressed a level of acceptance regarding the corruption

allegations, commenting it is systemic in India [20]. India is also a known for having a large

informal health sector susceptible to corruption and informal payments for health services

[7,20].

 

Sovereign country representatives are also involved. For example, corruption in Uganda

involving Global Fund disbursements of $45.3 million in 2006 revealed illegal acts by public

officials, government ministers, and community health workers [21]. Several actors

defrauded the Global Fund, leading to the temporary grant suspension and interruption of

patient antiretroviral therapy with adverse consequences for its recipients [21]. Corruption

was uncovered by a whistleblower, not internal evaluators, and later verified by an

independent auditor and national judicial commission that detailed misappropriation,

forgeries, nepotism, and lack of accountability [21].

 

Other findings show continued corruption in these initiatives. For example, the Global Funds

own independent audit unit and later the Associated Press revealed $34 million in Fund

grants that may have been misused in Djibouti, Mali, Mauritania, and Zambia [19]. This

includes allegations of forged documents, improper bookkeeping, donated drugs diverted and

sold on the black market, and a range of 30-67% of funds reportedly misspent [19]. This

prompted some donor countries (e.g., Germany, Ireland, Sweden) to announce they would be

suspending support of the Global Fund in light of corruption policy concerns [22,23].

Concerns also extend to the U.N. Development Program itself, which manages half the

Global Funds spending. It refused to share internal audit reports citing its own governance

rules on audit controls and disclosure.[19,22] This led to increased scrutiny regarding the

integrity of the Fund, further damaging its credibility.

 

In response, the Global Fund announced it would be restructuring its auditing procedures and

establishing additional measures to enhance financial oversight [24]. Coincidentally, the

Global Fund recently announced it was suspending future grant funding due to lack of funds

following the aftermath of fraud disclosures [25].

 

The consequences of these allegations make it clear that forms of corruption in global health

programs continue to represent a severe risk to progress in these important interventions as

donors and the public scrutinize funding use and management. This is despite the fact that the

amounts allegedly stolen represent less than 1% of total amounts disbursed by the Global

Fund [25].

 

Suggested Policy Approaches

In response to the threats posed by forms of domestic and international health corruption,

creative global health governance policy solutions should be explored. Individual state-based

legal and institutional reform measures that have been proposed include improving allocation,

monitoring, auditing and health expenditure tracking; adopting codes of conduct and ethics;

and developing rules to increase transparency [5,10]. However, a lack of a comprehensive,

internationally cooperative framework specifically addressing health corruption on a global

level undermines the effectiveness of these independent efforts.

 

To address these corruption challenges, we propose a global health governance approach.

This would be based upon creating international consensus and recognition of the concept of

“global health corruption.” Creating recognition of an overarching definition coupled with

development of an internationally binding treaty protocol and a governance framework can

lead to cooperation and potential for harmonized laws and regulations to effectively combat

global health corruption (see Table 1).

 

Table 1 Key Points of Global Health Anti-Corruption Framework

GOVERANANCE SYSTEM DESCRIPTION BENEFITS INSTITUTIONAL

RESPONSIBILITY

 

Establishing International Consensus on “Global Health Corruption”

Suggested definition: “misappropriation of authority, resources, trust or power for private or institutional gain that has adverse effects on regional, local, or international health systems and/or that negatively impacts individual patient and/or population health outcomes.”

 

Establishes an internationally recognized definition and draws needed attention to the unique risks

of health-related corruption International community and input from all relevant stakeholders (e.g. law

enforcement, regulators, judicial system, civil society, global health systems)

 

WHO-UNODC Global Health Corruption Protocol Under UNCAC

Development of an international binding treaty protocol on global health corruption and establishing the

necessary global health governance framework

Implements definition under an existing international treaty and establishes infrastructure for global

corruption framework Member states of WHO and UNODC

 

Global Health Anti-Corruption Governance Framework

Model Acts System: Development of Model Acts system of core anticorruption definitions and

requirements for individual states to implement with certain flexibilities Development of a model system

for states to follow in developing their own domestic systems and aids in harmonization

Signatories to Protocol in consultation with domestic stakeholders

 

Domestic and Regional Corruption Tools: Assessment of inclusion of existing domestic anti-corruption tools

that have had success

Examines existing enforcement tools that have curbed domestic level health corruption

Governance structure of protocol (e.g. conference of state parties, other developed governing body)

 

Useful International Tools and Systems: Assessment and active inclusion of existing methods, tools

and good practices addressing corruption developed by international organizations

Assesses existing tools developed by international organizations aimed at addressing global health

system corruption

Governance structure of protocol (e.g. conference of state parties, other developed governing body)

 

Governance System: Development and implementation of dynamic global health governance structure to address global health corruption flexible enough to deal with diverse forms of corruption in different settings

Governance system flexible enough to be tailored to domestic and global health system needs.

Should be comprehensive including components of protocol implementation, financing, incorporation of health system strengthening, and establishment/recommendation of various anti-corruption interventions.

All stakeholders

 

A Global Health Corruption Governance Framework

Definition of “Global Health Corruption”

A crucial first step in addressing global health corruption is establishing international

recognition and consensus of this specific type of corruption while emphasizing the

importance of developing anti-corruption tools in health policy and capacity building goals

[4]. Though the general concept of “corruption” has been recognized in the U.N. Office on

Drugs and Crimes (“UNODC”) 2003 U.N. Convention against Corruption (“UNCAC”), a

legally binding anti-corruption instrument, unique challenges created by both domestic and

global health system corruption impacting population-based health have not been delineated

[26].

 

In response, the concept of global health corruption should be expressly defined, discussed,

and adopted through an international legally binding framework employing partnership with

the World Health Organization (WHO) and the UNODC. This can be accomplished through

consultative meetings and development of a Global Health Corruption Protocol to the

UNCAC, with ongoing and active participation of WHO to add provisions specifically

addressing health. We believe an effective working definition of global health corruption

could start as the: “misappropriation of authority, resources, trust or power for private or

institutional gain that has adverse effects on regional, local, or international health systems

and/or that negatively impacts individual patient and/or population health outcomes.” This

definition should include the varying forms of corruption occurring both at the domestic and

global program system level, as both forms of corruption can have an impact on global

health.

This standard definition can provide the basis for strategic efforts to coordinate cross-border,

regional and international actors to detect and prosecute criminals in concert with existing or

future domestic and regional laws that recognize the important differentiation of general

corruption and corruption impacting health. This can result in individual countries enacting

domestic laws that are harmonized internationally to allow law enforcement to coordinate

global anti-corruption strategies for more effective prosecution. This can lead to development

of best practices, with defined subsets of forms of global health corruption, identification of

common vulnerabilities in health corruption, development of efficient financing mechanisms

and judicial systems, and minimum requirements for transparency, enforcement and

prosecution.

 

Model Acts System

To implement this governance system, a “model act” approach, similar to USA that allows

adoption of model clauses and harmonization by individual states, may be an efficient

strategy. This would allow WHO-UNODC to build on agreed upon global health corruption

definitions but tailor them for cultural and infrastructural differences, allowing more effective

adoption by individual countries sensitive to the local environment. Components could

include model requirements for public and private sector policies on disclosure, auditing,

procurement, drug supply, and payments to healthcare professionals.

 

Domestic and Regional Corruption Tools

Developed country anti-bribery laws may also serve as potential enforcement tools that can

be assessed for inclusion in a global health corruption framework. Laws such as the USA

Foreign Corrupt Business Practices Act and UK Anti-Bribery Act prohibit corporations and

individuals based in these countries from bribing public officials in other countries and

engaging in other forms of corruption; they have been successful in at least some health

sector prosecutions [17,18].

 

Other national laws, such as the USA Anti-kickback Statute and the False Claims Act,

impose both civil and criminal fines for the submission of false claims and for providing

forms of remuneration to healthcare professionals for referrals for services covered under

national healthcare programs [27]. These laws employ incentive and payment schemes that

reward whistleblowers who report illegal activity and have resulted in record-breaking fines

against criminal and industry actors [27]. Such enforcement tools could be incorporated into

other national healthcare programs to improve enforcement and prevention, and modified so

that recovered amounts are earmarked for public health financing/system strengthening.

Collectively, these domestic laws currently rely upon developed country enforcement and

could be more effective if they had global or regional coverage.

 

Further, domestic and regional efforts such as the UKs National Health System anti-fraud

unit and the European Healthcare Fraud and Corruption Network could also be considered.

These represent models for tailored anti-global health corruption systems that may be scaled

up for increased more regional/global coverage.

 

Useful International Tools and Systems

As part of enhanced governance efforts, WHO-UNODC should utilize existing research and

guidance on corruption in health, including methods, tools and good practices as developed

by the United Nations Development Programme (“UNDP”) [4]. These strategies, including

an emphasis on prevention, broad-based partnership and participation with various

stakeholders and sectors, whistleblowing mechanisms, and creating incentives and

disincentives for good and bad behavior respectively.[4]. This can include integration of

WHOs own programs on corruption, including diagnostic and risk assessment tools and the

WHO Good Governance for Medicines Programme [4]. They should also integrate World

Bank tools such as the Detailed Implementation Review, a proactive diagnostic tool used by

the Bank to evaluate projects for indicators of fraud and corruption using forensic accounting

and fraud investigation techniques that assess and detect the risk of fraud and corruption.

These tools, along with front-line tools developed by USAID, specifically target multilateral

global health programs and should be incorporated [4,28]. By coordinating these divergent

efforts into a central framework, better policy coherence and cooperation can occur across

agencies/platforms.

 

Governance Systems

Recognizing that there is no “one size fits all” approach in establishing a comprehensive

framework to deal with all forms of global health corruption, careful attention should be

given to programmatic differences between domestic versus global health systems. Hence,

vertically integrated global health initiatives spanning the scope of multiple, international

stakeholders focused on individual diseases need to be addressed uniquely within the context

of susceptibility to corruption. Similarly closed national health systems that are not primarily

funded by international health or development assistance and are primary-care focused need

to be assessed differently from their global health system counterparts.

 

Fortunately, global governance models are available for guidance. Using the UNCAC

experience, global governance approaches to corruption can include WHO-UNODC member

creation of formal and binding systems. This includes establishing a strategy for global health

corruption protocol implementation, anti-corruption system financing, and overall health

system strengthening. This can be accomplished by providing technical assistance to member

states, developing model policies and tools for anti-corruption, identifying “at-risk” countries,

exploring innovative financing mechanisms (e.g., funding through allocation of a percentage

of anti-corruption fines/recoveries) and coordinating efforts with other multilateral and

bilateral development, health, and enforcement agencies, civil society, and the private sector

[29]. These efforts can also be coupled with international initiatives to improve aid

effectiveness, by integrating developed anti-corruption strategies into efforts of the Paris

Declaration on Aid Effectiveness and related forums.

 

At a minimum, these governance systems should involve multiple interventions and include:

(1) transparency and audit policies; (2) a common framework for corruption monitoring and

evaluation of public health programs and funding; (3) Codes of Conduct for public and

private sector actors; (4) minimum standards for member state laws to specifically prevent

and prosecute health-based corruption; (5) health financing improvements to curtail the need

for an informal health sector; (6) a centralized surveillance and data repository system to

report and investigate global health corruption; (7) multilateral processes to freeze proceeds

from corruption and aid in recovery of diverted assets; and (8) commitment to earmark

portions of seized assets to fund and develop these anti-corruption systems among members.

This dynamic and comprehensive “global health anti-corruption” framework can build on

existing and future best practices, as well as examine previous corruption case studies to

determine appropriate strategies that are sensitive to domestic or regional limitations. Though

these policies may results in some additional costs and require administrative resources to

implement, they are nevertheless crucial in protecting and obtaining the benefits from public

health investments, enhancing health system strengthening, and maintaining public trust in

global health interventions.

 

Potential Benefits

The potential benefits of the proposed global health governance framework could be

significant, starting with global recognition regarding the unique risks of global health

corruption and its adverse impact on societies worldwide.

 

Importantly, this strategy can assist in addressing corruption both on a global and domestic

level. Beyond coordinating domestic and international law enforcement efforts, more focused

strategies to prioritize rapid review of health projects and systems that are most susceptible to

corruption and have the greatest negative impact on health outcomes should be addressed

immediately [4]. As an example, forms of pharmaceutical sector corruption that enable

production and consumption of dangerous counterfeit medicines and represent an immediate

patient safety threat can be prioritized in global anti-corruption efforts.

 

In addition, anti-corruption actions can be strategically targeted for diverse domestic

populations by disseminating community-based monitoring tools addressing different forms

of health corruption endemic in particular setting (e.g., border and migrant health). As well,

proactive regional risk assessment can allocate resources to populations most affected by

global health corruption. Such a “top down/bottom up” approach can allow for flexibility of a

dual global and domestic approach to combating global health corruption, ensuring better

accountability, transparency, and importantly, effective use of anti-corruption investment.

 

Summary

Global health corruption remains a serious, ongoing, and under recognized threat to global

health progress. Unfortunately, the worlds most vulnerable shoulder much of this life-and death burden. Further, recent global health initiative scandals serve to emphasize the need for

progressive and global reform.

 

Under Article 12 of the International Covenant on Economic, Social, and Cultural Rights,

every human has a fundamental right to the highest attainable standard of health [30]. Global

health corruption undermines this fundamental right. Domestic, international, public and

private entities must join together to ensure that health equity is given true weight. This

requires a commitment to collectively address global health corruption so that public health

benefits of global health efforts inure to the populations they are intended for.

 

Competing interest

The authors declare no potential conflicts of interest or competing interests associated with

this manuscript.

 

Author information

Tim K. Mackey, MAS: TKM is a Senior Research Associate, Institute of Health Law

Studies, Ph.D Candidate in the Joint Doctoral Program in Global Health at University of

California, San Diego-San Diego State University, and Clinical Instructor at University of

California, San Diego. He holds a Masters Degree in Health Law, UCSD-California Western

School of Law. He has a diverse professional background including public and private sector

experience and completing an internship at the World Health Organization. He has coauthored

over 50 publications and given numerous presentation on issues including

counterfeit medicines, global health governance, health migration, biodiversity, eHealth,

organized crime and corruption, and pandemic response.

Bryan A. Liang, MD, JD, PhD: BAL is Executive Director and Shapiro Distinguished

Professor, Institute of Health Law Studies, California Western School of Law; Director and

Professor of Anesthesiology, San Diego Center for Patient Safety, UCSD School of

Medicine. His work focuses upon the systemic impact of health policy and law on patient

safety, broadly construed. He combines experience working in policy contexts in Asia, the

European Union, and USA with legal, medical, and economics training to formulate rational

social policy promoting patient safety. He received his BS from MIT; PhD from University

of Chicago; MD from Columbia; JD from Harvard.

 

Authors contributions

We note that with respect to author contributions, Tim Mackey (TM) and Bryan A. Liang

(BAL) jointly conceived the study, TM and BAL jointly wrote the manuscript, TM, and BAL

jointly edited the manuscript, and BAL supervised its legal and policy analysis. All authors

read and approved the final manuscript.

 

References

1. Growing threat from counterfeit medicines. Bull. World Health Organ 2010, 88:247–

248.

2. Dyer O: New report on corruption in health. Bull. World Health Organ. 2006, 84:84–85.

3. Total expenditure on health as a percentage of gross domestic product (measured in US$).

http://www.who.int/gho/health_financing/total_expenditure/en/index.html.

4. Fighting Corruption in the Health Sector: Methods, Tools and Good Practices.

http://www.undp.org.tt/News/UNODC/Anticorruption%20Methods%20and%20Tools%20in

%20Health%20Lo%20Res%20final.pdf.

5. Kirigia JM, Diarra-Nama AJ: Can countries of the WHO African Region wean

themselves off donor funding for health? Bull. World Health Organ. 2008, 86:889–92.

discussion 893–5.

6. Corruption in the health sector. http://www.cmi.no/publications/file/3208-corruption-inthe-

health-sector.pdf.

7. Holmberg S, Rothstein B: Dying of corruption. Health Econ Policy Law 2011, 6:529–47.

8. Medicines: corruption and pharmaceuticals.

http://www.who.int/mediacentre/factsheets/fs335/en/index.html.

9. Impact of the global financial and economic crisis on health.

http://www.who.int/mediacentre/news/statements/2008/s12/en/index.html.

10. Global Corruption Report 2006. London: Transparency International; 2005:1–378.

11. Vian T: Review of corruption in the health sector: theory, methods and

interventions. Health Policy Plan 2008, 23:83–94.

12. Health care fraud prevention and enforcement efforts recover record $4 billion; new

Affordable Care Act tools will help fight fraud.

http://www.hhs.gov/news/press/2011pres/01/20110124a.html.

13. 73 Members and Associates of Organized Crime Enterprise, Others Indicted for Health

Care Fraud Crimes Involving More Than $163 Million.

http://www.justice.gov/opa/pr/2010/October/10-dag-1140.html.

14. Garuba HA, Kohler JC, Huisman AM: Transparency in Nigerias public

pharmaceutical sector: perceptions from policy makers. Global Health 2009, 5:14.

15. Cohen JC, Mrazek M, Hawkins L: Tackling corruption in the pharmaceutical systems

worldwide with courage and conviction. Clin Pharmacol Ther 2007, 81:445–449.

16. Liang BA: Fade to black: importation and counterfeit drugs. Am J Law Med 2006,

32:279–323.

17. Global drug industry tightens anti-corruption code.

http://www.reuters.com/article/2012/03/01/us-pharmaceuticals-corruptionidUSTRE8200E020120301.

18. Pfizer, Wyeth To Pay More Than $60 Million To Resolve FCPA Allegations.

http://www.thompson.com/public/newsbrief.jsp?cat=FOODDRUG&id=3912.

19. AP Enterprise: Fraud plagues global health fund.

http://www.businessweek.com/ap/financialnews/D9KUA79O0.htm.

20. Solberg KE: Indias health sector responds to new corruption charges. Lancet 2008,

371:464.

21. Cohen J: HIV/AIDS. Uganda confronts corruption, slowly. Science 2008, 321:522–

525.

22. Tough on truth. Nature 2011, 470:6.

23. Usher AD: Defrauding of the global fund gives Sweden cold feet. Lancet 2010,

376:1631.

24. Global Fund Announces Measures To Increase Fraud Detection, Prevention.

http://globalhealth.kff.org/Daily-Reports/2011/February/04/GH-020411-Global-Fund.aspx.

25. Global AIDS Fund Will Pause New Grants and Seek New Manager.

http://www.nytimes.com/2011/11/24/health/global-aids-fund-cancels-fund-raising-and-seeksnew-

manager.html.

26. Convention against Corruption.

http://www.unodc.org/unodc/en/treaties/CAC/index.html.

27. Mackey T, Liang B: Off Label Promotion Reform: A Legislative Proposal Addressing

Vulnerable Patient Drug Access and Limiting Inappropriate Pharmaceutical

Marketing. University of Michigan J. of Law Reform 2011, 45:1–54.

28. India - Government of India and World Bank Group Join Forces to Stamp Out

Corruption in Health Sector Projects.

http://www.worldbank.org.in/WBSITE/EXTERNAL/COUNTRIES/SOUTHASIAEXT/INDI

AEXTN/0,,contentMDK:21609990~pagePK:1497618~piPK:217854~theSitePK:295584,00.h

tml.

29. United Nations Convention against Corruption Priorities for the provision of technical

assistance. http://www.unodc.org/pdf/crime/corruption/corruption_gpac_strategy_jul04.pdf.

30. International Covenant on Economic, Social and Cultural Rights.

http://www2.ohchr.org/english/law/cescr.htm.