title: Exploring corruption in the South African health sector.
abstract: Recent scholarly attention has focused on weak governance and the negative effects of corruption on the provision of health services. Employing agency theory, this article discusses corruption in the South African health sector. We used a combination of research methods and triangulated data from three sources: Auditor-General of South Africa reports for each province covering a 9-year period; 13 semi-structured interviews with health sector key informants and a content analysis of print media reports covering a 3-year period. Findings from the Auditor-General reports showed a worsening trend in audit outcomes with marked variation across the nine provinces. Key-informants indicated that corruption has a negative effect on patient care and the morale of healthcare workers. The majority of the print media reports on corruption concerned the public health sector (63%) and involved provincial health departments (45%). Characteristics and complexity of the public health sector may increase its vulnerability to corruption, but the private-public binary constitutes a false dichotomy as corruption often involves agents from both sectors. Notwithstanding the lack of global validated indicators to measure corruption, our findings suggest that corruption is a problem in the South African healthcare sector. Corruption is influenced by adverse agent selection, lack of mechanisms to detect corruption and a failure to sanction those involved in corrupt activities. We conclude that appropriate legislation is a necessary, but not sufficient intervention to reduce corruption. We propose that mechanisms to reduce corruption must include the political will to run corruption-free health services, effective government to enforce laws, appropriate systems, and citizen involvement and advocacy to hold public officials accountable. Importantly, the institutionalization of a functional bureaucracy and public servants with the right skills, competencies, ethics and value systems and whose interests are aligned with health system goals are critical interventions in the fight against corruption.
authors.affiliation: Centre for Health Policy & Medical Research Council Health Policy Research Group, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, 27 St Andrew's Road, Parktown 2193, South Africa, laetitia.rispel@wits.ac.za.
authors.forename: Laetitia C
authors.initials: LC
authors.lastname: Rispel
authors.affiliation: School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, 27 St Andrew's Road, Parktown 2193, South Africa and Epidemiology and Surveillance Unit, National Institute for Occupational Health, 25 Hospital Street, Constitution Hill 2001, South Africa.
authors.forename: Pieter
authors.initials: P
authors.lastname: de Jager
authors.affiliation: School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, 27 St Andrew's Road, Parktown 2193, South Africa and.
authors.forename: Sharon
authors.initials: S
authors.lastname: Fonn
mesh_terms: D005607:Fraud; D019981:Health Care Sector / Q000941:ethics / Q000458:organization & administration*; D006801:Humans; D017149:Private Sector / Q000941:ethics*; D011634:Public Health / Q000331:legislation & jurisprudence; D017150:Public Sector / Q000941:ethics*; D012941:Social Responsibility; D013019:South Africa
keywords: Corruption; South Africa; agency theory; governance; health systems