Looking for a cure: World Bank's Abdo Yazbeck

World Bank health sector manager for Europe and Central Asia Abdo Yazbeck talks curbing corruption in healthcare, decentralisation and bringing cash to the system. Interview by Michael Bird

March 2009 - From the Print Edition

Bribes or informal payments given by patients to doctors, nurses and hospital staff are a serious problem which undermines the healthcare and national security of many developing countries.
Even in an EU nation such as Romania, many citizens dread going to the hospital for fear of having to negotiate in a black market of paying cleaners, nurses, doctors and even anaesthetists for basic services and sophisticated operations.
There is little analysis on the extent of the problem in Romania. Many campaigners have complained that previous Governments have been unwilling to tackle the gravity of the practice in Romania. One report indicated that, in 2005, around 300 million Euro was paid in bribes in the country’s healthcare sector.
Ending such a tendency is tough, says Abdo Yazbeck, sector manager in health, nutrition and population at the World Bank’s human development department for Europe and Central Asia. The Bank, a key financier of health reform in Romania, has analysed and funded strategies for limiting this practice in other countries. “It’s about creating a package for healthcare providers and communities,” says Yazbeck. “Making more money available for drugs, compensating providers differently and in return gaining clarity about who gets paid and cutting down on informal payments.”
Yazbeck says the distribution of accurate information to patients about the health market is vital. This includes defining a solid benefits package that patients know they are entitled to free-of-charge and which services need official co-payments. “A vagueness about the benefits package creates an incentive for [health staff] to ask for money,” he says.
Low wages to doctors are often cited as a reason for bribe-taking. But this is part of a vicious circle. Because of low salaries, some doctors feel they have a right to accept bribes. The practice of taking illegal payments then becomes so endemic that for health staff to sacrifice the black market for a higher salary may not be as lucrative.
Yazbeck says performance-related salaries and higher salaries can discourage informal payments. “If health providers are not compensated enough, they make up the difference and that is part of the problem,” says Yazbeck. “It creates a permissive system.”
In the Karghaz Republic over a five year period, the health system reduced informal payments significantly, especially in the under-the-counter purchase of medicine. The reform changed how facilities were paid and made more state money available for drugs. “With information, improved funding and having the right mechanism at a facility level for funding, we can decrease informal payments,” says Yazbeck.
Decentralisation of healthcare from the national to local level can also help, says Yazbeck. “In Asia, having a community-based board that supports hospitals became a wonderful accountability mechanism,” he says. “If there is too much graft or under the table payments, [patients] can go to a community board and this can intervene.”
Punishment is also a component, but evidence on whether locking up doctors for taking a bribe works as a disincentive to corruption is “not clear”, says Yazbeck. “Sometimes it’s a cultural response,” he says. “If that is the case, then you have to dig much deeper. You can’t only say we’re going to put a few people in jail, although that may help in extreme cases.”
Fixing the financing system is also necessary. Formalising the payment system can work, if there is a well-structured fee mechanism with a good exemption system protecting the vulnerable. “If funds are recycled within a system, that can be an incentive,” he adds. This is the case of family doctors, who are paid by the service given to the patient in Romania. “I would like to see Romania take a very aggressive stance – such as listing the five things to do to attack this problem – and in five years’ time we learn, we adjust and we improve,” he adds.
Such programmes, Yazbeck says, the World Bank would be “more than happy” to finance.

Moving out

From the late 1940s, Romania’s healthcare system followed the Soviet Semashko model, which centrally planned the system through the Ministry of Health in a bid to ensure universal healthcare. But in a bankrupt post-Decembrist climate, the cracks in this system became wider, such as inefficiency, a lack of delegation to regional and local authorities and an absence of accountability.
Since then Romania’s leaders have trumpeted the buzzword of decentralisation. But this is not a cure-all. Methods of decentralisation must be efficient and equitable, otherwise the Ministry of Health can end up outsourcing to regions or contractors who are unqualified and uninformed.
Decentralisation can either be of healthcare financing, including collecting taxes and distributing budgets to hospitals and clinics, or of service delivery, which gives clinics and hospitals greater autonomy or places them under local authority control.
Yazbeck says a healthcare system does not want too much decentralisation of financing. “For a country like Romania with a large health insurance fund, it makes no sense to fragment this,” he says. However he says that if patients pay for services at a local level – to a clinic or hospital – this money could be somehow retained locally. This gives local health services an incentive to take on new patients.
In service delivery, Yazbeck says decentralisation works. “Having an overly centralised control mechanism for decision-making in a country the size of Romania does not make sense,” he says. “It needs to have local authorities making decisions.”
The trick is matching the role with the correct decision maker, whether that be local, regional or national. “Setting standards is a national decision because standards do not change at a local environment,” he says. “But the day-to-day budget management should not be controlled centrally.”
However it is essential to ensure that new decision makers in the system have the correct information at their disposal and the capacity to carry out policies to the benefit of patients, doctors and authorities. At present heads of hospitals at a regional level are appointed at the national level. “It’s always good to have local accountability as well as national accountability,” says Yazbeck.
In family healthcare, Romania has 10,000 family doctors who are paid, by the state, for each service they provide a patient. This system has worked in Russia and Turkey. But Yazbeck says there is less of a consensus on allowing a similar level of autonomy to hospitals.

Private ambition

For 20 years ex-Communist countries have engaged with the private sector, but between the public and private extremes there is a lot of space where a health system looks to find the right balance. A clinic can take on a private wing of a hospital or a hospital can outsource contracts for activities – such as cleaning staff or lab services. A private company can manage a public hospital under contract with the Government or build, own and lease a hospital to the state. The extreme is for the state to sell a hospital to a business. Private-public partnerships (PPPs) are possible for systems which are cash-strapped. A company can inject money into the system and then retrieve this investment in the long-term. But there are trade-offs. The state sector may benefit from the efficiencies of enterprise, but has to worry about spiralling costs as the market demands a profit. “The issue is not to see the private sector as either the enemy or the final solution,” says Yazbeck. “It is a part of a large puzzle. [A country’s health system] does not want to tackle the health problems with one hand tied behind its back.”
The healthcare sector has a social imperative which can interfere with the profit incentive, especially as the neediest can be the most expensive consumers of medical care. “We want to use the energy and entrepreneurism of the private sector, but keep Government control to ensure high quality and equitability in institutions,” he adds.

Reform talk

In Romania, the new Minister of Health Ion Bazac has announced the necessity of a closer relationship with the World Bank in health financing. “If the Government is serious about reforms - and I have no doubt they are - we would love to help operationally in technical support and financially,” says Yazbeck.
Since 1992, the Bank has supported Romania’s health system in project financing and budget financing, assistance and analysis. Together with the European Investment Bank, the World Bank has launched a plan worth over 100 million Euro to reform the maternal health system. Now the Bank wants to move away from buying healthcare equipment to supporting ways to improve the delivery of healthcare.
A few years ago the cost of taking out a loan from the World Bank and raising a loan on the commercial markets was narrowing. “Money was cheap. For countries in Europe we were slowly getting out of the lending business,” says Yazbeck. Now the difference between the costs of commercial loans and World Bank loans is huge. “Since the financial crisis,” he says, “the demand for us to lend in Europe has gone incredibly high.”