Corruption is embedded in health systems. Throughout my life—as a researcher, public health worker, and a Minister of Health—I have been able to see entrenched dishonesty and fraud. But despite being one of the most important barriers to implementing universal health coverage around the world, corruption is rarely openly discussed. In this Lecture, I outline the magnitude of the problem of corruption, how it started, and what is happening now. I also outline people's fears around the topic, what is needed to address corruption, and the responsibilities of the academic and research communities in all countries, irrespective of their level of economic development. Policy makers, researchers, and funders need to think about corruption as an important area of research in the same way we think about diseases. If we are really aiming to achieve the Sustainable Development Goals and ensure healthy lives for all, corruption in global health must no longer be an open secret.

This situation is the reality today. Now that we have more resources than ever globally, the whole world is erupting in corruption, but we are not talking about or confronting the issue. Corruption is an open secret known around the world that is systemic and spreading.Over two-thirds of countries are considered endemically corrupt according to Transparency International.Although the perception of corruption in the health sector varies across countries, overall the sector is viewed very negatively.Corruption affects the poor and most vulnerable, and corruption in the health sector is more dangerous than in any other sector because it is literally deadly.Corruption violates the rights of individuals and communities.When corruption relates to health, health systems, individuals, and health outcomes are deeply affected.It is estimated that, each year, corruption takes the lives of at least 140 000 children,worsens antimicrobial resistance, and undermines all of our efforts to control communicable and non-communicable diseases.Corruption is an ignored pandemic.

My main disclosure is that I am not at all an expert on the topic, except that as someone from a middle-income country in Latin America, I have lived my entire life surrounded by corruption, which was viewed by many as the status quo or even as a coping mechanism. I have heard people within my country and colleagues from the north (by which I am referring to higher-income countries in the northern hemisphere) use terms such as survival corruption, to try to justify unjustifiable situations. As a medical student, 30 years ago, I saw corruption related to providers' practices, supplies, drugs, and more, but because resources were scarce at that time, there was not too much to steal. However, when I became the Peruvian Minister of Health in 2016, I realised the magnitude of the problem, especially because there are now more resources than ever. With more money, there is more corruption. The availability of foreign aid for health also fuelled corruption globally. I have seen how, in order to move a strategy on or complete an implementation, it was viewed as acceptable, although sometimes odd (in the words of funders), to pay extra for activities that were part of providers' jobs or to simply overlook things that were uncomfortable.One example is paying health-care providers to attend training sessions—isn't training part of their jobs and an incentive? Well, it used to be in my country, but for several global health programmes, paying health workers to attend a training session became a practice and created an unsustainable corrupt circle. This practice led to a situation in which health workers participating in training were not those who needed the training, but those who were chosen to receive the incentive. For global health experts who argue that it is important to identify whether corruption is or is not an obstacle to the success or implementation of a global health programme,I will argue that corruption is always a problem, even if the programme looks like a success. Corruption is a substantial cost-related driver that affects a programme's sustainability and effectiveness and the possibility of a country's graduation from aid or mother support.

I would like to advocate for the need for researchers and academicians from the global community to develop and test new models that could work to fight against corruption in global health, and to funders to support this effort. This task is urgent; corruption is the biggest threat for the future of health globally.

Here, I would like to clarify that I use the term global health to refer to the health of populations in the global context, not to refer—as many do (wrongly I think)—to investments by organisations, foundations, and high-income countries in efforts to address health and development challenges in less economically developed countries, usually in the southern hemisphere.

I have heard so many people around the globe saying that we live in an extraordinary time in the history of public health, and I kind of agree. Each day, more technology to fight diseases and improve lives is made available, and we are continuously doing numerous sophisticated randomised trials to test whether an intervention or a new drug works. This is indeed a key moment in history. However, all of these incredible breakthroughs will mean little if they do not work in the real world and we cannot reach all people. We talk about careful planning, implementation, commitment, and leadership to make things work in health systems, but we do not talk about the main challenge we are facing in global health—corruption.

In the past 30–40 years, corruption has really erupted, and since the early 1990s it has received more attention.Some explanations about the spread and growth of corruption link to the profound changes after World War 2 and with the Cold War.After World War 2 and after a very short period of reconstruction, the European countries that had occupied much of the world essentially de-occupied those territories, leading to the emergence of new countries. A similar phenomenon happened at the very end of the 1980s and the beginning of the 1990s, with the end of the Cold War. The new countries that were created after the breakup of the Soviet Union had institutions that were inexperienced and that were staffed with people who lacked sufficient knowledge or experience. These institutions were weak and vulnerable to exploitation, abuse, misuse, and corruption.Parallel to this, global markets started to expand to a broader range of commercial and trade relationships. Although North American and European businesses did not have experience working in other parts of the world, they sought expedited and convenient ways of interacting with these new places, which unfortunately were greasing the wheels for corruption. Such practices spread like a virus, leading to corruption as a way to facilitate interactions. In countries with authoritarian regimes, in which regular people had very little power, corruption found a space to bloom.In our global world, we have to recognise the role of developed countries as the supply side of the corruption equation in developing countries. We also have to recognise the existence of corrupted and corruptors, and the need to work together in the quest for a solution for this global problem.

Although there is no one comprehensive, universally agreed definition of corruption, corruption is clearly “the abuse of entrusted power for private gain”.Corruption presents in a range of ways, from the subtle to the very grandiose. Corruption has existed for a long time, probably as long as there have been human social structures.Some theories suggest that in the development of social structures, there are clear differences in what happened with nations in the north compared with the south, which could explain the endemicity and higher amounts of corruption in the latter. Governments in the north were created to serve citizens whereas in the south, colonies were structured to exploit resources and populations. Later on, when colonised nations became independent, the social structures maintaining these colonial practices continued to benefit the new individuals in power.

This equation shows that the more concentrated a supply of a good or service is, the higher the discretionary power of those that control the supply is, and the lower their accountability to others is; therefore the amount of corruption will be higher. Unfortunately, these are the characteristics of health systems. The complexity of the system, high public spending, market uncertainty, information asymmetry, and the presence of many actors (ie, regulators, payers, providers, consumers, and suppliers) interact at different levels, increasing susceptibility to corruption.Moreover, global health-care expenditures are on the rise due to growing ageing populations, chronic and more complex diseases, pressure to acquire high-tech and costly equipment, and an increasing number of expensive drugs pushed by powerful transnational vendors in an interconnected world, all of which cause social pressure for governments and attract more corruption.Additionally, issues such as a lack of good record keeping and inefficiency make it more complicated to differentiate corruption from honest mistakes.

Corruption is embedded and systemic in the health sector. Klitgaard and colleagueshighlight that the amount of corruption depends on three variables: monopoly (M) on the supply of a good or service, the discretion (D) enjoyed by suppliers, and the supplier's accountability (A) to others. The authors show that the amount of corruption (C) could be expressed as: C=M + D – A.

It is estimated that the world spends more than US$7 trillion on health services, and that at least 10–25% of global spending is lost directly through corruption, representing hundreds of billions of dollars lost each year.These billions lost to corruption exceed WHO's estimations of the amount needed annually to fill the gap in assuring universal health coverage globally by 2030.However, the true cost of corruption for people is impossible to quantify because it can mean the difference between wellness and illness, and life and death.

Corruption threatens any efforts to reform the public sector and to reach universal health coverage, which also affects efforts to achieve the UN's Sustainable Development Goal 3.Corruption limits access to health services and debilitates all dimensions that determine good health systems performance: equity, quality, responsiveness, efficiency, and resiliency, and also affects outcomes and lives.Corruption also causes demotivation and burnout of human resources. It is the “cancer of our health systems.”

Clientelism in the public sector: why public service reforms may not succeed and what to do about it.

The health sector is an attractive sector for corruption.Corruption can be seen in all societies. However, because it is influenced by organisational factors, the extent of corruption seen in any sector, including health, relates to the society in which it operates. In societies with less adherence to the rule of law, less transparency, and less accountability mechanisms, health systems are more corrupt.

Types of corruption in health

10 Transparency International

Global Corruption Report 2006. 38 Vian T

Nordberg C Corruption in the health sector. 37 Vian T Review of corruption in the health sector: theory, methods and interventions. 15 Transparency International

The ignored pandemic. 39 Kisakye AN

Tweheyo R

Ssengooba F

Pariyo GW

Rutebemberwa E

Kiwanuka SN Regulatory mechanisms for absenteeism in the health sector: a systematic review of strategies and their implementation. , 40 Ackers L

Ioannou E

Ackers-Johnson J The impact of delays on maternal and neonatal outcomes in Ugandan public health facilities: the role of absenteeism. , 41 Belita A

Mbindyo P

English M Absenteeism amongst health workers—developing a typology to support empiric work in low-income countries and characterizing reported associations. , 42 Callen M

Gulzar S

Hasanain SA

Khan Y The political economy of public sector absence: experimental evidence from Pakistan. , 43 Chaudhury N

Hammer J

Kremer M

Muralidharan K

Rogers FH Missing in action: teacher and health worker absence in developing countries. 15 Transparency International

The ignored pandemic. Corruption in health can range from petty corruption to high-level national, or even multinational, corruption.It presents in different ways, such as bribery, extortion, theft, embezzlement, nepotism, and undue influence.It appears at different points in the system: in the provision of services by medical personnel and other health workers, in the purchase, distribution, and use of equipment drugs and supplies, in regulation of the quality of products and services, in the hiring of human resources, and in the construction of facilities.Transparency International recently discussed the six most common types of corruption in service delivery.The first is absenteeism. Leaving aside legitimate causes such as illness, absenteeism is when employees do not show up to work. In the case of health services in low-income and middle-income countries, this is often because they are engaging in private practice during their regular public service working hours. Labour unions in several low-income and middle-income countries support this informal situation. Absenteeism is associated with the lack of accountability and penalties and, not only demotivates good workers, but also leaves patients without the care needed.Unfortunately, although absenteeism is a common problem (believed to affect 34–50% of employees globally,it has not been well studied.

44 Allin S

Davaki K

Mossialos E Paying for “free” health care: the conundrum of informal payments in post-communist Europe. , 45 Balabanova D

McKee M Understanding informal payments for health care: the example of Bulgaria. , 46 Cherecheş RM

Ungureanu MI

Sandu P

Rus IA Defining informal payments in healthcare: a systematic review. 47 Alcázar L

Andrade R Induced demand and absenteeism in Peruvian hospitals. , 48 Gibbons L

Belizán JM

Lauer JA

Betrán AP

Merialdi M

Althabe F The global numbers and costs of additionally needed and unnecessary caesarean sections performed per year: overuse as a barrier to universal coverage. 21 Naím M Corruption eruption. 49 Jimenez MM

Bui AL

Mantilla E

Miranda JJ Human resources for health in Peru: recent trends (2007–2013) in the labour market for physicians, nurses and midwives. 50 Consortium of Universities for Global Health. The second form of corruption is informal payments from patients, which include a range of situations and amounts that represent bribes in most cases.The third form of corruption is embezzlement and theft of money, supplies, and medications. Embezzlement is one of the most clear-cut forms of corruption. The fourth form of corruption is corruption in service provision, which includes actions (eg, treatments, procedures, and referrals) not driven by medical considerations alone and can be either over-provision or under-provision of these actions. Corruption in service provision happens worldwide in the public and private sectors, inflating the costs of services, and placing patients at risk. An example is the excess of caesarean sections in Latin American and other countries.According to Naím,“conflict of interest underlies all acts of corruption.” One example in Peru is the conflict between health professionals, such as the refusal of physicians to allow trained professional midwives to do particular procedures (eg, colposcopy or cryotherapy), alleging that it would intrude on their specialty. Peru has an important gap in health resources, especially with regard to physicians,and one challenge with high rates of cervical cancer with high mortality is how to reach women and treat them. The reality is that the core of the problem is the fear of losing clients and money, so task shifting and task sharing is not acceptable for such physicians, causing under-provision of services.

15 Transparency International

The ignored pandemic. , 51 Gaal P

Belli PC

McKee M

Szócska M Informal payments for health care: definitions, distinctions, and dilemmas. 52 Hernández Ávila M

Cervantes Trejo A

Santamaría Guasch C

et al. Salud deteriorada. Opacidad y negligencia en el sistema público de salud. The fifth form of corruption is favouritism, meaning that care is given preferentially to people who are recommended or have social connections, thereby affecting the care that other patients receive. The sixth form of corruption is manipulation of data, which Transparency International refers to as the billing for goods and services that were never sent or done because compensation is given according to the number of people treated.However, I would like to broaden this concept to include the manipulation of data reported—for example, coverage of public health activities such as vaccination. The manipulation of data is an issue that was recently raised in Mexico.We have also seen data being manipulated in Peru in the case of maternal syphilis screening. Providers disclosed that they repeatedly overestimated data for particular programmes because of fear of receiving less supplies, to assure that they received productivity incentives, and to not be identified as lazy. When this happens, data are not reliable and public health is affected.

From my personal point of view, individual acts of corruption at the level of the day-to-day interactions of patients with health services and providers can look small in scale, but they represent millions of negative interactions and have an enormous and damaging effect on our efforts to improve health. They are also more difficult to address than corruption occurring at a higher level. Additionally, these acts become normalised in society and are considered to be just the way things work. It is common to see any of the following forms of day-to-day corruption: a delay or denial of health services, supplies and medications being sucked from the public sector to feed the private sector, staff charging patients more than official prices and pocketing the difference, collusion between hospital staff and external pharmacies or external providers of medical tests, high absenteeism by doctors with a second job in the private sector, doctors referring patients to their private practice, and deliberate damage of equipment in the public sector to force people to pay for private services (which, by the way, are typically located adjacent to public health facilities and are owned and staffed by the same public providers who provide service in the public and private arenas).

In Peru, I was once shown a paper clip inside an x-ray machine. The paper clip was used to damage the equipment in a public health centre, forcing patients to pay for an x-ray in the private clinic in front of the health centre. Deliberate damage also happens with laboratory equipment, with diversion of medications from the public sector being one of the worse problems. The government purchases medications to be given for free to people with national insurance, but the medications are denied to the patients at the public health centres because the drugs apparently disappear. The Ministry of Health started an investigation and found an illegal operation that removed the drugs from storage and public hospital pharmacies and placed them in private pharmacies. Individuals called jaladores (pullers) were conveniently placed outside the hospital pharmacies and offered to take patients where they could buy medications at a so-called reasonable price. The operation was much more complex than I am able to describe here and involved important actors. Unfortunately, the investigation could not be completed during my time as Minister of Health (a period of 14 months) and the situation continues, causing the country millions of soles in losses.

During my time as Minister of Health, corruption was one of my biggest challenges. I had to handle and overcome the uncovering of fraud in the comprehensive health insurance programme by an individual who was the president's advisor. This event allowed us to confront the fragility of the system and, along with all of the corruption I observed in the health sector, pushed me to explore what was known to work against corruption and what could be done to prevent corruption from happening.