An expanded framework for understanding corruption in healthcare

Corruption in healthcare is ubiquitous across countries but differs in extent and nature based on the socio-political context and historical development of their health service systems. We review various approaches to defining and analysing corruption and examine their application to the health sector. Commonly adopted measures of corruption based on these frameworks, by covering certain actions and excluding others, tend to highlight poor countries as being more corrupt. These frameworks are largely ahistorical, and lack a systems approach, and consequently, miss institutionalised forms and types of corruption at higher levels between and within countries. The failure of anticorruption efforts makes it necessary to interrogate and understand the nature of corruption, its forms, types, and measurement, through a lens that can lead to effectively addressing the phenomenon from the perspective of low-and-middle income countries. We propose an expanded framework for understanding the systemic pathways of corruption, across the multiple levels and actors in the health system. We then discuss its relevance to low-and-middle-income countries, with a specific focus on India. We argue that historical socio-political structures, with a colonial hangover and elite dominance, legitimising only one health knowledge system (conventional biomedicine) and its medical professionals, have led to a healthcare system design which is unaffordable, unsustainable, unregulated and alienated from the majority of the population even while it creates a dependency on biomedical experts and institutions. The medical industrial complex ‒ the network of providers and industries in healthcare ‒ prioritises profit over health benefits, and contributes to escalating corruption in the healthcare sector, thereby pushing inappropriate solutions and policy choices. Such an ecosystem is fertile ground for corruption as it results in huge unmet needs and unreasonable expectations from the health services, underpaid health workers, weak regulatory structures, and poor accountability.