Item 73 (b) of the provisional agenda:
Promotion and protection of human rights,
23 October 2017,
Ladies and Gentlemen,
It is a pleasure to be here today to discuss my report on corruption and the right to health.
Corruption can have a devastating effect on good governance, the rule of law, development and equitable enjoyment of all human rights, including the right to health.
At the international level, both legal and political commitments have addressed the issue of corruption. While the United Nations Convention against Corruption provide a necessary set of norms and definitions, the 2030 Agenda for Sustainable Development and the Sustainable Development Goals stipulate that corruption and bribery, in all their forms, should be substantially reduced by 2030, and that effective, accountable and transparent institutions should be developed and consolidated at all levels.
The focus of my report is precisely on the links between corruption and the enjoyment of the right to the highest attainable standard of health. I elaborate on the many challenges and opportunities related to this topic; and I would like to highlight some of them in this statement.
In many countries, health is among the most corrupt sectors. This has significant implications for equality and non-discrimination since it has a particularly marked impact on the health of populations in situations of vulnerability and social exclusion, in particular those living in poverty and children.
Corruption is generally defined as “the misuse of public or entrusted power for private gain”. A distinction is frequently made between “grand” and “petty” corruption. Other definitions distinguish between types of corruption, which among other forms include political and institutional corruption. For example, “institutional corruption” results from the normalization of behaviours that compromise truth-seeking and lead to the formation of perverse incentive structures, and thus addresses the behaviour of actors who exploit their institutional positions to influence institutional processes and actions.
Three main characteristics make the health sector particularly vulnerable to corruption: power asymmetries and imbalance of information, uncertainty inherent in selecting, monitoring, measuring and delivering health-care services and complexity of health systems.
In my report, I focused not only on forms of corruption that are legally defined as breaking the law, but also on practices which undermine principles of medical ethics and social justice, as well as effective and transparent health-care provision.
The right to health provides a valuable normative framework and constitutes a legally binding imperative to analyse and address corruption affecting health and occurring in and beyond the health sector. This framework reflects notions of good governance, transparency, accountability and participation, which are key when it comes to addressing and combating corruption.
In terms of legal obligations, corruption undermines the State’s obligation to realize the right to health “to the maximum of its resources”.
Corruption, in society at large and in health sector in particular, affects the regulatory environment and the efficiency of State institutions. It hinders economic growth and sustainable development as well as the equitable distribution of resources. It undermines public confidence in the State and obstructs the attainment of commitments made through Sustainable Development Goals, in particular Goal 16 to create effective and accountable institutions.
I want to emphasize that corruption is a significant challenge to the delivery of quality health care, which is central both to the right to health and to the commitment under Sustainable Development Goal 3 to universal health coverage. In this regard, it is critical to strengthen health-care systems so that all segments of the population trust primary healthcare and mainly use this level of services for most health conditions.
This would be an effective anti-corruption measure to mitigate the tendency whereby users of services prefer to bypass primary care and use specialized health services. In this regard, I welcome initiatives in some countries through which health professionals educate the general population against wasteful or unnecessary use of medical tests, treatments and procedures. Such initiatives should be supported by States as effective measures to develop rational services and prevent unnecessary and costly use of specialized interventions.
While States are ultimately accountable for the right to health, all members of society, including health professionals and the private business sector have responsibilities regarding the realization of the right to health.
It is worth noting that corrupt practices that have a direct impact on the right to health have occurred in private sector companies, including private water companies, tobacco manufacturers, food and beverage manufacturers, car manufacturers and the natural resources extraction industry. Thus, a wide range of stakeholders are to be held accountable in the context of corruption and the effective implementation of the right to health.
Changing views and perceptions in institutions and society of corruption as normal, unavoidable and justified is an important element in addressing the problem of corruption.
In my report, I elaborate on a specific sector which I consider particularly affected by corrupt practices: the mental health sector.
Existing evidence shows that mental health policies and services are especially prone to ineffective and corrupt practices, as well as the use of biased evidence. These obstacles hinder implementation of Sustainable Development Goal 3 and a very important target: to promote mental health and well-being.
Mental health policies and services illustrate how lack of transparency and accountability in the relationships between the pharmaceutical industry and health sector, including academic medicine, can lead to institutional corruption and have a detrimental effect on mental health policies and services, not only at a national or regional scale but also at the global level.
In my report, I review three main areas in the mental health field using the framework of institutional corruption: the process of development and promotion of diagnostic categories for mental health conditions, psychotropic drug research, and clinical practice guidelines.
Institutional corruption in the mental health system has several consequences. One of them is the medicalization of human diversity and misery, which expands the number of persons diagnosed and labelled with mental illness.
The medicalization of the public mental health field is driven by lack of transparency and accountability in medical education and research, and leads to biased evidence being translated into practice worldwide. This is an unacceptable tendency and must be addressed by States and international organizations, with a view to ensuring that mental health policies nationally and globally are driven by non-biased evidence and a human rights-based approach.
The current crisis in academic psychiatry, influenced by a doubtful relationship with the pharmaceutical industry, has contributed to what could be called the “corruption of knowledge” in mental health and represents a warning signal not only to mental health-care practice and research but to the health sector as a whole.
Health-care systems should be effective, transparent and accountable, with a focus on primary health care and health promotion, and should be ready to address imbalances and power asymmetries within and beyond health-care systems in all decisions aimed at reaching universal health coverage.
Amongst other recommendations in my report, I urge States to fully implement the United Nations Convention against Corruption and to ensure that national anti-corruption laws and policies integrate the right to health as a standard. Those policies should include the effective protection of those who report corruption offences in the health sector and beyond.
I want to stress the need for sufficient checks and balances when elements of the health sectors are decentralized or handed over to the private sectors. Such transitions are particularly sensitive and can lead the health sector to a more important exposure to corrupt acts.
In order to mitigate such risks, States should ensure that health sector is firmly grounded on three basic human rights principles: participation of the population in all actions aimed at combating corruption in health; transparency, especially in determining the allocation of funding; and accountability. It is essential that effective mechanisms, procedures and remedies to address situations where corruption leads to a violation of the right to health are available to right holders.
I want to emphasize the importance of prevention of corruption in the health sector. For this, States should take any measure to prevent the misuse of dual practices and improper billings in hospitals, and make sure that the working conditions and the wages of health professionals are decent.
I strongly encourage States to raise awareness among health care providers against unethical practices and situations of conflict of interest, while health system users should be empowered to report corrupt acts. For this, the population needs to be informed of its rights and educated to the identification of corrupt acts.
I also urge all relevant stakeholders to address, through legal, policy and other measures, corrupt practices taking place in all stage of the pharmaceutical value chain, including during research and development, manufacturing, registration, distribution, procurement and marketing of medicines, taking into account to Human Rights Guidelines for Pharmaceutical Companies in relation to Access to Medicines.
I want to stress that the prevention of unethical behaviours in relation to corruption should be addressed through transparent change in medical education, development of guidelines and enhancement of transparency when investment in health care are addressed. This applies, in particular, to the production and dissemination of biased outcomes of research in the field of psychiatry.
All forms of corruption at all levels have a negative impact on realization of the right to health. Many of these forms originate from power imbalances and asymmetries, which are widely prevalent in the health sector. Such asymmetries are perpetuated by non-transparent decision-making and reinforce ineffective and harmful policymaking and health services provision.
There are clear obligations under international law as well as high level international political commitments under Agenda 2030 for Sustainable Development to address corruption and develop effective, accountable and transparent institutions.
States should show bold leadership to confront the domestic and global root causes of corruption and its impact on the right to health, through legal, policy and programming measures in the health and related sectors.