Date: Feb 1, 2020 Source: The Daily Star Fighting graft in health care is key Hussain Isma’eel Although many Lebanese feel it and live its consequences on a daily basis, only very few know that the health sector is seriously inflicted with corruption. As a matter of fact, corruption in the health sector is a global observation, and luckily many are ahead of us in finding solutions (UNDP; fighting corruption in the health sector: methods, tools and good practices). For us to better appreciate health sector corruption in Lebanon, one needs only: 1. Ask how many Lebanese go around repeating medical tests they have already done because the medical doctor insists on certain laboratories for the tests; 2. Remember the subjects of falsified medications where the most concerning and infamous examples are the stories of ineffective cancer therapies and antiplatelet medications; 3. Reflect on the mushrooming number of heart laboratories, known as cardiac catheterization suites, in Lebanon compared to worldwide benchmarks (71 labs up to 2016) and similarly the number of radiology suites with the number of magnetic resonance imaging and computed tomography machines that is among the highest in the world compared to the population size; 4. Listen to families who declare it openly that access to health services is facilitated either through political party affiliation or informal payments; 5. Review the media for the scandalous portrayal of the process of investigating medical malpractice cases; 6. Try, if you can, to understand the process of allocating budgets to hospitals from the Health Ministry; 7. Think well about how hospitals can afford to give “bills’ collection firms” 30 percent of the bill in return for this service, and how many of these bills are actually for services that were never delivered; 8. Figure out why the price of some of the medical supplies (hardware used in surgeries for example) is higher than in some European countries; 9. Ask about the relationship between all those involved in the chain of events starting from importing and marketing a medication up to a patient purchasing it and what measures are present to limit quid pro quo, bribery and conflict of interest in this “Bermuda of corruption”; and 10. Pause and think how many individuals were employed in the health sector (medical schools, hospitals etc.) due to cronyism. The list can go on, however, what is important is to know that corruption and fraud in the health sector have multiple entry points where many stakeholders are involved, and only by adopting a systematic approach can we combat them (WHO 2018; Integrating a focus on anti-corruption, transparency and accountability in health systems assessments). More importantly, as the whole country is recognizing the negative and destructive impact of corruption on every aspect of our lives, now may be the perfect time to seize the momentum and advance anti-corruption agenda. It is actually more pressuring to do so as a means of reducing costs and reallocating the savings to where they are truly highly needed. Equally in importance, bringing on board international agencies such as the WHO, UNDP, along with local stakeholders and health care consumer protection bodies to oversee these anti-corruption efforts, in addition to formally integrating these efforts within the Health Ministry is the only way to rebuild trust that we as a nation are seriously committed to this path. The public is fed up of media conferences where the efforts end once the camera is turned off with the last round of applause.Corruption and fraud in the health sector are different from each other as per the academic, administrative and legal perspectives and therefore not what the layperson understands. But effectively they both lead to the same results: loss of financial resources and declines in the predicted improvements in patients’ health outcomes. While proposed health-systems based solutions to solve the above examples can be enacted rapidly, data highlighted two phenomena “moral hazard” and “asymmetry of information” where patients and their families are heavily involved and pose a different challenge. Information asymmetry is where the service-providers have much more information than the patients and their families. In clinical care the tough to understand medical lingo commonly used further aggravates this problem. Thus, the consumers are denied the ability to better judge and decide among choices. We can see this abused at its peak particularly when patients and their families have to decide what to do in time-sensitive clinical conditions. In these conditions time loss may lead to harming the patient and thus a decision on the spot is needed. Here, the piece of paper labeled “informed consent” that the patients or their families are required to sign confirming they understand the harms attributed to the planned intervention could be but a façade. Ironically, at the reciprocal end of information asymmetry is the observation of moral hazard! The latter is what clinicians note when patients ask for tests that are not needed, even though these tests entail certain unwarranted clinical risks, only because they have private health insurance! The patients and the community fail to recognize that this behavior has several downstream destructive effects. These include that: 1. The cost of the insurance premiums increase, 2. The trust between the insurance companies and the service providers diminishes leading to tougher testing approval arrangements, 3. The patients are exposed to unwarranted risks, and 4. Such behavior leads to competitiveness among medical doctors / hospitals where those who agree to participate and request unwanted tests are hailed as “helpful and up to date” and gain more. The solutions proposed to these 2 problems rely heavily on raising awareness of the patient and building support systems to help guide them. Unfortunately, top to bottom solutions for these problems, such as denying claims by insurance companies or governmental/ national funds, will only be seen as illegitimate and met with resistance. Some researchers have postulated that countries are undergoing a hasty burst to correct the social imbalances that technological advances have imposed on humanity over these last decades. These imbalances were driven by permitting economics to replace all other social sciences as the sole source of guiding principles. In Lebanon, due to the absence of transparency and accountability, economics was an exercising arm of a corrupt political system. Accordingly, we know why the Lebanese are expressing this anger/violence and seek for connectedness in the virtual realm through social media. Among their aims are to escape the political system, and later organize to come back and hit it. When it comes to the health sector, by not admitting to the corruption present, and by being slow to implement systems-based approaches to combat corruption and fraud, the country and the sector are risking this anger/violence turning against hospitals and healthcare providers. The worst scenario would be if the illegal capital control imposed contributed to denying access to health care. We have a history of precedents of violence in emergency departments in Lebanon and this is a call to act fast to avoid more dramatic shows in our hospitals during these extra ordinarily difficult times. Hussain Isma’eel, MD, FSCCT, FESC Associate Professor of Clinical Medicine. President, Medical Committee AUBMC. Director, Vascular Medicine Program http://www.aub.edu.lb/fm/vmp/Pages/default.aspx. Division of Cardiology, American University of Beirut. THE DAILY STAR publishes this commentary in collaboration with Project Syndicate © (www.project-syndicate.org). A version of this article appeared in the print edition of The Daily Star on February 01, 2020, on page 4.