Understanding and eliminating health sector corruption impeding UHC at district level in Nigeria and Malawi: institutions, individuals and incentives

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Weak accountability and corruption (the abuse of entrusted power for private gain) threatens health in LMICs, especially among the poor. Evidence shows that corruption remains pervasive, harms health and access to care, and is a major barrier to achieving Universal Health Coverage. The health sector is consistently rated as among the most corrupt. Unaccountable and corrupt practice undermines the trust underpinning effective, equitable, and responsive health care and has a major impact on health outcomes. Corruption is often seen as an intractable problem-with limited evidence on successful strategies to address it.Most approaches to weak accountability and corruption have seen these as a failure of management, a result of poorly governed and financed systems or reflecting social norms. Many interventions seek to improve law, policy, accountability and transparency. We argue that these can be more effectively addressed through a) understanding the main types of corruption manifest in the provision of care at district and local level (e.g.informal payments, absenteeism, leakage of health commodities, inappropriate referrals), b) the individual and organisational characteristics that drive it, and c) the underlying power structures. Thus, research must explore how formal structures (policy and its implementation) interplay with informal social, economic and political structures (local elites and kinship networks) to shape everyday practice within the health system. With this knowledge, it is possible to identify pragmatic strategies ('openings') to address corruption that takes into account their fit within the broader organisational and political distribution of power. Drawing on health systems research, anthropology, and political economy, our hypothesis is that measures based on a detailed understanding of the intersections between formal and informal structures, incentives and networks can inform the design of contextually appropriate interventions to tackle corruption in public health systems. The study will take place in Nigeria and Malawi. Both have high levels of corruption and momentum-driven by political leaders and civil society-to tackle corrupt practice. We ask: how do health systems structures and practices, and informal socio-political and economic structures incentivise corruption at district level and how can these be overcome?Our choice of methods reflects our intention to explore incidents of corruption in real time within frontline exchanges between provider and patients in district management structures and local community. We will develop novel and ethically robust approaches and methods: content analysis of policies and regulations, media (print and radio) relating to accountability/anti-corruption. Institutional ethnography in district health offices, primary, secondary and tertiary levels facilities, in-depth interviews with formal and informal political and health systems structures, focus group discussions and a household survey with service users, data from anonymous calls/ messages by individuals reporting corruption cases. The analysis will also draw on political economy, with analysis of actors, their power and their informal networks, on systems theory, especially complexity, and will involve co-production workshops and policy dialogues to interpret and validate findings. In Nigeria we will work in the Enugu state in the south and in the Kano state in the north and, and within each, urban and rural areas, and in Malawi we will select up to 4 districts. These will be selected to represent diverse populations, needs, outcomes, level of resources and institutional strength. We will engage at all health system levels-with community organisations, districts/ state, as well as national authorities, to promote anti-corruption action. We will build a community of practice, share knowledge and support researchers and implementers in LMICs-linked to global anti-corruption initiatives.