No one knows for sure how much corruption exists in developing countries' healthcare systems, but the consensus is that it's prevalent, and experts are increasingly arguing that it is preventing the optimal use of global aid.

"One of the things we haven't done very well is ask, 'Are we doing what we think we're doing, are we having the outcomes we think we're having, are we achieving our objectives?'" healthcare corruption scholar Maureen Lewis said Thursday at the Woodrow Wilson Center for International Scholars. "Things are not working like clockwork, so we shouldn't assume they are."

Lewis authored a recent study suggesting that health-system corruption and mismanagement are extremely common in all regions of the world, and in some countries, healthcare may be the most corrupt sector.

Surveys have indicated that in some developing countries, particularly those of the former Soviet Union, as high as 85 percent of citizens consider the healthcare system to be corrupt.

A fraction of funds delivered to central governments often disappears before it ever makes it to a local-level clinic, the report said, corrupt officials demand kickbacks for the purchase of lifesaving equipment, and payrolls are filled with employees who are actually deceased, or "ghost" employees who never existed.

In the case of drugs, which can be easily stolen and sold, supplies are often eroded by corruption in a process called drug leakage, which can severely limit the supply available to the patients who need them.

In Uganda, for example, an estimated 73 percent of drugs disappear due to leakage, and in China, corruption has resulted in a drug supply that is about one-third expired or counterfeit, the report noted.

Another common phenomenon is doctors and nurses who work at public clinics for a few hours each day -- and then supplement their incomes with private practices or additional jobs in the private sector.

Healthcare providers, often saddled with barebones salaries, may also illegally demand money from patients to do their jobs.

"In some countries every single service is paid for individually. ... Essentially people are paying a lot of money for free care," Lewis said.

However, the solution to these problems is not just raising salaries, she said. Instead, it is a matter of aligning incentives so that workers and managers feel they must do a good job.

The best solution, she said, is a top-down, national anti-corruption strategy in which political leaders make it clear that no corruption will be tolerated anywhere and officials caught breaking the rules lose their jobs. Higher-ups then pass along the new crackdown to those working for them, as was the case during a relatively successful anti-corruption crusade launched by Nigerian President Olusegun Obasanjo.

But that requires the help of more than just the health sector, Lewis added. "If the prime minister is going to undermine what the minister of health does, the minister of health has no hope."

Yet stricter anti-corruption policies in these countries won't have much force without sufficient financial backing, experts agree. 

One of the most important national policies -- and the most basic -- is to simply make sure enough investment is being made in the public-health system in the first place, said Ruben Suarez, a health economics and financing adviser for the Pan American Health Organization.

Poor countries with high income inequality often rely on corruption as a portion of their healthcare financing strategy, he said. Instead of paying doctors and nurses more, for example, they are de-facto allowed to supplement their salaries by maintaining parallel private practices.

The solution is to make investments in public-sector health, he said. "Good governance is not cheap, it's expensive."

If countries are going to have the institutional capacity to make good use of aid funds, the public-health sector needs to be functioning, Lewis agreed. "I think we're headed for a train wreck, because we're putting lots of money into a parallel healthcare system and no money into the existing programs -- which is bad because we need them," she said. 

"There is a lot of money for individual diseases without paying attention to the context in which we have to function."

But simply having a national strategy is not enough if public officials are not sincere, said Aguima Tankoano, a researcher who has worked in the West African country of Benin.
"How do you fight against corruption without political will?" Tankoano said. "Often they put in place a national strategy against corruption, but everyone knows it's just empty boxes."

But in the absence of a coordinated national strategy, there are still steps that can be taken, Lewis told United Press International. 

Simply requiring audits can make a large difference, as well as having some sort of accountability for employees that could include giving managers the right to fire them, or signing them on only for one-year contracts. 

Empowering local leaders can also help. "There are islands of places where things work really well because you've got a strong leader," she said. Price lists for procurements can limit certain kinds of corrupt behavior, as can establishing performance goals and following up on them.

Unfortunately, however, there is rarely a "trickle-up" effect whereby such local-level progress creates national change, she said.

However it's accomplished, a focus on reducing healthcare corruption is worth the effort, Lewis said. "The return on health investment may be very low in cases where poor management and corruption are a persistent problem."