Sectoral Perspectives on Corruption in Kenya:

The Case of the Public Health Care Delivery

A Research Proposal

Research & Policy Department

Preventive Services Directorate

July 2007
1.0 INTRODUCTION
1.1 BACKGROUND

The economic development of any given country depends on the health

status of its citizens. The importance of health as a vehicle for economic
growth and poverty reduction is reflected as key development target in the
Millennium Development Goals (MDGs). Three out of the eight MDGs are
directly related to health hence underscoring the importance of health care in
any nation’s development process. The MDGs include: reduced child
mortality; improved maternal health and the fight against HIV/AIDS, malaria
and other diseases. One additional goal relates to access to affordable drugs
in the developing countries. The challenge to implement the MDGs is real as
the end of the implementation period draws nearer. The challenge to realise
these goals is greater for Kenya as she contends with two fundamental
questions, namely; (i) Where does Kenya stand in regard to the realization of
these goals?; and (ii) What are some of the challenges that Kenya faces
today in meeting these targets? The MDGs Status Report 2006 indicates that
Sub-Sahara Africa and Kenya included is lagging behind in implementing
programmes targeting these goals. Even though some progress has been
made in combating HIV/AIDS, the pace of implementation is slow due to poor
governance, marked corruption and poor economic policy choices among
other reasons.

The above factors have also compromised the provision of adequate

healthcare in Sub-Saharan Africa in general and Kenya in particular. Globally
corruption continues to pose serious challenges in the provision of
healthcare. It compromises the quality, effectiveness and equity in service
delivery while raising the cost of discharging the same. Health care provision
depends on a combination of financial and other resources, supplies and the
delivery of services in an efficient manner countrywide. This calls for a health
care system that is entrenched on transparency, accountability and integrity

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at all levels of service delivery. Ineffective and inefficient health care systems
that are deficient in transparency and accountability lend room to corrupt
practices. It is important to note that corruption in the health care sector is
not exclusive to any particular type of the health care system. It occurs in all
systems, whether public or private, well funded or poorly funded, and
technically simple or sophisticated.

The Global Corruption Report, 2006 indicates that every year more than US $
3.1trillion is spend worldwide on health services with the bulk of the financing
by the governments. These large flows of funds are an attractive target for
abuse. The MDGs Status Report for Kenya , 2005, indicates that the Kenya
government increased the overall funding for health care in the financial year
(FY) 2005/006 by 30%,, increasing the sector’s share as a percentage of total
government expenditure from 8.6% in FY2004/2005 to 9.9% in the FY
2005/2006. The Report further indicates that 20% of LATF funds are to be
spent on core poverty programmes which are essentially MDGs- related
programmes. A recent government survey of the CDF funds indicates that
over 60% of this fund on average is spent on health, water and education in a
given constituency at any one time.

The National Anti-Corruption Plan, (2006) identifies corruption as a major

contributor to the decline in economic growth, deterioration of infrastructure,
inadequate health care facilities and drugs, run down public institutions,
increased poverty incidences among others. The Plan further states that
corruption emanates from two basic conditions namely: erosion and
distortion of values and existence of opportunities.

In order to mitigate the impact of corruption in the provision of healthcare,

Kenya like any other developing country needs to design appropriate
prevention programmes and also put in place relevant statutes for monitoring
the success of these programmes and other public investment programmes
targeted to the sector. It is also important to measure the quality and access
of the health care on a continuous basis. To be able to achieve all the
objectives, broad and appropriate systems must be developed and

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implemented. A survey targeting both the healthcare providers and the
healthcare seekers as the key respondents is one such system that will allow
these objectives to be met.

1.2 Statement of the Problem

The findings of the National Corruption Perception Survey (2006) indicate

that 22.9% of the respondents ranked the health facilities as the third most
corruption prone areas in their locality. Consequently, 41.3% believe that the
Ministry of health is the second most corrupt ministry and a further 27.5%
perceive the government hospitals as the fourth most corrupt institution.
1
Furthermore, The Examination Report of Kenyatta national Hospital
established weakness in the key operational areas of the biggest referral
hospital. Subsequent Examinations within the health sector2 also confirmed
discrepancies in the procurement of pharmaceuticals and non
pharmaceuticals and general malpractices in the institutional operations.
Reports by other institutions indicate the same concerns. The Transparency
International report, 20053 on corruption and in Kenya’s National Aids Control
Council, NACC, revealed that for years high level public officers had grossly
abused their office. The funds squandered may seem petty when juxtaposed
with the colossal funding that the health sector attracts, yet when
consolidated and if spent effectively could have meaningful impact on the
lives of many Kenyans.

Fighting corruption is a constant concern for donors and governments

worldwide. Efforts towards improving service delivery like health care
provision often fall short of the agenda in improving peoples lives. This may
be attributed to the fact that governments, donors and philanthropists
1
Examination Report , 2003:The Management of Kenyatta National Hospital; Anti- corruption Police Unit
2
Corruption Risk Assessment Report, 2005; Procurement and Distribution of Drugs and Other medical
Supplies by the Ministry of Health and Kenya Medical Supplies Agency
3
This is a working paper on corruption and HIV/AIDS

4
underestimate the challenges of governance and corruption in healthcare
delivery. The rush to endorse MDGs and translate these goals into real
programmes has largely overlooked the limited ability of institutions to
deliver. The need to identify and address corruption and weak governance is
often lost in the commitment to raise funds and expand services. Corruption
in the health care industry takes a serious toll both in monetary terms and
human suffering. Corrupt practices in the health sector include: informal
payment, fraudulent procurement and billing, inappropriate influence on the
regulatory process, selling expired drugs in altered package, absenteeism
among other malpractices, undermine the quality of health care and
medication with dire consequences.

Determining whether public investments in health care are reaching their

target population requires knowing which outcomes to monitor. Traditional
measures such as the infant mortality rate are poor reflections of the health
sector performance because they are too general and because of the tenuous
link between health inputs and health status at high levels of infant mortality.
To compensate for poor data and the difficulty of measuring the impact in
health care delivery, indirect measures of performance can be used. The
more complex and important measures of health system performance
include: as staff availability; availability and quality of drugs and medical
supplies; functioning equipment, quality of construction and general
infrastructure.

These factors, Savedoff and Hussmann, 2006, state make the health sector is
the most complex sector in the society. They further explain that it is
characterised by a large number of dispersed actors, asymmetric information
and has specific mix of uncertainty. This is complicated by the fact that
patients are not in a position to shop around for the best price and quality
when they are ignorant of the costs, alternatives and precise nature of their
needs. The three features bedevilling the sector: uncertainty, asymmetric
information and the large number of actors help in propagation of corruption
and make it difficult to detect, punish and deter the malfeasance.

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Additionally, government regulation in the pharmaceutical industry while
essential to safeguard the citizens against sub–standard drugs and unfairly
priced goods makes this sector particularly prone to corruption. If regulators
are subject to pressure from commercial groups, health objectives can be
compromised. Due to the unpredictability of the health needs, governments
are unable to plan effectively for future medical needs which diminishes their
ability to resist offers of medicine at inflated prices or in excess quantities
and to detect corruption in such transactions.

The Kenya Government recognizes the role of healthcare in the economic

development and therefore allocated KSh. 33 Billion towards the health
sector in the current financial year, 2006-2007. This huge investment outlay
necessitates interventions to improve planning and reporting including the
integration of financial data and service utilization statistics to enhance
transparency and focus attention on areas most vulnerable to abuse. Further,
the Global Corruption Report (2006) cites Kenya’s health care system as
lacking accountability mechanisms resulting to abuse and misappropriation
of the funds meant to alleviate disease. Some of the areas or processes cited
in the Report as vulnerable to corruption are: construction and rehabilitation
of health facilities: purchase of equipment and supplies including drugs;
distribution and use of drugs and supplies in service delivery; regulation of
quality in products, services, facilities and professionals; medical research
and provision of services by frontline health worker.4
This findings call for intervention measures and an urgent assessment of
existing anti-corruption initiatives within the public health care sector. The
increased attention to corruption in the health care sector has elicited
questions that have aroused the concern of anti- corruption advocates: which
areas and processes are vulnerable to corruption; what types of corrupt
practices are prevalent; what is the cause of the malfeasance in the sector;
how effective are the existing strategies and interventions; and what new
policy and strategy interventions need to put in place to combat the vice?

1.3 Objectives of the Study

4
Taryn Vian, Sectoral Perspectives on Corruption: Corruption and the Health Sector(2002)

6
The main objective of this study is to assess the magnitude, nature and
impact of corruption in the Kenya’s public health care sector and the
healthcare systems. The specific objectives are to:

i. Identify the areas and processes that are vulnerable to corruption;

ii. Establish the types of corrupt practices in the various processes in the
health care system;
iii. Identify the causes of corruption in the sector;
iv. Determine the impact of corruption in the provision of healthcare;
v. Establishment of the effectiveness of the existing anti-corruption
strategies and other interventions; and
vi. Propose anti-corruption policies and strategies for the public health
care sector;

1.4 Scope and Rationale of the study

The Study seeks to explore the policy, legal and institutional frameworks
within the health sector and how they impact on the state of corruption and
governance. Thus areas of special focus will include corruption in
procurement of drugs and equipment, including construction; corruption
affecting provider –patient interaction, and financing within the public health
sector.

The study seeks to integrate anti-corruption strategies in the health sector with the overall
anti-corruption strategies at the national level. The paper intends to provide a benchmark
study for further research in this area.

2.0 KENYA’S PUBLIC HEALTH CARE SYSTEM

The health sector comprises the public system, with major players including
the Ministry of Health, (MoH) and Parastatal organizations and the private
sector, which includes private for profit, Non-Governmental Organizations,
NGO and Faith Based Organizations, FBOs, facilities. The health services are
provided through a network of over 47000 health facilities countrywide, with
the public sector accounting for about 51% of these facilities.

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The public health systems consist of the following levels of health facilities:
i. National referral hospitals are the apex of the health care system,
providing sophisticated diagnostic, therapeutic and rehabilitative
services. The two are Kenyatta national Hospital and Moi referral
hospital.
ii. Provincial hospitals, which act as referral hospitals to the district
hospitals.
iii. District Hospitals which concentrate on the delivery of health care
services and generate their own expenditure plans and budget
requirements based on the guidelines from headquarters through the
provinces.
iv. Health Centers provide ambulatory health services. They generally
offer preventive and curative services that are inmost cases adapted
to the local needs.
v. Dispensaries are meant to be system’s first line of contact with
patients, but in some areas, health centers or even hospitals are
effectively the first points of contact. They provide wider coverage for
preventive and curative services, mostly adapted to needs.

In 1994, the Government of Kenya approved the Kenya Health Policy

Framework (KHPF) as a blue print for developing and managing health
services. It spells out the long term strategic objectives and the agenda for
Kenya’s health sector. The Ministry of Health, (MoH), established the Health
Sector Reform Secretariat (HSRS) in 1996 to spearhead and oversee the
implementation process. The above policy initiatives were aimed at
responding to the following constraints: decline in health sector expenditure,
inefficient utilization of resources, centralized decision making, and
inequitable management information systems, outdated laws, inadequate
management skills, worsening poverty levels, increasing burden of disease
and the rapid population growth. The first National Health Sector Strategic
Plan (NHSSP-1) for the periods 1999-2004, was a follow up to the Ministry of

8
Health’s efforts to translate the policy objectives into implementation
programmes.

An evaluation of the NHSSP-1 by a team of independent consultants revealed

that the overall implementation of the NHSSP-1 did not lead to the
transformation of the healthcare system and promotion of socio economic
development as envisaged in the plan. The failures were attributed to the
lack of well articulated, prioritized strategic plan; weak management systems
and low personnel morale at all levels among others. Poor management
systems and low morale are breeding grounds for corruption and corrupt
practices.

In renewed effort to improve the health service delivery, the MoH and
stakeholders reviewed the NHSSP-1 service delivery system in order to devise
a new strategy for making health care more effective and accessible to
people. These efforts led to the formulation of the Second Health Sector
Strategic Plan (NHSSP-II): 2005-2010 which puts more emphasis on
promotion of individual health as opposed to disease burden.

Adequate resources are critical to sustainable provision of health services.

The Kenya policy framework of 1994 identified several methods of health
services financing. These included; taxation, user fees, donor funds and
health insurance. These methods have since evolved into important
mechanisms for funding health services in the country. These methods ought
to reflect the cost and quality of service provision as well as the ability of the
population to pay.
In view of the myriad inflows of funding and players in the sector, proper
policies, guidelines and regulations should be put in place to manage and
monitor the funds so as to ensure that they are utilized for the intended
purpose, enhancing public health care delivery.

3.0 LITERATURE REVIEW

3.1 Conceptual Review

9
 A study by Norberg(2006) confirmed that on a macroeconomic level,
corruption limits economic growth , since private firms perceive corruption as
a sort of ‘tax’ that can be avoided by investing in less corrupt countries. In
turn, the lower economic growth results in less government revenue available
for investment, including investment in the health sector. Corruption also
affects government choices in how to invest revenue. Within the healthcare
sector, investments may also tend to favour construction of hospitals and
purchase of expensive, high tech equipment over primary health care
programmes such as immunization and family planning, for the same reason.

Subsequently, the growth, governance and corruption literature (Elliot, 1997;

Transparency international, 2005; World Bank, 1997; Economic Commission
for Africa, 2005) largely ignores governance when it comes to public policies
in the social sectors. However, efficiency in resource use would suggest the
need to consider such themes.
Furthermore, most developing countries depend heavily on public
intervention rather than regulation, hence the predominance of public health
care systems in these countries. A limitation in assessing existing health
care systems is the lack of any single measure of what constitutes a
functioning system. For developing countries, systems differ and information
on comparable indicators simply does not exist.
Lewis (2006) formulated the production function of a health care framework
representing the core of public health care systems embodying capital, labor
and governance. A simple representation is as follows:

Health outcomes= (L, K, G)

Where governance, (G) represents some measure of institutional quality of

governance, increase in the labor, (L) and capital, (K) can improve outcomes;
(G) may dampen or enhance these effects.
Labor encompasses management, physicians, nurses and other medical staff.
Capital is made of infrastructure, equipment and other fixed assets, as well
as financing: government transfers for local purchase, in–kind provision of
drugs and supplies, and third party and consumer payment.

10
Lewis (2006) further affirms that, while straight forward in concept, the
production function is far from simple and the market failures identified
above plague both private and public systems (principal agent and
information asymmetry problems) , which undermine incentives and limit the
extent of accountability.

Multiple institutions collect indicators of governance. Kaufmann, Kraay and

Mastruzzi
(2005) have broken them down to six dimensions of governance; voice and
accountability; political stability and lack of violence; government
effectiveness; regulatory quality; rule of law ; and, control of corruption – all
of which affect the environment within which health care services function.
Accordingly, the costs for the official are not the only factor affecting his/her
decision to limit access to users. His/her potential benefits also play a role; by
limiting access to service, the public official can extract additional rent from
users who need the services he /she provides. Thus the presence of
corruption can translate into a more limited access to services desired.

Kaufmann et al, 2005, postulate a model that aims to explain the degree of
accessibility to a public service by the governance and corruption
characteristics of the public agency providing it:
Accessibility of public service=f (governance characteristic) = f (citizen voice,
quality of rules, audit mechanisms, effectiveness, resources, meritocracy,
mission, service performance, wage satisfaction, corruption)

3.2 Empirical Review

The evidence on the link between institutions and health largely relies on
analyzing the cross–country relationships between corruption and health
outcome measures. With evidence from 89 countries for 1985 and 1987
Gupta, Davoodi and Tiongson (2002) show corruption indicators negatively
associated with child and infant mortality, the likelihood of unattended birth,

11
immunization and low- birth weight. The correlation in explaining the same
health outcomes is reduced once factors such as mother’s education, public
health spending, education and urbanization are controlled.
In measuring the impact of corruption on the effectiveness of health
spending, Rajkumar and Swarrop (2002) analyze data for the 1990 and 1997
controlling for GDP per capita, female educational attainment, ethno-
linguistic fractionalization, urbanization among other factors, and find that
the effectiveness of public health spending in reducing child mortality hinges
on the integrity rating, with higher integrity associated with reduced
mortality.

At a sectoral level, a number of surveys on medical personnel in Latin

America public hospitals provide a sense of the kinds and frequency of
corruption in facilities as surveys indicate corrupt practices, which by their
nature are not typically visible. Perceptions may be the only alternative in
instances where hard data is either unobtainable or unreliable; moreover,
corruption in general does not lend itself to straight forward data collection. A
review of research in Eastern Europe and Central Asia found evidence that
corruption in the form of informal payments for care reduces access to
services, especially the poor and causes delays in care seeking behaviour.

Health reforms involve changing government institutions and policies in

purposeful, fundamental and sustained ways.5

Savedoff (1998) confirmed that when combined with differing interests

among health sector actors, asymmetric information leads to a series of
problems that are analyzed within the framework of “principal-agent
relationship” iIn such as a framework the principal hires an agent to perform
some function. When an agent has interest that differ from those of the
principal and when the principal can not get complete information about the
agents output, it is difficult to find contracts that are optimal. These two

5
Peter A Berman & Thomas LJ Bossert, ‘ A Decade of health sector Reform In Developing Countries:
What have we learned’ ( Boston, MA; Data for Decision making Project , Harvard School of Public Health,
2000)

12
characteristics –diverging interest and incomplete information – are inherent
and widespread in the health sector. The principal agent problem s in the
health care sector have mainly been analyzed in terms of their impact on
health system efficiency, these same problems increase opportunities for
corruption. Savedoff (1998) further concurs that the difficulty of fully
monitoring the actions of doctors, hospitals, pharmaceutical companies and
regulators makes it hard to hold them accountable for the results of their
actions.
Akunyili (2006) established that unregulated medicines which are of sub-
therapeutic value can contribute to the development of drug resistant
organisms and increase pandemic disease spread. Additionally, corruption
could also lead to shortages of drugs available in government facilities, due
to theft and diversion to private pharmacies. Kassirer (2005) states those
promotional activities and other interactions between pharmaceutical
companies and physician, if not tightly regulated, can influence physicians to
engage in unethical practices. Wazana (2000) showed that these interactions
can lead to non –rational prescribing and increased costs with little or no
additional benefits.

Ensor (1997) availed evidence on corruption in the health systems with direct
public provision as being largely focused on informal, or illegal, payments for
services or transition economies. This form of corruption has a particularly
negative impact on access to care for the poor when they can not afford
these payments.
Dr. S Kumar (2003) affirms that the medical education system is to blame for
failing emphasis adequately on the humane aspects and also offering
insufficient training in managerial roles essential for success in the
hierarchical healthcare system.
4.0 METHODOLOGY
4.1 Research Design
The study will involve desks research where relevant and related
literature will be reviewed. In addition, quantitative and qualitative data
will be collected form identified respondents and key informants within
the health care sector and related sectors. A semi structured

13
 questionnaire and discussion guide will be designed to gather relevant
information from identified service providers and seekers.
The study will therefore:
i. Review policy, statutes and related documents to establish the
channels, types, causes of corruption and the policies and
regulation governing the sector and affiliate sectors.
ii. Analyse and synthesize information from the three diagnostic
surveys by KACC; Examination and Assessments reports on KEMSA,
Kenyatta National Hospital and the KACC and the Advisory Report
2006 on the Moi Referral Hospital.
iii. Incorporate interviews with consumers, providers, key informants
and other stakeholders within the public healthcare sector to
enhance the study.

4.2 Targeted Respondents

Key informants from the below listed organizations will be targeted.

Respondents Type of information Method of data

collection

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 1. KEMSA 1. Quantitative and 1. Semi-structured
2. NACC quantitative data on questionnaire
3. KEMRI types, causes, impact through face to
4. Pharmacy & Poisons and areas prone to face interview
Board corruption
5. Ministry of Health • In-depth
2. Status of reforms on interviews
(officials of key
harmonization of • Review of
departments)
rules, regulations and statutes, policies,
6. Government Hospitals
policies in the health regulations &
(Referral institutions,
care industry other documents
provincial hospitals,
districts &
2. Analysis of
dispensaries)
relevant cases
7. National Hospital
Insurance Fund, (NHIF)
8. Private Healthcare
providers Medical
Insurance providers
9. Suppliers of non-
pharmaceutical
products

11. Medical Educational

3. Aspects of the
institutions(Universitie
training to aspiring
s & KMTC)
medical personnel
End-users of public health
care services

4.3 Research Instruments and Data processing

15
An instrument will be developed to guide the review of documents including
relevant statutes, policies and regulations. For the qualitative data, a
discussion guide will be developed for each category of participants
(providers and healthcare seekers). Discussions and interviews will also be
conducted with key informants.

The study tools will be pre-tested to ensure consistency, language

appropriateness, flow and sequence of questions, length of interview, and
clarity of questions, ethical considerations and general appropriateness.
Comments from the pre-test will be incorporated before proceeding with the
assignment.
An appropriate package will be utilized to analyze the data gathered.

5.0 IMPLEMENTATION PLAN AND BUDGET

In addition to rigorous desk research, the study will involve interviews with
the various stakeholders, key informants and consumers of the health
services. Therefore, the team will need transport, stationery, telephone
and night out allowance to facilitate the exercise. Provided below is the
budget for the study.

16
5.1 Implementation Schedule:

Activity Output Timeframe

FY2007/08
July Aug Sep Oct
W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3 W4 W1 W2 W3
1. Development & approval Approved proposal
of proposal
2. Generation of field tools & 1. Field questionnaire
logistics 2. key informant guide
3.Field work Sector wide interview and data
collection
4. Data processing Draft report
5. Draft Report Report for comments
6. Final Report Report for approval for
dissemination
7.Publication & Final Research paper published
Dissemination of the & dissemination to stakeholders
report( Workshop)
5.2 The budget

Due to lack of consensus on scope of the study, I have not adjusted the budget. Some
members insist it should be more of a desk study with key informants involvement only.
Kindly advice.

14. Budget
Cost Item Quantity Day Unit Total
s Cost/Ra (Kshs)
te
Preparator
y
Research Instruments (Printing & 2500 20 50,000.00
Photocopying)
Training and pre-testing
workshop
Lunches and Teas (Field team 35 5 1000 175,000.00
including Commission staff)
RA’s training allowance & transport 25 5 500 62,500.00

287,500.0
Sub-Total 0

Fieldwork
Research Assistants (RAs) fee & 25 14 3500 1,225,000.
Subsistence 00
Field Supervisors (KACC Staff) - Per 6 14 5200 436,800.00
diem
Drivers’ night out allowances 6 14 3500 294,000.00

Fuel Expenses 6 14 1000 84,000.00

Telephone expenses 6 14 500 42,000.00

Telephone expenses 31 14 100 43,400.00

Sub-Total 2,125,200
.00
Data
manageme
nt
Data Coding & Entry Clerks' fee 10 15 2000 300,000.00

Data entry Supervisors fee 2 15 4000 120,000.00

CBS Entry Team 10 15 2000 126,000.00

Sub-Total 720,000.0
0
Disseminati
on Costs
Printing 3000 1 350 1,050,000.
00
Publicity/Advertisements

Distribution (postage etc) 50 1 200 10,000.00

Hire of venues 100 1 1000 100,000.00

Lunches, Teas and snacks 100 1 1000 100,000.00

Sub-Total 1,260,000
.00
Grand Total 4,392,70
0.00

6.0 References

1. Akunyili D., The fight against counterfeit drugs in Nigeria, part 1.5 in
Transparency International’s Global Corruption Report 2006.
2. Berman P., & Bossert L.J T, ‘ A Decade of health sector Reform I Developing
Countries: What have we learned’ ( Boston, MA; Data for Decision making
Project , Harvard School of Public Health, 2000)
3. Ensor T., ‘What is the Role of State Health Care in Asian Transition economies?,
Health Economics 6 (5), 1997
4. Examination Report, 2005; procurement and Distribution of Drugs and Other
medical Supplies by the Ministry of Health and Kenya Medical Supplies Agency
5. Examination Report , 2003:The Management of Kenyatta National Hospital; Anti-
corruption Police Unit
6. Gupta S., Davoodi HR, Tiongson E, Corruption and the provision of health Care
and Education Services, Governance, Corruption and Economic Performance,
Washington , DC : International Monetary Fund, 2002.
7. Kassirer J., The Corrupting influence of money in Medicine, part 1.5 in
Transparency international’s Global Corruption Report 2006.
8. Kauffman D, Montoriol –Garriga J and Recanatini F. “How Does
Corruption Affect Public Service Delivery? Micro- Evidence from Service
Users and Public officals in Peru.
9. Lewis M, Governance and Corruption in Public health care systems (Centre for
Global Development, 2006).
10. Lewis M., ‘Tackling Health care corruption and governance woes in Developing
countries, CGD brief , working paper 78, Washington DC.2006
11. Ministry of Planning & National Development(Kenya) and United nations
Development in partnership with UNDP, Kenya and the government of Finland,
MDGs Status Report for Kenya, 2005
12. Savedoff D W, The Characteristics of Corruption in Different Health Systems,
2003, World Health organization , p6
13. Savedoff D. W., (ed), ‘Social services Viewed through New lenses’, Organization
matters: Agency problems in health and education in Latin America ( Washington
DC : IADB, 1998
14. Sparrow, M. K. "Corruption in Health Care Systems: The U.S.
Experience." Global Corruption Report 2006: Special Focus - Corruption
and Health. Ed. Transparency International. Pluto Press, 2006, 16-22.
15.UN Department of Economic and Social Affairs, Statistics Division, ‘
Millennium Development Goals: 2005 progress report’ NY: UN DESA,
2005
16.Vian T, Corruption and the health Sector, 2002, UAID and Management
Systems International ( MSI), p. 1, 2-3,28

19
17.Wazana A., Physicians and the pharmaceutical Industry: is a gift ever
just a gift?, Journal of the American Medical Association,2000, 283:373-
380

20
i

7.0 Appendix
7.1 Proposed tools