The Cure Against Corruption in Hospitals
The media often report estimates of the cost of corruption for Italy's public health service. The most reputed international studies (World Bank, 2014) estimate that corruption amounts to around 4-5% of public spending on healthcare, thus around €5-6 billion. The fact remains that measuring the level of corruption in the country's Aziende Sanitarie Locali (Local Health Organizations, managed by Italy's Regions) is very difficult, and it is equally difficult to distinguish between inefficiency, inappropriateness, fraud and corruption. All this leads, at times, to a sensationalism that induces sterile distrust towards hospitals and health agencies. This is also behind simplistic proposals such as the call for a 5% cut in health spending, with the belief that this would automatically eliminate 5% of the corruption. However, without understanding the complex causes of such a damaging phenomenon and designing targeted countermeasures, budget cuts would only diminish the health coverage of those in need of treatment.
In light of this, the 2017 edition of the OASI Report compiled by CERGAS, the Bocconi Center for Research on Health and Social Care Management, has addressed the subject from a different perspective, the vantage point of those who are engaged in activities to prevent corruption every day. We thus designed a questionnaire which was submitted to anti-corruption managers in Italian healthcare organizations (Responsabili della Prevenzione della Corruzione, RPCs), a position officially established by Italian Law 190/2012. In total, the anti-corruption managers of 83 local healthcare organizations answered the survey, representing 41% of a total of 202 in Italy. 85% of respondents say they have worked in public healthcare for at least 8 years, and have covered the role of corruption watchdog for less than 4 years. Therefore, on average, RPCs have the experience necessary to understand their operational context well, while their experience in fighting corruption is still limited.
With the current mechanism, the task of a RPC is given to healthcare managers who already have to fulfill other functions. This overlap of roles can have negative effects, both in terms of potential conflicts of interest and limited availability of time. Only 23% of RPCs say they devote at least 50% of their worktime to anti-corruption activities. Moreover, only 37% of RPCs say they have staff support. But it is precisely the RPCs who have a special staff under them that allocate the largest share of worktime to corruption prevention activities. The presence of collaborators allows the delegation of bureaucratic requirements, such as the updating of hefty Anti-Corruption Plans, thus freeing up time to carry out those activities that are deemed to be most effective in combating misconduct: auditing reports, in-house training, context analysis.
Moreover, in terms of crucial anti-corruption activities, almost all RPCs (78 out of 82) have activated whistleblowing tools, that is to say procedures to collect anonymous reports of illicit behavior. This was not always followed by a high number of reports: only 42% of respondents say they received alerts from whistleblowers in the last year; and only 8 RPCs (10% of the sample) received more than 5 reports, i.e. more than one every two months on average. The average reported usefulness of whistleblower reports was only 3.5 out of 7. RPCs do know that whistleblowing is useful, but also that it can lend itself to abuse.
In terms of potential development of the anti-corruption function in Italian healthcare, some indications emerge clearly. First of all, at the organizational level, enjoying the support of health directors is fundamental, since it enables RPCs to perceive the usefulness of their work. In fact, perceived levels of support from the top decrease in areas of the country where illegality is more widespread, ranging from 3.8/7 in Northern Italy to 3.1/7 in Southern Italy.
On the regulatory front, the role and activities of an RPC should be strengthened and extended, by giving this professional figure also the functions of internal audit and control and a dedicated staff, while lightening requirements in terms of drafting of reports and internal documents, and decreasing his or her other managerial duties. Finally, it would be valuable to network those embryonic but promising experiences, in order to share the best practices for the prevention of corruption undertaken by healthcare professionals across Italy.