Mobilizing Action Against Corruption
U. S Agency for International Development
Building Good Governance in Health and Education:
Workshops and Technical Assistance
Yerevan, Armenia
September 22-October 4, 2008
Final Report
Prepared by:
Taryn Vian, Health Governance Specialist and
Yemile Mizrahi, Governance Specialist
Casals & Associates, Inc.
1199 North Fairfax
Alexandria, VA 22314 USA
1
I. Objectives
On September 22, Taryn Vian, Assistant Professor at Boston University and Health
Governance Specialist, and Yemile Mizrahi, Senior Associate at Casals and Associates,
and Governance Specialist, traveled to Yerevan, Armenia to conduct a series of
workshops and provide technical assistance to MAAC partners at USAID, selected
USAID implementing partners, the Ministries of Health and of Education, representatives
of the Anticorruption Strategy Monitoring Commission (ACSMC) Expert Group, and
selected non-governmental organizations, NGOs.
The main objective of this training/technical assistance was to provide a basic
understanding of the elements of good governance and of its importance for economic
development to health and education specialists. Issues relating to capacity,
transparency, accountability and political participation were introduced and discussed in
an open forum. A conceptual framework to understand the problem of corruption, a
serious governance problem, was introduced and the main vulnerabilities of corruption in
the health and education sectors were identified. In an open and interactive process,
participants identified and discussed corruption problems in the health and education
sectors in Armenia, and then they were presented with a range of possible tools and
strategies to address the problem of corruption based on successful experiences from
other parts of the world. Lessons learned from these interventions were discussed.
Through group discussions and individual consultations, participants were able to reach a
common understanding on the significance of good governance for their work and were
sensitized about the very important role they can play in addressing corruption issues in
their country.
II. Activities
1. Conduct interviews with health experts and USAID to gather relevant background
information prior to workshop.
2. Design and conduct a two-day workshop for USAID Health Team and selected
implementing partners.
3. Design and conduct a one-day workshop for NGOs focused on community-based
monitoring for anticorruption and health.
4. Design and conduct a one-day workshop for Ministry of Health (MOH) officials and
the Anticorruption Strategy Monitoring Commission (ACSMC) Expert Group to
identify priorities for the MOH over the next 5 years.
5. Facilitate and be one of the key speakers at an Anticorruption Forum on the topic of
the Free Maternity Healthcare Program. (This event had to be cancelled due to
international travel of key MOH personnel.)
6. Provide consultative services in area of anticorruption and health to the
representatives of the Ministry of Health, USAID, USAID health implementing
partners, Armavir and other NGOs, as needed.
7. Design and conduct a one-day workshop for Ministry of Education (MOE) officials
and the Anticorruption Strategy Monitoring commission (ACSMC) Expert Group to
identify priorities for the MOE over the next 5 years.
2
8. Design and conduct a one-day workshop for NGOs focused on community based
monitoring for anticorruption and education.
A. Interviews with health experts and review of documents
In preparation for the health sector workshops, Taryn Vian held phone interviews or
discussions with the following experts and stakeholders:
 Mary Segall, PhD, RN, Technical consultant who has worked with the USAID
Primary Healthcare Reform (PHCR) Project to help advance Armenia’s Quality
Assurance Initiative;
 Kimberly Waller, USAID/Armenia Health Team Leader, and Mark Levinson
(USAID/Armenia Democracy & Governance Officer;
 Roger Vaughan, Senior Health Advisor for the Moldova Governance Threshold
Country Program;
 Frank (Rich) Feeley, Technical consultant who has worked with the PHCR
Project to review health financing issues in Armenia.
Following discussions with USAID, Taryn Vian, Yemile Mizrahi and Francois Vezina
finalized the goals, objectives, and agenda of the workshops (see Annex A). Discussions
with the other experts covered health initiatives and governance issues in Armenia
(interviews with Dr. Segall and Professor Feeley), anticorruption experience in Moldova
(Roger Vaughan), and objectives and areas of focus for the workshop (Kimberly Waller
and Mark Levinson). Observations on two particular health initiatives—the Quality
Improvement Program and the Maternity Care Certificate Program—are included in the
results section. A summary of Moldova’s efforts to prevent corruption in the health
sector can be found in Annex H.
B. Workshops
Taryn Vian and Yemile Mizrahi developed training materials for several audiences:
 USAID staff (health and democracy & governance) and implementing partners
 NGO sector (including Amavir, an NGO selected by MAAC for a Small Grant
under its APS program, Partnership and Training, another NGO selected for a
Small Grant to develop transparency and accountability procedures for secondary
school governance bodies).
 Expert Group on Anti-Corruption Monitoring (Government of Armenia)
 Officials of the Ministry of Health and Ministry of Education
A total of 65 participants were trained through the workshops, as shown in Table 1
3
Table 1: Participation in MAAC Workshops on Good Governance in Health,
September /October 2008
Workshop
Dates/length
Organizations Attending
Good governance in the
health sector for USAID and
implementing partners
Sept. 25-26
two half-days
(8 hrs)
Building good governance in
health: civil society
monitoring
Sept. 27
half-day
(5 hrs)
Building good governance in
health: input to AC strategy
Sept 29
half-day
(5 hrs)
Building good governance in
education: input to AC
strategy
Oct. 2
half-day
(5 hrs)
Building good governance in
education: civil society
monitoring
Oct. 3
Half-day
(5 hrs)
2 USAID units (health and D&G—6
participants)
5 implementing partners
 Armenian Eye Care Project (2)
 NOVA Project (1)
 Academy for Educational
Development (1)
 Primary Healthcare Reform
Project (9)
Armavir Development Centre (5
participants)
Kaghni (2)
Millennium (1)
Ajakic (1)
Support to Communities (2)
Public Health Charity Fund (1 )
Anticorruption Strategy Monitoring
Commission Expert Group
( including Head of the Expert
Group, two legal experts, two health
experts and one other expert)
Anticorruption Strategy Monitoring
Commission Expert Group
( including Head of the Expert
Group) two other members of the
expert group, five representatives
from the Ministry of Education and
one representative from the
International Center for Human
Development.
Partnership and Training (6
participants); Millennium (2
participants); The future is yours (7
participants) and Center for Regional
Development and Research (1
participant)
#
Participants
22
12
6
9
16
C. Technical meetings
Following the workshops, technical meetings were held with:
 Health advisor from Armenia’s Expert Group on Anticorruption Strategy, Ashot
Melkonyan, who participated in the NGO workshop and the workshop for the
Expert Group;
 PHCR project staff;
 World Vision project staff;
 Leading specialist from the Ministry of Health, Mother and Child Division.
Meetings were also held with the USAID Health Team Leader and MAAC staff, to
discuss programming options to promote good governance.
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IV. Results
This section first presents the workshop results, including evaluation findings and
comments. This is followed by observations from pre-workshop interviews and postworkshops technical meetings held with PHCR project staff, Lead Specialist from
Ministry of Health, Mother and Child Division, World Vision project staff, and a health
expert from the Armenia’s Expert Group on Anticorruption Strategy.
A. Workshop Results
The Casals consultants prepared a set of three PowerPoint presentations and two breakout group discussion guides for each of the workshops related to the health sector. Parts
of presentations were combined for some of the shorter workshops. The presentations
included the following (PowerPoint files and related break-out tools submitted separately
to USAID and available through MAAC (contact [email protected]):
Presentation
 Building Good Governance
Topics covered
Overview of governance concepts

Governance and Health
Governance principles for health sectors

Tools and Strategies
Review of anticorruption strategies and
international experience in AC and
health
For the two workshops related to the education sector, the consultants prepared one long
presentation that included an overview of governance concepts, vulnerabilities of
corruption in the education sector, and a review of strategies and tools to address
corruption problems in the health sector based on international best practices. The power
point presentations are available through MAAC. The workshop also included break out
discussion group sessions where participants identified major vulnerabilities in their
sector, discussed several possible interventions to address these problems and adequate
indicators to assess impact.
The USAID workshop was held in English, with whispered translation for 1-2 Armenian
speakers. The NGO and Expert Group workshops were simultaneous translation.
Workshops were well received, with active small group work and large group discussions
and question and answer period.
The main task of group work was to identify weaknesses in governance and possible
corruption problems in the sector, and then to brainstorm ways in which the good
governance principles presented might be applied to solve them. Annex A-F contains the
output of all the different workshops.
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Participant Evaluations
After each workshop, participants were asked to fill in an evaluation form. Part I of the
evaluation consist of four questions were participants were asked to give numerical
ratings for workshop content, approach/organization, quality of trainers, and meeting of
expectations. Numerical ratings range from 1 to 5, where 1 is poor and 5 is excellent.
Part II of the questionnaire consists of qualitative questions related to the knowledge
acquired, the relevance of the workshop for participant’s work and general comments
about the workshop.
Participants were highly satisfied with the workshops as reflected in their evaluations.
Numerical results for each one of the workshops are presented in the following table.
Due to the limited number of participants, evaluations were not passed at the end of the
workshop with the members of the expert committee and representatives of the Ministry
of Health. Comments from some of the participants are also described below.
Workshop
Workshop
Content
Workshop
Approach/Organization
Trainers
Good governance
in the health
sector for USAID
and implementing
partners
Building good
governance in
health: civil
society
monitoring
Building good
governance in
health: input to
AC strategy
Building good
governance in
education: input
to AC strategy
Building good
governance in
education: civil
society
monitoring
4.27
4.18
4.6
Workshop
Good governance in
the health sector for
USAID and
implementing
partners
4.6
Workshop
Met my
Expectations
4
Number of
evaluations
received
11
4.9
4.7
4.5
12
NA
NA
NA
NA
NA
4.2
4.2
4.8
3.6
5
5
4.9
5
4.8
15
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

Selected Participants Comments
I found the workshop valuable; I learned a framework for thinking about
corruption
Group Discussions were particularly useful
In designing and implementing health projects, I will be able to plan better
anticorruption activities/components
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Workshop












Building good
governance in health:
civil society
monitoring









Building good
governance in health:
input to AC strategy
Building good
governance in
education: input to
AC strategy
Selected Participants Comments
It would have been helpful to cover specific country related problems
I found international experiences and practices particularly useful
The workshop was good for its interactive nature; excellent expertise of
trainers
Would have liked to have the opportunity to develop a more concrete action
plan
Would have liked to receive articles, website, sources of information
The workshop was excellent; I will look at how community awareness can be
strengthened
Before the workshop I thought we were corrupt because we are poor; now I
understand that it is actually the reverse
I found the selection of one particular project in health very useful; we
identified the vulnerabilities problems and the possible solutions
People were active until the last minute of the workshop which says how
interesting the theme is and how well the workshop was facilitated
I would have like it if presenters had more knowledge of local realities
I think the workshop was very useful. Thank you.
The warm environment contributed to the effectiveness of the workshop. All
was perfect
I enjoyed learning about Armenia’s position in the CPI as well as about
anticorruption experiences in other countries
I learned that cooperation, rather than confrontation with the government is
more effective for civil society participation
I was going to submit an application for a program and I feel now, after the
workshop, that I will make some changes to my application, particularly with
reference to monitoring and evaluation and indicators proposed
I would have liked to learn more about anticorruption tools used by NGOs in
other countries
I feel more empowered to combat corruption; I will start to teach and explain
to people what are the consequences of corruption
The workshop covered topics that were explained in a manner I could
understood
It would be useful to organize similar workshops on an ongoing basis
I am more informed as a result of this workshop. After the completion of
projects, we should gather again and discuss results
I found the break out session particularly useful
NA








The workshop was good; high quality
Dialogue between experts and Ministry representatives was extremely useful.
Presentation of international anticorruption experience was also useful
I would like to see similar workshops being organized, with broader circles;
bigger audiences
The workshop will contribute to the development of next year’s anticorruption
action plan
Representatives from the Ministry should have been given more time to
present
I would like to see similar workshops in the future
The results of the workshop should be publicized
I would have liked a more participatory approach
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Workshop
Building good
governance in
education: civil
society monitoring
















Selected Participants Comments
The workshop was conducted in an interactive environment; translation was
excellent; break out groups were good; it was a pleasure to work with
experienced personnel
I learned a lot from international experiences; the workshop was very useful
for my work; the workshop increased my faith that something can be done
about corruption
Corruption is everybody’s problem; every person has to be responsible for
fighting corruption; we cannot accept corruption as normal
All sessions were good, but I liked the break out groups
I gained understanding on the concept of corruption
The topic was presented in an interactive and interesting manner
The workshop exceeded my expectations. It was very useful both on the
presentation of the topic and the information of statistical data of Armenia and
neighboring countries
The introduction of anticorruption indicators for each activity was particularly
useful. Identification of stakeholders who suffer or benefit from corruption
was also useful
The workshop could be more effective if it included films related to the topic,
and then organize discussions related to the film
I wish similar workshops were held more frequently
Interesting examples from other countries were presented which I will use in
my work
The workshop was rather informative in terms of results and anticorruption
programs already implemented. This gave me hope that one day we can also
achieve our goals: reducing corruption
I learned that corruption needs to be address in a step by step manner; not all at
once
The timing of the workshop was perfect since a new anticorruption strategy is
being discussed and elaborated in the country
Very interesting examples were provided from other countries
We should organize similar workshops in the future; since corruption in
education is endless, we could organize more frequent discussions to insure
greater effectiveness in the implementation of our programs
B. Results from Interviews and Technical Meetings
1. Governance issues related to the Quality Improvement Strategy: Taryn
Vian’s interview with Mary Segall, Technical Consultant who has worked
with USAID Primary Healthcare Reform (PHCR) Project to help advance
Armenia’s Quality Assurance Initiative.
The Government of Armenia approved a quality assurance strategy in June 20081, and is
expected to soon approve an implementation plan. At the central and Marz level, Quality
Boards will be created, along with a new position for Quality Coordinator. At the facility
level, Quality Teams will conduct improvement activities using a Quality Improvement
1
Government of Armenia, Strategy of Quality Assurance in Primary Health Care, 2008-2015, Decree 19
Approved 19 June 2008, Protocol #24. (Extracted in: PHCR. Strengthening Quality Assurance in Primary
Health Care in the Republic of Armenia: Implementation Toolkit. Draft. August 2008.
8
(QI) toolkit including mechanisms like clinical audit, patient satisfaction surveys, and
self-assessment checklists with instructions. The Quality Coordinators will help the teams
to access resources and use the tools from the toolkit.
The quality indicators will be linked to a performance-based financing mechanism which
has already been proposed to the MOH. Financial incentives will be contingent upon
indicators such as percentage of women enrolled in prenatal care during first trimester,
immunization coverage, and use of EKG services. Six QI indicators have been chosen to
start. Specific governance issues and vulnerabilities to corruption in this initiative include
the following:
1. Tracking of funds from central level for the performance-based payment initiative.
Are the facilities getting the funds? To improve governance, a procedure should be in
place to measure the timeliness of flow of funds, and monitor whether funds are
actually reaching facilities. This information should be compared across regions and
the data should be made public.
2. Decisions for how the funds received are spent by the PHC facilities. How much
autonomy will facilities have to share these funds among staff? Need to assure that
spending is transparent and fair. This could be promoted by making sure that diverse
staff and the Quality Board are involved in decisions, and that process is rule-based
and made clear to all concerned.
3. Data from indicators evaluation. These indicators are used to decide if facilities will
get a payment, so there may be an incentive for fraudulent reporting if the real
performance data are not good enough. Strategies to minimize this incentive, and to
detect fraudulent reporting, need to be in place. In the short run, PHCR plans to
develop audit procedures for verifying manual reports. In the longer-run, the
Government should aim for an automated primary health care encounter system
which will be harder to manipulate in order to fraudulently inflate performance
numbers.
4. People at national level, who evaluate performance data and decide who gets the
bonuses, may have an incentive to slow the process (to extract speed money) or to
ask for bribe or kickback. Proxy indicators to measure the time it takes to disburse
performance-based payments could provide data which would help assess whether
this is a problem. There may be a need for an external review including confidential
interviews with providers to gain a sense of the prevalence of problem.
5. Board management. The members of the new Quality Boards, set up at the central
level and in each Marz, may not have experience in good governance. The Boards
may need assistance in creating transparent and accountable procedures for
decision making, and help defining roles and relationships (conflict of interest
policies, voting procedures, selection of members, etc.). Training of boards in
effective governance could be a worthwhile intervention.
9
PHCR has hired an Armenian consultant on governance who is helping to strengthen
structures and process in this area.
2. Discussion with PHCR staff: PHCR Related Projects
Discussions with PHCR staff show that many of their activities already are promoting
health reforms which will increase accountability and transparency, and reduce
vulnerabilities to corruption. Especially important initiatives include:





Automation of financial accounting systems, improved financial reporting, and
skills training, which will reduce discretion and increase accountability of
government agents
Training of journalists on health reform topics, to increase the quality of
reporting, and to support engagement of civil society in public policy debates.
Technical support for the Government’s Open Enrollment reform, a major change
in how health care is financed where doctors receive a “per capita” payment for
patients who enroll with her/him. This type of reform reduces incentives for
informal payments and referrals.
Advocacy training of community health committees through NGOs, an activity
which is meant to build capacity of civil society for external monitoring for
accountability
Institutionalization of the national health accounts (NHA) procedures and
reporting. The NHA and household health expenditure survey output need to be
more user friendly, and the press needs to understand them better. A start was
made in August, with the production of a short report on affordability of care in
Armenia (Feeley 2008). The measures in that report—including such critical
statistics as the percentage of households with catastrophic health expenditures,
the burden of out-of-pocket payments for different services shouldered by
different income quintiles, and the percentage of income spent on health care by
each quintile of the population--should be provided to the press on a regular basis,
with efforts made to assure that the press are able to interpret the data properly
and that they share data widely. Engagement of the population on these statistics
is critical to measure government effectiveness and to hold government
accountable for progress in increasing health care coverage, use, and outcomes.
Annex G summarizes the different areas where PHCR has been active and suggests other
areas where past gains could be leveraged to support additional transparency (e.g. expand
to more communities)
3. Interview with Lead Specialist from Ministry of Health: Taryn Vian’s
observations on the Maternity Care Certificate Program.
10
Maternity care, including deliveries and pre- and post-natal care, has been part of the
Basic Benefit Package guaranteed to all Armenian citizens.2 Such care was supposed to
be free to all, not just the poor. However, due to low levels of Government funding in the
hospital sector, formal and informal payments for maternity services were widespread.
Even for the poor, who are guaranteed a more extensive medical benefit package, out of
pocket expenses for deliveries were apparently common.
In 2008, the Ministry of Health decided to address these barriers to maternity services
directly by restructuring the system of paying for care. Starting in July 2008, pregnant
women are now issued certificates directly guaranteeing full coverage of delivery
(including C section where required) and the attendant drugs and tests. The certificates
state that there is to be no additional charge for these services. The pregnant woman can
go to any participating institution to obtain care with the certificate. The Ministry of
Health has set reimbursement rates substantially exceeding the rates previously paid
under the basic benefit program. When a facility is reimbursed for certificate-based care,
a portion of the funds are shared among staff (approximately 60-65%), while the rest
supports technical care costs (e.g. medicines and supplies). The certificate
reimbursement rate does not currently take into account equipment depreciation or other
capital costs. In tandem with the implementation of the certificate system, base salaries
for obstetricians were increased a small amount. The Ministry of Health has produced
posters which are in every facility, and has made significant efforts to inform the public
of the policy change. In addition, efforts are being made to enforce the “no additional
charges” requirement.
This is an innovative effort to address informal payments by influencing the rational
choice model. The program increases incentives for honest behavior by increasing
salaries and linking facility-level reimbursement rates to number of services delivered (so
that “funding follows patients”), while also increasing the probability of detection and
punishment by supporting government- and community-based monitoring and enforcing
administrative laws against public employees accepting bribes or illegal payments.
In June 2008, the Ministry of Health issued a decree on monitoring for the new system.
Three tools include a patient satisfaction questionnaire, a list of monitoring and
evaluation indicators, and a summary of usage data reported by facilities. The Decree
emphasized the role of civil society organizations in monitoring, and suggested creating
monitoring commissions at Marzpetarans/Yerevan City Hall and health facilities. The
members of the commissions would include state officials, program managers, and NGO
representatives.
MAAC has approved a proposal from one civil society organization, Armavir
Development Center, to conduct a public awareness campaign and external monitoring
on the Maternity Care Certificate Program. Armavir’s campaign will include
dissemination of information booklets and posters, and community meetings to promote
2
This summary is drawn in part from Frank Feeley. Trip Report for Primary Healthcare Reform Project.
Yerevan, Armenia September 3-16, 2008. Draft Sept. 19, 2008, p. 45-49, and conversations with Professor
Feeley.
11
knowledge about the certificate program. It also will include dissemination of
monitoring results through round table meetings, public presentations, and media. The
anticorruption monitoring component of the grant will involve the creation and testing of
external monitoring tools such as observation checklists, questionnaires for standardized
interviews, and guides for focus group discussions. NGO staff will help form community
groups, train community members to use the tools, and support the community groups in
carrying out at least 12 observation visits, six focus groups, and 60 individual interviews
to monitor the program. The external monitoring by NGOs and community groups is
expected to reduce risks of corruption in the certificate program through identification of
implementation problems, increased transparency with regard to government
performance, and increased awareness and public engagement among beneficiaries in
advocating for their rights and program improvement.
Possible vulnerabilities
1. Informal payments. While the program is designed to reduce informal payments, it
is possible that it will not work, and that physicians will continue to pressure patients
to make informal payments (perhaps more discretely) and/or patients will continue to
urge doctors and other staff to accept them. This could be due to flaws in program
design or how it is implemented. It could also be because attitudes are hard to change,
and the program focuses more on economic systems rather than psycho-social
behavior change models.
2. Fraudulent certificates is a risk, i.e. certificates submitted to government for
reimbursement by facilities which have not actually delivered services.
3. Diversion of funds, kickbacks. Managers at different levels may try to divert the
reimbursement payments from the staff who are entitled to get them. Managers could
also try to extort a kickback (percentage of the reimbursement) from the frontline
providers of care. A prevention strategy is increase reporting of funds received and
how they were used. Possibly this report could be required to be certified by a staff
committee or facility board with public participation. Audit of the program could
also detect this practice.
3. Governance of monitoring commissions. As with the Quality Initiative’s new
Quality Boards, the “monitoring commissions” proposed by the Government of
Armenia to provide oversight for the Maternity Voucher Program may need training
and assistance in creating transparent procedures and defining roles. To reduce the
number of duplicative governance structures created, it may make sense to use the
Quality Boards to monitor the Maternity Voucher Program as well.
4. Induced demand and unnecessary care. Over-use of c-sections has been mentioned.
This indicator and other clinical care indicators are part of the GoA monitoring plan.
Reporting of statistics on c-sections could be supplemented by clinical audit of
medical records to test for medical necessity.
12
A rigorously designed impact evaluation, conducted after the program has been
operating for some time, could help determine whether the program is successful at
deterring informal payments, when it is implemented as designed. An evaluation could
compare the Marz (or Marzes) where external monitoring by civil society organizations
has been supported (e.g. Armivar’s MAAC sub-grant) to Marz where CSOs were not
active. This could be an important “best practice” example for transitional economy
countries in the region and low-income countries elsewhere in the world as they try to
curb with informal payments without increasing the financial burden on patients. See
Feeley Trip Report, September 2008, Annex 2.D (p. 45-49) for a proposed case study and
impact evaluation.
4. World Vision Related Programs
Discussions were held with World Vision staff, focused on strategies to increase external
accountability through community mobilization, and issues of good governance in the
Country Coordinating Mechanism and other Global Fund-related institutions and
governance procedures. The consultants shared lessons learned in other countries.
World Vision’s progress in community mobilization for health has created important
grassroots resources which can be tapped for MAAC activities as well. World Visionassisted local NGOs should be encouraged to apply for MAAC grants, for example, and
should be informed about activities and opportunities organized through the new regional
anticorruption offices being established with MAAC assistance.
5. Meeting with health expert from the National Anticorruption Expert
Committee
The national strategy workshop raised many problems in the health sector. Five which
seemed important to most all participants included:

Under-funding of government commitments and obligations in health,
creating pressure for illegal payments and other unofficial “coping mechanisms”
(e.g. diversion of drugs).

Conflict-of-interest, lack of institutional capacity, and lack of transparency in
pharmaceutical systems, resulting in government over-payment for supplies,
patronage-influenced targeting policies and distribution, inequitable access and
irrational use of medicines

Lack of accountability of providers for giving good quality of care, creating
vulnerabilities for corruption and reducing government effectiveness in service
provision

Low expectations on the part of the population for government to be more
effective, resulting in lack of external pressure and low government accountability
13

Frequent practice of informal, illegal payments for services which should be
free, resulting in higher out-of-pocket expenditures, lower use of services, and
lower trust in government
Annex D summarizes the results of a discussion with the health expert from the National
Anticorruption Expert Committee, who along with Taryn Vian, elaborated on the results
discussed at the workshop. The results of this consultation are presented in a table that
illustrate a set of possible strategies to address identified problems, along with needed
activities and expected outcomes. This information, along with the results of the
workshop, was translated into Armenian and will be shared with the entire Expert Group
as input to the national Anticorruption Strategy.
V. Recommendations
USAID implementing partners in the health sector are already undertaking many
activities which support good governance and anticorruption. In particular, the efforts to
measure quality outcomes and link them to performance, strengthen primary health care
administrative and financial systems, facilitate the implementation of the new Open
Enrollment policy, and promote community mobilization and advocacy for health, all
will help to create an environment which fosters transparency, reduces opportunities for
abuse, and holds government accountable for performance.
Specific programming changes and enhancements may help to promote good governance
and control corruption even further. These include:
1. Put in place systems to track funds for performance-based payments and activitybased reimbursements under the Quality Assurance initiative and the Maternity
Certificate program. Create and disseminate reports on the timeliness of funds
disbursement, and whether funds are being used as intended. Data should be compared
across regions and made public. Work with media and with local NGOs to promote
public debate on the results. (Who? World Vision working with local NGO sector, PHCR
project, Quality Councils and Maternity Certificate Monitoring Councils)
2. Strengthen governance structures (e.g. Boards or Councils) used in the Quality
Assurance and Maternity Certificate programs. Enabled by government decree, the
operation of these boards should be guided by explicit and detailed scopes of work,
policy and procedure manuals, and democratic principles for the selection of members
and for voting and decision-making. (Who? PHCR project, MAAC, Government of
Armenia)
3. Promote legal and administrative changes to reduce false claims and false reporting.
Two types of activities are needed. First, projects like PHCR should put in place audit
procedures to detect false reporting of quality indictors or other information on which
funds flow decisions are based. As the Open Enrollment system is implemented, there is
a need to check databases to detect and investigate anomalies. In the long run, the GoA
14
will need assistance in the implementation of computer based systems to audit reporting
and detect false claims.
Secondly, the GoA needs to adopt government-wide legal changes to increase the
penalties of making false claims or filing false reports with a government agency. This is
not only a problem affecting the health sector, but one that affects all government
services. With increased penalties and increased probability of detection and
enforcement, levels of corruption through the filing of false reimbursement claims will
decrease. (Who? MAAC, PHCR project)
4. Support monitoring and evaluation of the Maternity Certificate Program. This
program is an innovative approach to reducing informal payments and must be rigorously
monitored and evaluated. Support for the Government of Armenia’s planned monitoring
program, and to fund independent scientific evaluation of the program, is advised. Local
NGOs should be encouraged to provide external accountability and to seek support
through the MAAC small grant program. (Who? USAID, MAAC GOA)
5. Institutionalize and expand health accounts analyses. National health accounts
data is essential for measuring government performance in the health sector.
Performance data is in turn critical for accountability. Yet, the health accounts data
collection and analysis processes, including household level health expenditure surveys,
are not institutionalized and risk ending when USAID support ends. Measures should be
taken now to support the institutionalization of these critical functions, and to expand the
types of analyses undertaken (e.g. reproductive health sub-analysis) (Who? PHCR
project, USAID)
6. Expand public awareness of the Basic Benefit Package (patient rights and
entitlements), expand advocacy training for NGOs, and continue to support informed
journalism and dissemination of user-friendly statistical information from the health
accounts database. These activities will help to create an informed, active citizenry who
can express their voice and hold government more accountable for Armenia’s
performance on health indicators. As these activities are currently being undertaken
already on a limited scale, stakeholders will need to discuss and set targets for expanded
scope (Who? PHCR project, NOVA, World Vision, MAAC)
In the education sector, the MAAC program is supporting Partnership and Training, an
NGO in the Syunik region is developing a package of procedures to increase
transparency and accountability of secondary schools governing bodies, school boards,
parents boards, and teachers boards. They are also going to conduct an awareness
campaign to raise the general public’s awareness about these new procedures as well as
the importance of community participation in the secondary school governance and
management structures.
Similar efforts to encourage citizen oversight in other regions of the country could be
supported to increase the demand for transparency and accountability in the education
15
sector in Armenia. Reducing tolerance for corruption can be achieved by empowering
the community; convincing citizens that they do not have to accept substandard education
services; that they do not have to pay for services they are entitled to receive free of
charge, and that through collaboration with school boards and education authorities, they
can increase both the quality of education and the trust and confidence in the system.
Participants of the workshops suggested that similar workshops could be organized in the
future to keep track of their activities, receive feedback and discuss challenges and
progress achieved.
List of Annexes
Annex A
Workshop on Good Governance in the Health Sector for USAID and
implementing partners: agenda and results of workshop break out
discussion groups
Annex B
NGO Workshop on Good Governance in Health and the Role of Civil
Society Monitoring: agenda and results of workshop break out discussion
groups
Annex C
AC Strategy Workshop with Expert Group and Ministry of Health:
agenda and results of break out session discussion group
Annex D
Results of Discussion with Health Expert from Anticorruption Expert
Committee
Annex E
AC Strategy Workshop with Expert Group and Ministry of
Education: agenda and results of break out session discussion groups
Annex F
NGO Workshop on Good Governance in Education: agenda and
results of break out session discussion groups
Annex G
Notes from Technical Meeting with PHCR Staff
Annex H
Moldova Anticorruption Strategy for the health sector
16
Contacts
Dr. Mary Segall, PhD, RN, Director, Quality Improvement Program
Private Sector Partnerships-One Project
Tel. 301-347-5315
[email protected]
Roger Vaughan, Senior Health Advisor
Moldova Governance Threshold Country Program (Millennium IP3 Partners)
Tel. 011-373-69-892-747
[email protected]
Rich Feeley, Health Finance Specialist (BU under sub-contract to PHCR Project)
[email protected]
Kimberley Waller, MPH, PhD, Health Team Leader
USAID/Armenia
Tel. 374-10-494362
[email protected]
Mark Levinson, Democracy and Governance Officer
USAID/Armenia
Tel. 374-10-494362
[email protected]
Franois Vezina, Chief of Party
Mobilizing Action Against Corruption (MAAC) Activity, Casals & Associates
Tel. +37410 514 834
[email protected]
Garik Khachikyan, Public Management Specialist
MAAC Activity, Casals & Associates
Tel. +37410 514 834
[email protected]
Christine Manvelyan, NGO Specialist
MAAC Activity, Casals & Associates
Tel. +37410 514 834
[email protected]
17
Contacts of NGOs, Experts, and Implementing Partners Attending Workshops (this list
contains at least one participant from each organization but is not comprehensive)
Inna Sacci, Country Director, Nova Project
[email protected]
Nune Yeghiazaryan, Country Director, Eye Care Project of Armenia
Tel. 374-10-57-76-11
[email protected]
Mark Kelley, Country Director, World Vision
[email protected]
Anahit Yernjakyan, Human & Institutional Capacity Development Program, AED
Rick Yoder, Chief of Party, Primary Healthcare Reform (PHCR) Project
[email protected]
John Vartanian, Deputy Chief of Party, PHCR Project
[email protected]
Mr. Ashot Melkonyan
Health expert, NGO sector (name of NGO is Public Health Charity Fund). Former
Chief Specialist in the Control Inspectorate of the MOH
[email protected]
Dr. Armen Khudaverdyan
Head of the ACSMC Expert Group
18
ANNEX A
Workshop on Good Governance in the Health Sector
For USAID staff and implementing partners
Purpose: The health sector in Armenia faces challenges due to the complex interactions
of regulators, payers, providers, suppliers, and consumers. Mixed incentives, imperfect
information, and power imbalances can lead to decisions which seem inefficient or
unresponsive, and do not lead to better health care quality, access, or outcomes. The goal
of good governance is to strengthen institutions, rules, and administrative systems to
promote accountable, transparent, representative, and effective policies and programs.
Benefits of participating:
This workshop will introduce participants to the concepts of good governance as they
apply to the health sector. We will review tools and strategies for increasing
accountability, and see how they have been applied in other countries in the region,
including Albania, Moldova, Estonia, and Kyrgyzstan. Break-out groups will leave
ample time to discuss how these principles and examples might apply to health initiatives
supported by USAID and implementing partners, including the National Quality
Assurance Initiative and the maternity voucher system.
After attending the workshop, participants will be able to:
1. Define components of good governance and enabling factors, including transparency,
accountability, and political participation;
2. Identify causes and negative effects of weak governance, including consequences of
corruption;
3. Use a conceptual framework to discuss governance problems and to identify levers to
improve good governance and reduce vulnerabilities to corruption;
4. Analyze the design and (where available) impact of good governance initiatives and
anticorruption strategies in other countries in the region;
5. Apply principles of good governance to improve the accountability, transparency,
effectiveness, and responsiveness of public health initiatives in Armenia.
Who should come:
USAID Health team members, Democracy & Governance team members, and
implementing partners are invited. Chiefs of Party and Deputy Chiefs of Party, Team
Leaders affiliated with health reform initiatives, and others who work on capacity
strengthening in government institutions or systems will benefit from this workshop.
Governance concepts are also applicable to effective and transparent management of nonprofits.
19
ANNEX A (cont.)
Agenda
Thursday September 25th
Welcome and Introductions
Presentation: Building Good Governance in Health
Yemile Mizrahi, Casals and Associates
Presentation: Identifying and Addressing Vulnerabilities
Taryn Vian, Boston University
Small Group Work
Identify and analyze governance issues in health sector, explore implications
Large Group Discussion and Q&A
Presentation: Selected Country Experiences in the Region
Taryn Vian
Friday September 26th
Presentation: Tools, Strategies, and More Country Experience
Taryn Vian
Small Group Work
Analysis of QA Initiative, Maternity Voucher Program, applying tools and
strategies
Large Group Discussion and Q&A
20
ANNEX A (Cont)
USAID/Implementing Partners Workshop: Governance Problems in Health Sector
September 25-26, 2008
Break out session 1
WHAT are the most significant
WHY do they happen?
problems that need to be addressed?
What enables these problems to go on?
 Low quality of care due to lack of
accountability for delivery of quality
services
 Pervasive problem of informal payments
 Non-transparent procurement
 Lack of protection of patient rights
 Free care pool is being abused (unfair
distribution not based on need)
 Lack of reporting on corruption
 Conflicts of interest which affect
regulation and resource allocation
 Weak institutional capacity
General Conditions
 Lack of standard treatment guidelines and other benchmarks for performance
 Lack of systems for monitoring quality of care
 Low demand for quality services and for transparency/accountability
 Lack of enforcement of regulations, perhaps due to perception of health sector as “market driven”
meaning self-regulating (no need for government to intervene, create guidelines)
 High level of tolerance of corruption among citizens and public officials
 Low salaries
 Lack of accountability on part of Government, which is allowed to make commitments which are
not funded with sufficient resources, leading to implementation problems and lack of sustainability
 Too much discretion in decision making regarding how free care pool is spent
 Lack of political will to reform, resistance to change
 Lax licensing and accreditation procedures
 Norms for planning are not available (staff per bed etc.), resulting in government not fulfilling role
as regulator
Drivers of informal payments
 Lack of information on what people are paying now
 Mindset of patients (think they get higher quality by paying, afraid not to pay)
 Government officials who own private facilities may have bias in regulating private sector
 Lack of conflict of interest laws or rules
 Small country—everyone knows everyone
21
ANNEX A (cont)
USAID/Implementing Partners Workshop: Breakout Session 2
Group 1 ---- Program Analyzed: Open Enrollment
Strategies to Improve Governance:
1. Transparency
 Public access to published budget allocation per facility
 Making transparent the process by which budget amount is determined
 Provide transparency in budget disbursement and control discretion of SHA by
making sure that the open enrollment numbers which they use for disbursement of
funds are actually prepared by a separate entity.
 Create a manual, in lay language, which explains how open enrollment works
 Assure that people have consistent information about open enrollment (e.g. use
mystery patients who seek care at a facility and record what they are told by staff,
making sure they get accurate and complete information)
2. Accountability
 Control for adverse selection, i.e. the probability that doctors might enroll only
people who are well and will not need many health care services. Do data
analysis to detect this problem.
 Control for accuracy of registration, i.e. making sure that two doctors are not paid
for the same patient (i.e. double enrollment)
 Put in place an external audit system, perhaps through the Chamber of Control
3. Rewards and Consequences
 Have consequences for doctors who enroll only healthy patients or who provide
poor quality care. This requires getting approval on what the standards of care
should be.
 Use CSOs in a watchdog role
 Decide what information to make public/publish about performance
 Need to have consequences for poor practicing doctors
 Operational research to monitor and evaluate
4. Education
 Develop awareness and emphasize the responsibility of the population for its own
health
 Use NGOs to promote prevention and early access to services
22
ANNEX A (cont)
USAID/Implementing Partners Workshop: Breakout Session 2
Group 2 ----- Program Analyzed: Basic Benefit Package
Insurance program for those who cannot afford to pay for care. Problems identified:
1. Low satisfaction with services
2. Inadequate funding to fulfill demand
3. Approach to this program is not scientifically grounded
Strategies to Improve Governance:
1. Transparency
 Regularly update MOH web site with information on contracts awarded for BBP
 Patients are told there is “no funding available” but there is no real way to find out
if this is true. Need more transparency here.
 Need to provide information to patients on patient rights and obligations
 Need for a social services-health ombudsman to handle complaints
2. Accountability
 Make the public more aware of some of the abuses in the health system. This
would be a way to increase pressure for reform.
 Need to train journalists on how to report on health care fraud cases
 Need to develop treatment protocols and service protocols or performance
indicators (i.e. people should not have to wait more than 10 days to see a
provider). This way, patients will know what they are entitled to.
 Spot checks or audits of records to assure that services were provided
3. Participation
 Need greater participation of grassroots organizations.
 More training of grassroots organizations in communication strategies
 More investment in effective dissemination strategies
4. Control
 Study effectiveness of allocated funds (what is achieved for money spent)
 Human resource management needs strengthening, especially the allocation of
specialists and their training; labor optimization
 Currently MOH monitors the program, but it is not clear what are the results of
this monitoring. Need to analyze the MOH monitoring efforts as they are
currently implemented. How do they use the monitoring data? Are they holding
people accountable for performance? Are there consequences which result from
monitoring?
 Advocating for patients to take more personal responsibility for their health
23
ANNEX B
Workshop on Good Governance in the Health Sector
Civil Society Organizations
September 27, 2008
Agenda
Civil society participation is critical to good governance, and can help increase external
accountability and citizen voice. This workshop focuses specifically on the role of
community organizations in providing external oversight and providing a means for
citizens to articulate the wants and needs which shape the goals of government policies
and programs. While the workshop focuses specifically on one program--the free
maternity care initiative--the strategies and concepts are applicable to other health
programs as well, and should be of interest to a range of NGOs.
10:30-10:45
Introduction and Opening
10:45-11:45
Explaining Governance and Governance Challenges in the Health
Sector
Coffee Break
12:00-1:00
Strategies and Tools for Civil Society Organizations
1:00-3:00
Discussion Group: Developing a Plan for External Monitoring
Activities
24
ANNEX B (Cont)
NGO Workshop on Good Governance in Health and the Role of Civil Society
Monitoring: Summary of Discussion and Group Work
1. Some NGOs have worked on creating community boards and have had some
success. These are usually informal boards, not a formal (approved by government)
entity. Yet, other times the boards are not functional, in part because there is so much
discretion on the part of MOH that it is hard to hold government officials or facilities
accountable.
2. One type of corruption not mentioned in presentation is doctors who refer patients to
pharmacies where the doctor “expects a reward.” This could be a pharmacy which
the doctor owns or has part ownership, but it also might just be a “shady deal.”
3. Transparency and the Open Enrolment Program. Participants mentioned that this law
is supposed to promote citizen choice, and in theory it should therefore decrease
corruption. But in reality there are problems. For example, patients are told they can
choose any doctor, but they still will have to go only to the district doctor to get
certificates. Also, though they have “choice” they may choose unwisely. Finally, in
rural areas there are few doctors and sometimes choice is limited or there is no
choice.
4. One participant emphasized that not only are flows of funds in the health sector nontransparent, but the allocation of funding in health sector is unrealistic, given the
goals. Government is over-promising and without adequate funding it is impossible
to be effective in meeting goals.
5. We discussed at length the issue of honesty of response to patient satisfaction
surveys. One participant felt that survey respondents were mostly honest, while
another participant thought that people were not honest in responding to satisfaction
surveys because they were worried about possible negative repercussions, especially
in rural areas. In one NGO they have tried to increase the comfort level of
respondents by using volunteers to administer the patient surveys. This NGO feels
that people are more honest because they are talking to someone who is more
“objective”. Still, people agreed that reporting bias (i.e. reluctance to be critical or
honest) is an important issue, and facilities themselves would be unlikely to gather
honest information from patient surveys. This is therefore a good role for CSOs.
6. Much of the discussion centered on the maternity care voucher program. People
mentioned that obstetricians are already talking about how they are not getting the
payments.3 Participants emphasized that the policy is not clear on how exactly the
facility should use the revenue from the voucher-based reimbursements, and there
3
It was not clear if the participants in workshop thought OBs were supposed to receive a portion of the
case-based reimbursement (which is paid to facility on basis of number of certificates they honor) or if they
were referring to OBs not getting the higher level salaries which were approved.
25
could be differences between facilities. These differences would make it hard to
evaluate outcomes (i.e. it could be a confounding factor in observed differences in
program effectiveness between facilities). One NGO representative mentioned that
the voucher program has affected interpersonal relations between providers and
patients: the vouchers make providers act more formally and less warmly with
patients because they do not have any expectation of reward and because they are
afraid of patients reporting on them. NGOs felt that the maternity voucher program
has had a positive effect in eliminating provider rationalization of informal payments,
i.e. eliminating the excuse that “salaries are low”. However, a new problem is arising
with the certificates. One NGO said that when voucher is given, it is not sealed by
the facility. Armenians then use the unsealed voucher to go elsewhere.
7. One NGO representative mentioned that corruption has become systemic, so it is hard
for a single program (e.g. maternity voucher program) to have an impact. For
example, even though the maternity voucher program provides for increased salaries
of some doctors, other do not receive increased salaries (e.g. neonatologists) and this
may make them feel left out or resentful. When the informal payments were paid to
doctors, doctors usually shared these fees with other providers; perhaps the same
should be done with the subsidies which are meant to replace the informal payments.
8. Regarding enforcement, one NGO participant felt that the State might have too much
discretion and be cracking down on informal payments in arbitrary ways. The MOH
is criminalizing the acceptance of informal payments, but in a selective way, so that it
becomes a witch hunt.
9. One participant suggested that government might be raising expectations of doctors
and patients without being able to deliver. There is a fear that the system will collapse
without corruption. Eliminating the corruption overnight is not possible. Health
sector risks stem from institutional issues which really need to be addressed.
10. We discussed issue of role of NGOs vis-à-vis the State with regard to anti-corruption:
should the NGO be a partner or an adversary? Presenters encouraged NGOs not to
only see themselves as adversaries or watchdogs, but to try to also be a partner in
implementing changes. One NGO said their staff have met with different health
departments and have had different responses. One health department (Marz level)
was angry with the NGO and felt they were interfering, while another health
department was glad and wanted to meet with the NGO about program monitoring.
This example suggests that not all government officials are threatened by CSO
oversight, and some do see NGOs as implementing partners. This same NGO
described how staff had also met with the Prosecutor General’s office, which was
supportive of CSO monitoring. But NGO participants agreed that it is a difficult
balance between the different roles (watchdog/oversight vs. implementation
partner/capacity building assistance).
26
ANNEX B (Cont)
Group Work
Group participants analyzed CSO roles in external monitoring of a government program.
Both small groups chose the Maternal Health care Vouchers Program. The groups first
analyzed the goals, objectives and activities of the program itself, then suggested
indicators to measure program effectiveness, and ways in which civil society
organizations could contribute.
Program Goals:
 To promote maternal and child health by increasing access to and quality of child
birth services.

To reduce systematic corruption risk, especially in childbirth services delivery

To reduce poverty by reducing informal payments.
Objectives:
 To issue maternity vouchers to women.

To provide information about the program to potential beneficiaries (women).

To provide good quality childbirth services for women.

To make sure that providers receive compensation for the real costs of childbirth
services

To increase competition and get rid of monopoly of health care providers
(monopoly is a favorable condition for corruption, so if we reduce it there is less
risk of corruption)

To reduce the circulation of cash payments, i.e. elimination of informal payments

To increase trust in the State medical care system.
Expected outcomes:
 Reduction of corruption risk and shadow economy

Improved quality of medical care

Spending by State on maternity care services matches the actual cost of care
provided (including increased spending on salaries of providers)

Decrease in patients having to pay for services (reduction in informal payments)

Increased access to services, e.g. rate of facility-based deliveries as opposed to
home deliveries

Increased satisfaction of patients, satisfaction of providers
27

Increased birth rate

Increased trust in government
Implementation Activities and Monitoring:
Some activities to implement the program are undertaken by government alone
Other activities may be undertaken by State or NGOs (or both together), including
awareness campaigns to advertise availability of certificates and services, and setting up
commissions at the national and Marz level to monitor. The government has a hotline
where people can obtain information about the program or register a complaint.
Groups felt that NGOs will have to come up with indicators in order to do monitoring.
Suggestions:

Level of public awareness about the program and about patient rights.

Patient satisfaction

Provider satisfaction

Effect of the voucher system on the income of health personnel

Effect of the voucher system on the practice of cash payments (reported amounts
paid by patients)

Indicators of physical condition of facilities, workload of facilities, and
“competition of facilities”
Transparency Strategies:
Some strategies that NGOs can use to help make this program more effective and
transparent include:
1. Using tools to monitor, such as doing surveys with patients using volunteers (to
increase honest responses), or holding focus groups with doctors or other providers
2. Working with the State as a “partner”, identifying and raising problems then trying to
fill them. NGOs can make sure that the government has taken all the steps to
implement the program, identify gaps in implementation, and make
recommendations. NGOs can also can help work on solutions to problems as they
come up.
3. Inform the population about the results of the program (achievements and failings).
Continue to act in “watchdog” role. Use the media to organize roundtable discussions
so that the public is aware of what is being done.
28
4. Create positive incentives for good performance by providers, such as creating a prize
for the best hospital. A prize is a positive incentive for performance and creates more
competition, as patients will want to go to the facilities which have better reputations.
29
ANNEX C
AC Strategy Workshop with Expert Group
Mon. Sept. 29, 2008
Agenda
9:00 -9:30
Registration
9:30-9:40
Opening Remarks
9:40-10:00
Armen Khudaverdyan, Head of the ACSMC Expert Group
10:00-11:00
Building Good Governance in Health: Definitions, Risks, Vulnerabilities.
Main Elements of an Anti-Corruption Strategy
11:00-11:30
Corruption Vulnerabilities in Health: Inputs from some Health Specialists
in Armenia
11:30-11:45
Coffee Break
11:45-12:15
Anti-Corruption Strategies and Tools
12:15-1:15
Break Out Discussion Session: Building an Anti-Corruption Strategy and
Action Plan for the Health Sector
1:15-2:00
Plenary Discussion
2:00-2:15
Closing Remarks and Evaluations
30
ANNEX C (Cont)
Discussion in Morning Session: Problems

Not good costing of health services

No existing regulation for conflict of interest

No code of ethics for personnel in health sector

Non-well regulating system for hiring and firing personnel

Government awareness campaigns don’t seem to be effective in informing the public and
in changing public opinion. This results in high level of tolerance for IPs. (need to have
information at the time when you are seeking care)

Lack of trust in the system.

Awareness campaigns are done mostly by donor community. Government itself is not
investing in public information, especially disseminating the AC message

Problems with the targeting policy, i.e. how patients gain access to free care, including
patronage

Patients do not know how much they are supposed to be charged and what services are
included in the benefit package vs. extras

Outpatient clinic referrals to inpatient facilities may be resulting in unnecessary referrals

Appropriate treatment protocols are not universally known/used

Government does not have credible monitoring and evaluation information source to
keep track of own programs

Journalists are not well trained, resulting in sensationalism in press rather than objective
investigation

Some important health legislation is not implemented/enforced

Institutions lack capacity

Unclear criteria for referring patients to particular pharmacies, which can result in
referrals which provide kickbacks or are to pharmacies in which the provider has a
financial interest
31
ANNEX C (cont.)
Possible solutions
National health insurance. This is a large reform, that may address some existing corruption
risks but would introduce others (perhaps bigger).
Separation of purchaser and provider
Better controls on access to free care services (including referrals to free care, medications),
including objective indicators of need of beneficiaries, external monitoring system
32
ANNEX C (Cont)
Workshop on Building Good Governance in Health
September 29, 2008
(Output of Afternoon session)
Expected Outcome
Actions Already Taken
What, if anything, has already been done to
achieve this outcome?
Government health budget is
increased to adequately fund
Government commitments
(objectives)
Analyses have been done to determine
the true cost of providing selected
government services (SHA analysis of
diagnostic services costs)*****
National health accounts database
exists and is updated and analyzed
annually, providing data on sources
and uses of funds in the health sector)
MOH conducts household health
expenditure surveys and health system
performance assessments (this has
information on out-of-pocket
payments) Armenia NIH Working
Group on Health System Performance
Assessment
Next Steps
Actions to Take
Describe the activities that need to inbe
introduced to achieve the expected
outcome
Inventory of existing cost data in
the country
Additional costing assessments as
needed to establish true cost of
government entitlement programs
Advocacy for increased
Government budget for health
Anticipated
Risks
Identify who
should take the
lead
What can stand in the
way of implementing
the tool?
Tension between
need to allow
appropriate
discretion in
choosing treatment
options and
ensuring consistent
use of protocols.
Effective use of
protocols requires
buy-in of many
stakeholders; if
they do not all
agree, the efforts
may not be
successful
33
Expected Outcome
Rationalization of procurement
process so that the right
medications are purchased by
government
Clear and consistent use of
service protocols
Actions Already Taken
What, if anything, has already been done to
achieve this outcome?
Next Steps
Actions to Take
Protocols and list of medications
should be developed by MOH
Demand projections (for drug
needs)
Protocols exist but they are not being
consistently used
Review existing treatment
protocols
Develop, as needed, treatment
protocols and quality indicators
based on best practice standards
(according to RoA strategy on
quality assurance, decree 19June-08))
Anticipated
Risks
Protocols and
list of
medications
should be
developed by
MOH
What can stand of
in the
Development
way
of
implementing
protocols costs
the tool?
money; lack of
funding may be
rationalization for
no action
Systemic reforms
may be successful
at first, but may
become vulnerable
to new types of
fraud as people
learn how to game
the system
Support government and
community entities (e.g. Quality
Improvement Boards) to monitor
quality
Minimum requirements for
accreditation of health facilities
Update list of essential
medications on regular basis, with
reference to WHO guidelines
34
Expected Outcome
Rationalization of prescribing
practices and use of drugs
Actions Already Taken
What, if anything, has already been done to
achieve
thisthey
outcome?
Protocols exist
but
are not being
consistently used
Patients are more aware of rights,
entitlements, and obligations
Better informed and professional
journalism on health
Studies are available on corruption
risks (e.g. UNDP “Strengthening
Awareness and Response in Exposure
to Corruption in Armenia” 2007)
Increased competition in retail
pharmacy market (competition
keeps prices down and provides
more choices for patients)
Next Steps
Actions to Take
Anticipated
Risks
What can stand in the
way of implementing
the tool?
Reduction of paperwork for
approving provision of free
medications to patients
Continuous dissemination of
information to the public to raise
knowledge of government
policies, patient rights,
obligations, and entitlements
Training of journalists in health
investigation/research for articles,
and reporting
Develop code of ethics for MOH
and train personnel (including
conflict of interest provisions,
disclosure of assets for senior
officials, and corresponding
sanctions)
Armenian
National
Institute of
Health;
USAID PHCR
Conduct regular household
expenditure and health system
performance surveys
Price transparency activities in
pharmacies (e.g. comparison of
prices across pharmacies,
dissemination of price
information)
35
Expected Outcome
Actions Already Taken
Next Steps
Actions to Take
Anticipated
Risks
What, if anything, has already been done to
achieve this outcome?
What can stand in the
way of implementing
the tool?
Audits of reimbursement records
(e.g. how facilities contract with
and reimburse pharmacies)
Continuous education of doctors
(protocols, ethics)
Increase internal controls of the
distribution of drugs from
procurement agency to hospitals
/pharmacies
Eliminate informal payments
Maternal Health Care Voucher
Program has been implemented since
Jan 2008 (IPs)
Social audits / participatory
monitoring of health process and
outcome indicators to generate
demand for higher transparency
and accountability in health
service provision (e.g.
satisfaction, amounts paid,
waiting time)
Definition of secondary
legislation to implement health
laws
MOH has established administrative
sanctions for accepting informal
Put in place ways to “test” the
system to make sure it is
operating as intended (i.e.
journalists who will pretend to be
patients)
Monitor whether penalties for
accepting informal payments are
MOH
MOH (MCH
officials for
36
Expected Outcome
Actions Already Taken
What, if anything, has already been done to
payments.achieve this outcome?
Sanctions are defined for not
providing services adequately;
providing good quality. Legal
framework exists for hospitals and
clinics that do not provide good
quality care.
Civil law provisions exist whereby the
MOH could require facilities to repay
government funds if facilities do not
comply with regulations or provide the
services
Performance-based incentives have
been developed by PHCR Project to
reward high quality providers
Next Steps
Actions to Take
enforced fairly or whether they
are arbitrary
Improve enforcement of
legal/regulatory framework for
sanctioning facilities for poor
quality and rewarding facilities
for good quality
Anticipated
Risks
the Maternity
Care Voucher
Program)
NGOs (civil
society
monitoring)
What can stand in the
way of implementing
the tool?
Civil society monitoring of
informal payment practice and
effective implementation of
Maternity Voucher reform
Design a system for reporting and
resolution of citizen complaints
*** Please note that items in blue indicate Taryn and Yemile’s inputs; not discussed in the workshop.
37
Annex D
Health Sector AC Strategy: Input to Expert Group. Results of discussion with Health Expert from
Anticorruption Expert Committee
Problem
Government commitments and
objectives for state-sponsored health
care services are not adequately funded,
creating incentives for illegal payments
from patients, and other "coping
mechanisms" by government agents
seeking to make a living wage
Expected Outcomes
1. Key stakeholders in government and
civil society are made aware of what it
really costs to deliver the services that
government claims to be providing, and
the size of the gap between the true cost
and the current government budget
Actions already taken
1. Analyses have been done to determine
the true cost of providing selected
government services
Actions to take
1. Conduct additional
expenditure analyses needed to
establish true cost of
government programs, as input
to public budgeting process
Who?
MOH, State Health
Agency, National
Institute of Health
2. Government spending on health is
increased to adequately fund
commitments
2. National health accounts database
exists, providing data on sources and
uses of funds in health sector
2. Public meetings on budget
process to increase external
accountability
MOH, Civil
Society
organizations
3. Approved, transparent policies and
regulations for hospitals, public health,
and drug policy
3. Household health expenditure surveys 3. Institutionalize the processes MOH, USAID,
and health system performance
for updating national health
other partners
assessments have been conducted
accounts regularly and
conducting regular household
health expenditure surveys
Risks
1. Funding is needed for
analyses and to promote
budget transparency and
accountability
4. Reform of healthcare
regulations and policies, to
clarify
38
Annex D (cont)
Problem
Conflict of interest, lack of institutional
capacity, and lack of transparency in
pharmaceutical policies and systems,
resulting in Government over-payment
for supplies, patronage-based
distribution of medicines and targeting
of free care benefits, inequitable access
by poor, and irrational use.
Expected Outcomes
1. Tender process for pharmaceuticals is
transparent and vulnerabilities to
corruption are reduced
Actions already taken
1. Studies have been conducted which
analyze pharmaceutical procurement
policy and systems, and make
recommendations for improvement (e.g.
RPMPlus, USAID)
Actions to take
Who?
1 Regulatory reform to permit GOA
monitoring of procurement
compliance with regulations and
to make public the results of
procurements
Risks
1. Systemic reforms may be
successful at first, but may
become vulnerable to new
types of fraud as people learn
how to game the system
2. Create inter-agency tender
commission with public
representation
2. Several activities require
funding
MOH, MOF
3. Disseminate reports from
MOH, Civil
commission and promote public Society
dialogue
organizations
2. Medicines purchased with
Government funding are selected in
transparent, non-biased manner,
resulting in a limited list of medicines
which are effective, of high quality, and
provide value for money
2. Studies have been conducted which
4. Reform of process for
analyze pharmaceutical selection process medicines selection (essential
and make recommendations for
medicines list)
improvement (e.g. RPMPlus, USAID)
3. Medicines provided through the
Government's free care programs (BBP,
Maternity Certificates, etc.) are available
in sufficient quantities and at reasonable
costs to qualifying patients
3. Studies have been conducted which
analyze policies related to the Basic
Benefit package (e.g. RPMPlus, PHCR
Projects USAID)
4. Increased percentage of patients,
especially the poor, who receive the
drugs they have been prescribed
MOH,
development
partners such as
WHO, USAID
5. Analysis on risks and benefits
of reform options, and pilot
testing of reforms, in
distribution systems for free
medicines
6. Increase transparency of
quantification process (i.e.
process by which quantities of
drugs needed are calculated) and
monitoring of measures of
unmet need
7 Implement price transparency Civil society (using
study to monitor prices paid by WHO/HAI
consumers; disseminate results methodology)
39
Annex D (cont.)
Problem
Lack of accountability of providers for
good quality care, which creates
vulnerabilities for corruption and
reduces government effectiveness
Expected Outcomes
1. Clear and consistent use of standard
treatment protocols and service
protocols
2. Health professionals adhere to
professional ethical norms
Actions already taken
1. Some protocols exist but are not
followed
Actions to take
1. Develop new protocols, as
needed, for treatment and
quality indicators, based on best
practice standards
Who?
MOH, University
partners (medical
schools),
development
partners such as
WHO, USAID
Risks
1. Tension between need to
allow appropriate discretion
in choosing treatment
options and ensuring
consistent use of protocols
2. RoA has approved a quality assurance 2. Support government and
community-based monitoring of
strategy for primary health care
quality of care and other health
care process and outcome
measures
2. Effective use of protocols
requires buy-in of many
stakeholders; if they do not
all agee, efforts may not be
successful
3. Develop guidelines for
implementation of code of ethics
for government health sector
professionals and officers
3. Lack of funding for
development of protocols
may be a rationalization for
not taking action
3. Draft law on health care addresses
some ethics issues
4. Support pre-service and
continuing education of doctors
on standard treatment protocols
and on codes of ethics
Low expectations on part of population
for government to be more effective,
leading to lack of external pressure on
government to be more effective
1. Patients are more aware of their
rights, entitlements to services or
government benefits, and their own
responsibilities for their health
1. Community mobilization activities
have trained NGOs in advocacy skills
and human rights issues related to health
(e.g. PHCR Project, USAID)
MOH, USAID
1. Expand programs to
(through MAAC
continuously disseminate
and PHCR)
information the public and to
raise awareness of patient rights
and government policies
2. Some journalists have been trained in 2. Continue training and
development of high quality
how to report on health reform issues
journalism related to health
(PHCR Project, USAID)
issues
40
Annex D (cont.)
Problem
Expected Outcomes
Frequent practice of informal (illegal)
1. Eliminate abusive informal payments
payments for government health services for services that should be free
that are supposed to be free, resulting in
high out-of-pocket payments, lower use
of needed health care services, and lower
trust in government
Actions already taken
1. Studies have been conducted which
analyze out of pocket expenditures by
patients (e.g. RPMPlus, USAID) and
informal payments (e.g. 2001 study cited
by World Bank)
Actions to take
1. Implement Maternity Care
Certificate Program and
continue Government
monitoring and public
dissemination of performance
results
Who?
GOA
2. GoA has committed 1 billion AMD
over six months to implement a
Maternity Care Certificate Program
which is intended to reduce informal
payments by increasing official
reimbursement of providers for
maternity care and enforcing rules
against informal payments
2. Support effective
implementation of communitybased information campaigns
and external monitoring,
including dissemination of
results
GOA, USAID
(MAAC), other
development
partners
3. Civil law would permit GoA to
recover funds spent by facilities which
do not comply with regulations and
crack down on informal payments
3. Revise program based on
monitoring and evaluation
findings, and expand to other
services if appropriate
GOA
Risks
41
42
ANNEX E
AC Strategy Workshop with Expert Group and Ministry of Education
October 2, 2008
Agenda
9:00 -9:30
Registration
9:30-9:40
Opening Remarks
9:40-10:00
Armen Khudaverdyan, Head of the ACSMC Expert Group
10:00-11:00
Building Good Governance in Education: Definitions, Risks,
Vulnerabilities. Main Elements of an Anti-Corruption Strategy
11:00-11:30
Corruption Vulnerabilities in Health: Inputs from some Education
Specialists in Armenia
11:30-11:45
Coffee Break
11:45-12:30
Anti-Corruption Strategies and Tools
12:30-1:30
Break Out Discussion Session: Building an Anti-Corruption
Strategy and Action Plan for the Education Sector
1:30-2:00
Plenary Discussion
2:00-2:15
Closing Remarks and Evaluations
43
ANNEX E (Cont)
During the workshop, the results of an UNDP study on corruption in Armenia were
presented and discussed. These were the problems identified as most important for the
education sector:

High school students unauthorized absences; students do not attend school but
obtain their diploma through bribes.

Partiality in the evaluation of students knowledge; grading not based on merit
criteria

Out of school private tutoring

Lack of transparency in the process of school budget and management of financial
resources

Collection of money from parents at the school; no transparency on how these
resources are used

Lack of financial accountability of school budget

Low salaries of teachers

No clear and/or transparent criteria for hiring teachers exist

Principals are appointed to schools as a result of patronage (governors and mayors
have a lot of influence on the appointment of principals)

Arbitrariness in the relationship between principals and teachers

No clear mandate for advisory bodies
44
ANNEX E (Cont)
Anti-Corruption Results Framework: Results from Break Out Discussion Group
In a group discussion, please identify the most important corruption problems affecting the education sector, the results you would
like to achieve, the activities that to can be introduced to address these problems, the stakeholders responsible for the successful
implementation of these activities and the indicators that are most appropriate to measure impact and monitor the results of these
anticorruption activities.
Identify the top three
corruption problems
affecting the education
sector in your country
Evaluation of students
based on
kickbacks/assessment
not conducted according
to merit based criteria
Identify for each
problem the anticorruption result or
outcome you need to
achieve
Impartial and correct
assessment of
knowledge based on
criteria
Identify for each result or
outcome
two anti-corruption activities
or tools to achieve the stated
result
Use of modern methods
Introduction of independent
assessment mechanisms
Strengthening internal control
HR recruitment and
appointment not based
on merit
High professional
quality teachers
Introduction of competitive
procedures
Introduction of ethics and
conflict of interest regulations
Identify the stakeholders
who should be responsible
for carrying out these
activities
Present for each activity
two anti-corruption
indicators that will enable you to
measure achievement of results
MOES
Number of complaints
Assessment and Testing
Center
Relation between the assessment
results at different levels of
education
Monitoring results
School Boards
Assessment and Testing
Center/ Education
Inspectorate
MOES
Number of observations
Marzpets (Regional
Governors)
MOES
Level of participation
Number of complaints
Number of statements/declarations
Number of surveys
Financial management is
Transparent and
Encourage citizens’ voice at
NGOs
Budget amount
45
not transparent
accountable system
local levels
Introduce accessible system by
means of new technologies
Community councils, unions
MOES
Number of surveys
System introduced
Statistics derived from the system
46
ANNEX F
Workshop on Good Governance in the Education Sector
Civil Society Organizations
October 3, 2008
Civil society participation is critical to good governance, and can help increase external
accountability and citizen voice. This workshop focuses on the role of community
organizations in providing external oversight and providing a means for citizens to
articulate the wants and needs which shape the goals of government policies and
programs. The workshop will provide a forum to discuss and debate corruption problems
in the education sector in Armenia and will assist civil society organizations in defining
strategies and activities to increase transparency and accountability in the provision of
education services.
Agenda
10:30-10:45
Introduction and Opening
10:45-11:45
Explaining Governance and Governance Challenges in the
Education Sector
Coffee Break
12:00-1:00
Break out Discussion Group: Identifying Most Important
Corruption Problems
1:00-1:30
Strategies and Tools for Controlling and Combating Corruption
1:30-2:45
Discussion Group: Developing a Plan for Civil Society Monitoring
Activities
47
ANNEX F (Cont)
Breakout Session #1: Corruption Problem Identification—Group 1
Assignment: Please identify the major forms of corruption in the education sector. Why are the main causes? Who are key
stakeholders who benefit from corruption and who are victimized by it? How does this affect your activities?
WHAT are the
most significant
corrupt practices
that need to be
addressed?
WHY does it happen?/
What enables these
practices to go on?
WHO are those
benefitting from
corrupt practices?
WHO are the
victims?
HOW does this affect
your activities or your
programs?




Lack of sanctions
Low salary
Mentality
Tolerance





Teacher
Director
Pupil
Professor
Student



Public
State
Progressing
pupils

Abuse of
administrative
expenditures

Lack of controlling
mechanism
Perception

Management
bodies
Complicates the activity
Obstacles
implementation of
programs

Lack of hiring
mechanism
Lack of control
Political point of
view

People lacking
appropriate
competences;
Directors,
management
People having
good contacts
Pupils
Public
State
Teachers
Professors
Pupils,
Students
Teachers
State
Public


Hiring of staff is
arbitrary; does not
follow merit criteria












Loss of credit
Lack of confidence
Grades are obtained
through bribes. No
objective criteria for
grading






Lack of civil society
establishment
Lack of quality staff
48
ANNEX F (Cont)
Breakout Session #1: Corruption Problem Identification—Group 2
Assignment: Please identify the major forms of corruption in the education sector. Why are the main causes? Who are key
stakeholders who benefit from corruption and who are victimized by it? How does this affect your activities?
WHAT are the most
significant corrupt
practices that need to
be addressed?
WHY does it happen?/
What enables these
practices to go on?
WHO are those
benefitting from
corrupt
practices?
WHO are the
victims?
Appointment of officials
in academic institutions:
directors, rectors, etc.
not based on merit based
criteria
Abuse of power/title
Low performance of
educational sector
management board
Officials
(managers)
Public
Informal payments
Lack of transparency and
accountability
Director,
Teacher
Parents
Grading (examinations)
not done according to
merit; bribes
Low level of academic
delivery, low salaries
Current need for improving
educational system
Directors,
Teachers
Parents,
Pupils
HOW does this affect your
activities or your
programs?
49
ANNEX F (Cont)
Break Out Session 2. Anti-Corruption Results Framework—Group 1
In a group discussion, please identify the most important corruption problems affecting the education sector, the results you would
like to achieve, activities to address these problems, the stakeholders responsible for the successful implementation of these
activities and the indicators that are most appropriate to measure impact and monitor the results of these anticorruption activities.
Identify the top
three corruption
problems affecting
the education sector
in your country
Payment for receiving
mark
Abuse of
administrative
expenditures
Payment for hiring
teachers
Identify for each
problem the anticorruption result or
outcome you need
to achieve
Receiving mark
adequate to
knowledge
Improvement of
conditions;
ensuring
accountability
Hiring according to
certain mechanism
(competition)
Identify for each result or
outcome
two anti-corruption activities
or tools to achieve the stated
result
 Increasing control over
teachers;
 Control over staff
recruitment
 Strengthening relationship
with parents;
 Monitoring
 Assuming control
 Improvement /enforcement
of procedures regarding
hiring and firing of staff;
 Commission’s unbiased
approach
Enforcement of sanctions
Identify the stakeholders who
should be responsible for
carrying out these activities
School council
Present for each activity
two anti-corruption
indicators that will enable you
to measure achievement of
results
Increasing role of schools
Parents’ council
Increasing progress
Management (Director, etc.)
Pupils’ council
High attendance
School council
Publication of annual reports
Parents’ council
Introduction of basic
commodities
Pupils’ council
Director, State
School council
Increasing level of education
Management (Director, etc.)
Hiring qualified professionals
Ministry of Education
Department
…? (unclear)
50
ANNEX F (Cont)
Break Out Session 2. Anti-Corruption Results Framework—Group 2
In a group discussion, please identify the most important corruption problems affecting the education sector, the results you would
like to achieve, the activities that to can be introduced to address these problems, the stakeholders responsible for the successful
implementation of these activities and the indicators that are most appropriate to measure impact and monitor the results of these
anticorruption activities.
Identify the top
three corruption
problems affecting
the education sector
in your country
Appointment of
officials in the
education sector
(Director, etc.)
Identify for each
problem the anticorruption result or
outcome you need
to achieve
Designing and
introducing system
of hiring
professionals in
education sector
Identify for each result or
outcome
two anti-corruption activities
or tools to achieve the stated
result
Designing system of hiring
professionals in education
sector
Introduction and awareness
Identify the stakeholders who
should be responsible for
carrying out these activities
NGO-s
Schools, universities
Present for each activity
two anti-corruption
indicators that will enable you
to measure achievement of
results
Was adopted by the MoE in 2010
Pupils’ satisfaction increased by
30% in relation to 2008
Ministry of Education
Mass Media
Informal payments
Formalizing
payments
Awareness campaigns
NGO-s
Parents, teachers
Development of procedure for
payments
Messages regarding informal
payments were disseminated
Procedure on informal payments
was developed by school and
adopted
Schools
Directors, Council
Grading process
(examination, etc.)
Transparent grading
mechanisms are in
place
Introduction of grading
methodology
National Education Institute
Pupils’ satisfaction
Ministry of Education
51
ANNEX G
Transparency and Accountability Activities: Notes from Technical Meeting with PHCR Staff, Oct. 1, 2008
Current activities which increase transparency
and accountability and reduce discretion
Area
Open Enrollment Policy for open enrollment decreases
vulnerabilities to fraud which are inherent in fee for
Policy
service or cost reimbursement systems.
Financial
management
capacity
strengthening
Quality
improvement,
quality
indicators, and
performancebased
reimbursement
Advocacy
training of
community
health
committees,
using NGOs
Strengthening capacity through automated
accounting, improved reporting, and increased
budget literacy (awareness and engagement) are
critical to reducing discretion and holding
government agents accountable for using funds to
achieve publicly-approved objectives. It also
lessens chances for embezzlement, fraudulent
reporting, and diversion of funds.
Measuring quality of care reduces discretion and
opportunities for financially-motivated decision
making. Establishing a link between performance
and financial incentives is a positive motivator for
government effectiveness and reduces
opportunities for facility directors to extort
kickbacks from poor providers (to keep position).
Possible additional
Ways to extend these activities for
greater impact, within current PHCR activities if funding can
be made available
budget and program plan
NA
Assist Goverment of Armenia in
comparing the database of enrollees with
other accurate population databases (e.g.
police) to identify possible fraud. Help
develop procedures for what to do with
results.
NA
NA
Incorporate question(s) about informal
payments into the patient satisfaction
survey.
NA
Related activities which may be
appropriate for other partners or GOA
Develop audit procedures for detection of
false claims and reporting fraud. Capacity
building on enforcement: write laws and
regulations, advocacy for legal reform to
create and enforce penalties for false
reporting (applicable to all government
sectors, not just health)
GOA or development partners working
directly with hospitals may want to extend
these reforms to hospital sector, and to
public health programs managed centrally
NA
Extend advocacy training NA
to more communities
Advocacy training helps to build capacity of civil
society and increase citizen voice. It expands
democratic participation in health policy decisions
and increases external accountability of
government.
NA
52
Annex G (cont.)
Area
Training of
journalists
National health
accounts
Ways to extend these
Current activities which increase transparency
activities for greater
and accountability and reduce discretion
impact, within current
Journalist training increases democracy by
NA
promoting free press and increasing citizen
engagement on health policy reform issues.
National health accounts is a tool which can help
promote government performance measurement
and accountability. It provides data on sources and
uses of funds, which can be compared to
government objectives in order to evaluate
shortfalls or progress in achievement of goals.
Human Resource Over-production of physicians and other clinical
Planning
personnel creates pressure for induced demand for
health care services. Though difficult to draw a
"bright line", some instances of induced demand
may be abusive and driven by financial gain.
Possible additional activities if
funding can be made available
1. Public awareness campaigns
(through media) to increase
knowledge of Basic Benefits
Package (BBP) provisions. This
activity would help strengthen
citizen voice and demand for
accountable government
performance.
2. Study tour for health reporters to
visit other country(ies) in the region
which are more advanced in
dissemination strategies, health
journalism, and engagement of
public on health issues
Local health accounts sub-sector
analysis for reproductive health
household expenditures would
provide data needed to evaluate
government performance in this
priority area
Related activities which
may be appropriate for
other partners or GOA
NA
Institutionalize national
health accounts and health
expenditure surveys.
Requires cross-ministry
collaboration (MOH,
National statisics center)
Study to compare projected
need for trained and licensed
providers with current and
expected numbers available
given enrollment projections
from medical and nursing
training schools. World
Bank may be appropriate
development partner for
such a study.
53
ANNEX H
Moldova Threshold Country Program: Activities to Promote Good Governance in
Health
Moldova is one of the only countries in the region receiving assistance through USAID
for anticorruption activities in the health sector. The Moldova Threshold Country
Program (TCP) is a $24.7 million dollar program, funded by the U.S. Government
through the Millennium Challenge Corporation (MCC) and managed by USAID. The
goal of the TCP is to promote good governance, reduce corruption and improve public
sector service delivery in Moldova. The TCP is designed to help Moldova reach Compact
Country status, at which point the country will qualify for $300m. in grant funds from the
MCC. One of the TCP objective’s is to reduce opportunities for corruption in the health
care delivery system by:
 decreasing the discretionary powers of specific health personnel including
health care providers, budget managers and procurement agents through the
establishment of norms and standards; and
 increasing accountability through increased oversight.
The USAID implementing partner working in health sector is Millennium International
Public Private Partners (“MIP3”). MIP3 has been working in Moldova since June 2007
and will finish in March 2009.
The master plan for change for the Threshold Country Program includes 14 action items
for health. Working groups have been created, each taking 3-5 items from the list. MIP3
follows up closely with the working groups.
Anti-corruption interventions in health sector
Four intervention areas of particular interest to Armenia include increasing external
oversight and transparency, measuring and monitoring quality of care, increasing
transparency in hiring, and physician licensing. These are discussed below.
1. Increasing External Oversight and Transparency. MIP3 helped to develop
performance indicators which will be required under an 8-year program of budget
support to Moldova from the European Community. Two of these indicators include
audits and patient surveys.
 Audits. The budget support program will require audits of medical equipment
procurement. Moldova has already approved a Public Procurement Law that
conforms with EU standards. MIP3 has helped Moldova develop detailed
guidelines for procurement & with other steps to implement the law. The
required audits will assure that the guidelines are actually followed (or at least it
will be one step toward creating incentives to follow the guidelines, because you
might actually be caught and punished if you do not).
 Patient surveys. The budget support program will fund annual patient satisfaction
surveys. MIP3 is helping Moldova work on first one now. Patients are excited by
54
the idea of having their opinions asked. These surveys will be annual and will
increase accountability. MOH will post the results, which include a “quality
score” and a “corruption score”. As part of the latter, patients are asked if they
paid for care, and if they did pay, was it a gift or did the provider ask/require it.
2. Measuring and Monitoring Quality. The TCP plan for increasing accountability in
health sector is based on premise that quality and corruption are very closely
related, and that allowing physicians and facilities to continue to provide poor quality
care creates more corruption. In a sense, bad outcomes create corruption because
physicians try to hide the bad information. Directors have an incentive to keep bad
staff on board because staff have been known to pay the directors to keep their jobs.
This can continue as long as the staff performance is not audited. To improve
accountability and reduce corruption, you need to have standard treatment protocols,
and you need to monitor quality to be sure they are followed.
 Clinical protocols. A big focus of the working groups has been to create the
clinical protocols. The groups have so far created 50 of them. MIP3 set up a
standard template, and makes sure that the working groups follow the draft
template. Eventually they plan to make 1,000 copies of each of the protocols to
distribute widely in protocol libraries. They’ve worked closely with many
important stakeholders, to be sure the protocols are accepted by all and integrated
into education (teaching curriculum, accreditation, MOH standards, national
health insurance standards, etc.).
 Quality monitoring. Then, to assure that people use the new treatment protocols,
MIP3 is helping to create Quality Improvement Councils. The inter-departmental
QI Councils manage peer chart reviews (internal auditing), and they are working
with the accreditation bodies and the national insurance fund to help incorporate
external chart audit results into contracting and accreditation processes.
3. Transparency in Hiring. Another focus of the TCP has been to create transparency
and accountability in the hiring process. MIP3 has helped implement a system
whereby directors are chosen by open competitive tender, with clear standards for
candidates and for selection, as well as objective review of candidates for positions.
In fact, of the 180 health facilities in the country, all the existing directors had to go
through the selection process. Four or five directors decided that they didn’t want to
compete for their jobs, and another 4-5 actually lost their jobs because they didn’t
meet the standards. The continued operation and expansion of this kind of human
resource management improvement will support merit-based staffing and provide an
important control on patronage and the risk of jobs-for-sale.
4. Physician Licensing. Another initiative just starting (as of September 2008) is to
create a physician licensing review board. Moldova does not have review now. Once
you become a doctor, you are a doctor for life, and there is no review of
qualifications, no review of patient complaints. Having a system to re-qualify doctors
will greatly contribute to increased accountability in the medical care system.
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