Legislating for Good Governance in the Pharmaceutical Sector through UN Convention Against Corruption (UNCAC) Compliance.

Pharmaceutical sector corruption undermines patient access to medicines by diverting public funds for private gain and exacerbating health inequities. This paper presents an analysis of UN Convention Against Corruption (UNCAC) compliance in seven countries and examines how full UNCAC adoption may reduce corruption risks within four key pharmaceutical decision-making points: product approval, formulary selection, procurement, and dispensing. Countries were selected based on their participation in the Medicines Transparency Alliance and the WHO Good Governance for Medicines Programme. Each country's domestic anti-corruption laws and policies were catalogued and analysed to evaluate their implementation of select UNCAC Articles relevant to the pharmaceutical sector. Countries displayed high compliance with UNCAC provisions on procurement and the recognition of most public sector corruption offences. However, several countries do not penalise private sector bribery or provide statutory protection to whistleblowers or witnesses in corruption proceedings, suggesting that private sector pharmaceutical dispensing may be a decision-making point particularly vulnerable to corruption. Fully implementing the UNCAC is a meaningful first step that countries can take reduce pharmaceutical sector corruption. However, without broader commitment to cultures of transparency and institutional integrity, corruption legislation alone is likely insufficient to ensure long-term, sustainable pharmaceutical sector good governance.

Shared health governance, mutual collective accountability, and transparency in COVAX: A qualitative study triangulating data from document sampling and key informant interviews.

Background: To facilitate global COVID-19 vaccine equity, the World Health Organization, the Coalition for Epidemic Preparedness Innovations, the Global Alliance for Vaccines and Immunizations, and the United Nations Children's Fund supported the COVID-19 Vaccine Global Access (COVAX) partnership. COVAX's goals may have best been pursued through shared health governance - a theory of global health governance based on six premises, in which global health actors collaborate to achieve a shared goal. Shared health governance employs a framework for accountability termed "mutual collective accountability", in which actors hold each other accountable for achieving their goal, thus relying on transparency with one another. Methods: We conducted a multi-method qualitative study triangulating document analysis and key informant interviews to address the question: To what extent did COVAX employ shared health governance, mutual collective accountability, and transparency? We thus aimed to explore the governance structures and accountability and transparency mechanisms in COVAX and determine whether these constituted shared health governance and mutual collective accountability. Results: We identified 117 documents and interviewed 20 key informants. Our findings suggest that COVAX's co-convening organisations were governed by their individual formal governance mechanisms, while each was formally accountable to its own leadership team, resulting in challenges when activities and decisions involved collaboration between organisations. Furthermore, COVAX's governance lacked transparency, as there was little public information about their decision-making processes and operations, including information about the algorithm with which they make vaccine allocation decision, possibly contributing to its inability to achieve its goals. Conclusions: The COVAX partnership only achieved four of the six premises of shared health governance. Since actors involved in COVAX did not hold one another accountable for their role in the partnership, it did not employ mutual collective accountability, while also lacking in transparency. Although these results do not entirely explain COVAX's shortcomings, they contribute to evidence about the roles of good governance, transparency, and accountability in large global health initiatives and underscore failures of the current global governance system.

Examining corruption risks in the procurement and distribution of COVID-19 vaccines in select states in Nigeria.

BACKGROUND: Public health emergencies raise significant concerns about corruption and accountability; however, these concerns can manifest in different ways across diverse locations. For instance, more developed countries with a stronger rule of law may experience more corruption in vaccine procurement, whereas developing countries may experience more corruption at the point of distribution and delivery to end users. This research focuses on corruption concerns in Nigeria, specifically examining the procurement and distribution of COVID-19 vaccines. METHODS: This paper utilizes a scoping review and a qualitative research approach. Key informants (n = 40) involved in the procurement and distribution of COVID-19 vaccines across two states in Nigeria were interviewed. Findings from the scoping review were summarized, and collected data were inductively coded and analysed in themes, revealing clear examples of implementation irregularities and corruption in the country's COVID-19 vaccination processes. RESULTS: Vaccination programme budgeting processes were unclear, and payment irregularities were frequently observed, resulting in vaccinators soliciting informal payments while in the field. Recruitment and engagement of vaccination personnel was opaque, while target vaccination rates incentivized data falsification during periods of vaccine hesitancy. Accountability mechanisms, such as health worker supervision, vaccination data review, and additional technical support provided by donors were implemented but not effective at preventing corruption among frontline workers. CONCLUSIONS: Future accountability measures should be evidence-driven based on findings from this research. Personnel recruitment, contracting, budgeting, and remuneration should focus on transparency and accountability.

Corruption risks in health procurement during the COVID-19 pandemic and anti-corruption, transparency and accountability (ACTA) mechanisms to reduce these risks: a rapid review.

BACKGROUND: Health systems are often susceptible to corruption risks. Corruption within health systems has been found to negatively affect the efficacy, safety, and, significantly, equitable distribution of health products. Enforcing effective anti-corruption mechanisms is important to reduce the risks of corruption but requires first an understanding of the ways in which corruption manifests. When there are public health crises, such as the COVID-19 pandemic, corruption risks can increase due to the need for accelerated rates of resource deployment that may result in the bypassing of standard operating procedures. MAIN BODY: A rapid review was conducted to examine factors that increased corruption risks during the COVID-19 pandemic as well as potential anti-corruption, transparency and accountability (ACTA) mechanisms to reduce these risks. A search was conducted including terms related to corruption, COVID-19, and health systems from January 2020 until January 2022. In addition, relevant grey literature websites were hand searched for items. A single reviewer screened the search results removing those that did not meet the inclusion criteria. This reviewer then extracted data relevant to the research objectives from the included articles. 20 academic articles and 17 grey literature pieces were included in this review. Majority of the included articles described cases of substandard and falsified products. Several papers attributed shortages of these products as a major factor for the emergence of falsified versions. Majority of described corruption instances occurred in low- and middle-income countries. The main affected products identified were chloroquine tablets, personal protective equipment, COVID-19 vaccine, and diagnostic tests. Half of the articles were able to offer potential anti-corruption strategies. CONCLUSION: Shortages of health products during the COVID-19 pandemic seemed to be associated with increased corruption risks. We found that low- and middle-income countries are particularly vulnerable to corruption during global emergencies. Lastly, there is a need for additional research on effective anti-corruption mechanisms.

Medicine donations: a review of policies and practices.

BACKGROUND: To help promote the effective delivery of drug donations, the World Health Organization (WHO) developed the Guidelines for Medicine Donations. The need for revisions is timely given the large-scale influx of medicine donations since the start of the COVID-19 pandemic. This study analyses current policies of donors and recipients that are commensurate with the recommendations in the Guidelines and examines current practices, challenges, and revision suggestions. RESULTS: A search for medicine donation policies of donors and recipients was conducted in May/June 2022 and repeated in January 2023. Potential donor countries were identified from the high-income countries on the United Nation's (UN) List of G20 Countries. Potential pharmaceutical company donors were selected from those with 2021 revenue of $30 billion or greater. Potential non-government organization donors came from the WHO list of non-governmental organizations (NGOs) and two other sources. Potential recipient countries were those on the UN List of Least Developed Countries. These four lists were supplemented with actual donors and recipients identified from the literature. All policies retrieved were screened to identify which of the 12 recommendations from the WHO Guidelines were incorporated. We identified 38 policies from 1 donor country, 6 brand-name multinational pharmaceutical companies, 6 NGOs and 25 recipient countries. Most policies incorporated all 12 recommendations. Twenty-five of the 38 policies were developed in 2010 or later. The majority of actual donors and recipients did not have policies that were publicly available. A rapid literature review for publications from 2010 onwards identified challenges in implementing the WHO Guidelines and suggested for revisions. Challenges included: (1) information management; (2) medication presentation; (3) influence from the pharmaceutical industry; (4) donation sustainability; and (5) the belief that donations are inherently good. CONCLUSIONS: Our findings suggest that both donors and recipients could further align their policies with the existing Guidelines and both groups should be consulted on any revisions to ensure that their experiences are reflected and their needs are addressed. While the current WHO Guidelines for Medicine Donations are a solid base for medical humanitarian efforts, evidence points to the need for an update to meet current challenges.

Improving Access to COVID-19 Vaccines: An Analysis of TRIPS Waiver Discourse among WTO Members, Civil Society Organizations, and Pharmaceutical Industry Stakeholders.

Throughout the COVID-19 pandemic, international access to COVID-19 vaccines and other health technologies has remained highly asymmetric. This inequity has had a particularly deleterious impact on low- and middle-income countries, engaging concerns about the human rights to health and to the equal enjoyment of the benefits of scientific progress enshrined under articles 12 and 15 of the International Covenant on Economic, Social and Cultural Rights. In response, the relationship between intellectual property rights and public health has reemerged as a subject of global interest. In October 2020, a wholesale waiver of the copyright, patent, industrial design, and undisclosed information sections of the Agreement on Trade-Related Aspects of Intellectual Property (TRIPS Agreement) was proposed by India and South Africa as a legal mechanism to increase access to affordable COVID-19 medical products. Here, we identify and evaluate the TRIPS waiver positions of World Trade Organization (WTO) members and other key stakeholders throughout the waiver's 20-month period of negotiation at the WTO. In doing so, we find that most stakeholders declined to explicitly contextualize the TRIPS waiver within the human right to health and that historical stakeholder divisions on the relationship between intellectual property and access to medicines appear largely unchanged since the early 2000s HIV/AIDS crisis. Given the WTO's consensus-based decision-making process, this illuminates key challenges faced by policy makers seeking to leverage the international trading system to improve equitable access to health technologies.

Anti-corruption in global health systems: using key informant interviews to explore anti-corruption, accountability and transparency in international health organisations.

OBJECTIVES: Corruption undermines the quality of healthcare and leads to inequitable access to essential health products. WHO, Global Fund, United Nations Development Programme (UNDP) and World Bank are engaged in anti-corruption in health sectors globally. Throughout the COVID-19 pandemic, weakened health systems and overlooked regulatory processes have increased corruption risks. The objective of this study is thus to explore the strengths and weaknesses of these organisations' anti-corruption mechanisms and their trajectories since the pandemic began. DESIGN, SETTING AND PARTICIPANTS: 25 semistructured key informant interviews with a total of 27 participants were conducted via Zoom between April and July 2021 with informants from WHO, World Bank, Global Fund and UNDP, other non-governmental organisations involved in anti-corruption and academic institutions. Key informant selection was guided by purposive and snowball sampling. Detailed interview notes were qualitatively coded by three researchers. Data analysis followed an inductive-deductive hybrid thematic analysis framework. RESULTS: The findings demonstrate that WHO, World Bank, Global Fund and UNDP have shifted from criminalisation/punitive approaches to anti-corruption to preventative ones and that anti-corruption initiatives are strong when they are well funded, explicitly address corruption and are complemented by strong monitoring and evaluation mechanisms. Weaknesses in the organisations' approaches to anti-corruption include one-size-fits-all approaches, lack of political will to address corruption and zero-tolerance policies for corruption. The COVID-19 pandemic has highlighted the necessity of improving anti-corruption by promoting strong accountability and transparency in health systems. CONCLUSIONS: Results from this study highlight the strengths, weaknesses and recent trajectories of anti-corruption in the Global Fund, World Bank, UNDP and WHO. This study underscores the importance of implementing strong and robust anti-corruption mechanisms specifically geared towards corruption prevention that remain resilient even in times of emergency.

An exploration of anti-corruption and health in international organizations.

Corruption is a global wicked problem that threatens the achievement of health, social and economic development goals, including Sustainable Development Goal # 3: Ensuring healthy lives and promoting well-being for all. The COVID-19 pandemic and its resulting strain on health systems has heightened risks of corruption both generally and specifically within health systems. Over the past years, international organizations, including those instrumental to the global COVID-19 response, have increased efforts to address corruption within their operations and related programs. However, as attention to anti-corruption efforts is relatively recent within international organizations, there is a lack of literature examining how these organizations address corruption and the impact of their anti-corruption efforts. This study addresses this gap by examining how accountability, transparency, and anti-corruption are taken up by international organizations within their own operations and the reported outcomes of such efforts. The following international organizations were selected as the focus of this document analysis: the World Health Organization, the Global Fund, the United Nations Development Programme, and the World Bank Group. Documents were identified through a targeted search of each organization's website. Documents were then analyzed combining elements of content analysis and thematic analysis. The findings demonstrate that accountability and transparency mechanisms have been employed by each of the four international organizations to address corruption. Further, these organizations commonly employed oversight mechanisms, including risk assessments, investigations, and audits to monitor their internal and external operations for fraud and corruption. All organizations used sanction strategies meant to reprimand identified transgressors and deter future corruption. Findings also demonstrate a marked increase in anti-corruption efforts by these international organizations in recent years. Though this is promising, there remains a distinct absence of evidence demonstrating the impact of such efforts on the prevalence and severity of corruption in international organizations.

State capture through indemnification demands? Effects on equity in the global distribution of COVID-19 vaccines.

BACKGROUND: State capture by the pharmaceutical industry is a form of corruption whereby pharmaceutical companies shift laws or policies about their products away from the best interest of the public and toward their private benefit. State capture often limits equitable access to pharmaceutical products by inflating drug prices and increasing barriers to entry into the pharmaceutical industry. During the COVID-19 pandemic, the high demand and low supply of COVID-19 vaccines has put governments that manage vaccine procurement at risk of capture by COVID-19 vaccine manufacturers, both through bilateral deals and the COVID-19 Vaccine Global Access (COVAX) Facility; this threatens equity in the global distribution of these products. The purpose of this study is to determine whether COVID-19 vaccine manufacturers have been engaging in state capture and, if so, to examine the implications of state capture on equitable access to COVID-19 vaccines. METHODS: A targeted rapid literature search was conducted on state capture by the pharmaceutical industry. Results were limited to journal articles, books, and grey literature published between 2000 and 2021 in or translated to English. A literature search was also conducted for information about state capture during the COVID-19 pandemic. Results were limited to media articles published between March 2020 and July 2021 in or translated to English. All articles were qualitatively analyzed using thematic analysis. RESULTS: COVID-19 vaccine manufacturers have demanded financial indemnification from national governments who procure their vaccines. While most high-income countries are legislatively capable of indemnifying vaccine manufacturers, many low- and middle-income countries (LMICs) are not. A number of LMICs have thus changed their legislations to permit for manufacturers' indemnification demands. Amending legislation in this way is state capture and has led to delays in LMICs and vaccine manufacturers signing procurement contracts. This has critically stalled access to vaccines in LMICs and created disparities in access to vaccines between high-income countries and LMICs. CONCLUSIONS: COVID-19 vaccine manufacturers' indemnification demands constitute state capture in many LMICs though not in high-income countries; this has enhanced global COVID-19 vaccine inequities. Results underscore the need to find alternatives to financial indemnification that do not hinder critical efforts to end the pandemic.

A systematic review of digital technology and innovation and its potential to address anti-corruption, transparency, and accountability in the pharmaceutical supply chain.

INTRODUCTION: The urgent need to acquire medical supplies amidst the COVID-19 pandemic has led to bypassing of controls that govern the global pharmaceutical supply chain, increasing the risk of corruption. Hence, promoting anti-corruption, transparency, and accountability (ACTA) in supply chain and procurement has never been more important. The adoption of digital tools, if designed and implemented appropriately, can reduce the risks of corruption. AREAS COVERED: Following PRISMA guidelines, we conducted an interdisciplinary systematic review of health/medicine, humanities/social sciences, engineering, and computer science literature, with the aims of identifying technologies used for pharmaceutical supply chain and procurement optimization and reviewing whether they address ACTA mechanisms to strengthen pharmaceutical governance. Our review identified four distinct categories of digital solutions: e-procurement and open contracting; track-and-trace technology; anti-counterfeiting technology; and blockchain technology. EXPERT OPINION: Findings demonstrate an increase in research of technologies to improve pharmaceutical supply chain and procurement functions; however, most technologies are not being leveraged to directly address ACTA or global health outcomes. Some blockchain and RFID technologies incorporated ACTA mechanisms and mentioned specific policy/governance frameworks, but more purposeful linkage is needed. Findings point to the need for targeted policy development and governance to activate these innovative technologies to improve global health .

Disclosure, transparency, and accountability: a qualitative survey of public sector pharmaceutical committee conflict of interest policies in the World Health Organization South-East Asia Region.

BACKGROUND: Weak governance over public sector pharmaceutical policy and practice limits access to essential medicines, inflates pharmaceutical prices, and wastes scarce health system resources. Pharmaceutical systems are technically complex and involve extensive interactions between the private and public sectors. For members of public sector pharmaceutical committees, relationships with the private sector can result in conflicts of interest, which may introduce commercial biases into decision-making, potentially compromising public health objectives and health system sustainability. We conducted a descriptive, qualitative study of conflict of interest policies and practices in the public pharmaceutical sector in ten countries in the World Health Organization (WHO) South-East Asia Region (SEAR) (Bangladesh, Bhutan, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, Thailand, and Timor-Leste) between September 2020 and March 2021. RESULTS: We identified 45 policy and regulatory documents and triangulated documentary data with 21 expert interviews. Key informants articulated very different governance priorities and conflict of interest concerns depending on the features of their country's pharmaceutical industry, market size, and national economic objectives related to the domestic pharmaceutical industry. Public sector pharmaceutical policies and regulations consistently contained provisions for pharmaceutical committee members to disclose relevant interests, but contained little detail about what should be declared, when, and how often, nor whether disclosures are evaluated and by whom. Processes for preventing or managing conflicts of interest were less well developed than those for disclosure except for a few key procurement processes. Where processes for managing conflicts of interest were specified, the dominant strategy was to recuse committee members with a conflict of interest from relevant work. Policies rarely specified that committee members should divest or otherwise be free from conflicts of interest. CONCLUSIONS: Robust processes for conflict of interest prevention and management could ensure the integrity of decision-making and build public trust in pharmaceutical processes to achieve public health objectives. Upstream approaches including supportive legislative frameworks, the creation of oversight bodies, and strengthening regulatory institutions can also contribute to building cultures of transparency, accountability, and trust.

The Global Fund: why anti-corruption, transparency and accountability matter.

BACKGROUND: The creation of the Global Fund to Fight AIDS, Tuberculosis and Malaria, also known as the Global Fund, was prompted by the lack of a timely and effective global response, and the need for financing to fight against three devastating diseases: HIV/AIDS, tuberculosis, and malaria. During the formation of the Global Fund, necessary anti-corruption, transparency, and accountability (ACTA) structures were not put in place to prevent fraud and corruption in its grants, which resulted in the misuse of funds by grant recipients and an eventual loss of donor confidence in 2011. The Global Fund has instituted various ACTA mechanisms to address this misuse of funding and the subsequent loss of donor confidence, and this paper seeks to understand these implementations and their impacts over the past decade, in an effort to probe ACTA more deeply. RESULTS: By restructuring the governing committees in 2011, and the Audit and Finance; Ethics and Governance; and Strategy Committees in 2016, the Global Fund has delineated committee mandates and strengthened the Board's oversight of operations. Additionally, the Global Fund has adopted a rigorous risk management framework which it has worked into all aspects of its functioning. An Ethics and Integrity Framework was adopted in 2014 and an Ethics Office was established in 2016, resulting in increased conflict of interest disclosures and greater considerations of ethics within the organization. The Global Fund's Office of the Inspector General (OIG) has effectively performed internal and external audits and investigations on fraud and corruption, highlighted potential risks for mitigation, and has implemented ACTA initiatives, such as the I Speak Out Now! campaign to encourage whistleblowing and educate on fraud and corruption. CONCLUSIONS: From 2011 onwards, the Global Fund has developed a number of ACTA mechanisms which, in particular, resulted in reduced grant-related risks and procurement fraud as demonstrated by the decreased classification from high to moderate in 2017, and the reduction of investigations in 2018 respectively. However, it is crucial that the Global Fund continues to evaluate the effectiveness of these mechanisms; monitor for potential perverse impacts; and make necessary changes, when and where they are needed.

Intellectual property and access to medicines: mapping public attitudes toward pharmaceuticals during the United States-Mexico-Canada Agreement (USMCA) negotiation process.

BACKGROUND: Transparency and accountability are essential components at all stages of the trade negotiation process. This study evaluates the extent to which these principles were upheld in the United States' public consultation process during the negotiation of the United States-Mexico-Canada Agreement (USMCA), with respect to public comments about the pharmaceutical sector and access to medicines. RESULTS: The public consultation process occurred before the start of official negotiations and was overseen by the Office of the United States Trade Representative (USTR). It included both written comments and oral testimony about US trade negotiation objectives. Of the written comments that specifically discussed issues relating to pharmaceuticals, the majority were submitted by private individuals, members of the pharmaceutical industry, and civil society organizations. Nearly all comments submitted by non-industry groups indicated that access to medicines was a priority issue in the renegotiated agreement, with specific reference to price affordability. By contrast, more than 50% of submissions received from members or affiliates of the pharmaceutical industry advocated for strengthened pharmaceutical intellectual property rights, greater regulatory data protections, or both. This study reveals mixed outcomes with respect to the level of transparency achieved in the US trade negotiation process. Though input from the public at-large was actively solicited, the extent to which these comments were considered in the content of the final agreement is unclear. A preliminary comparison of the analyzed comments with the USTR's final negotiating objectives and the final text of the USMCA shows that several provisions that were advanced exclusively by the pharmaceutical industry and ultimately adopted in the final agreement were opposed by the majority of non-industry stakeholders. CONCLUSIONS: Negotiators could increase public transparency when choosing to advance one competing trade objective over another by actively providing the public with clear rationales for their negotiation positions, as well as details on how public comments are taken into account to form these rationales. Without greater clarity on these aspects, the public consultation process risks appearing to serve as a cursory government mechanism, lacking in accountability and undermining public trust in both the trade negotiation process and its outcomes.

Exploring anti-corruption, transparency, and accountability in the World Health Organization, the United Nations Development Programme, the World Bank Group, and the Global Fund to Fight AIDS, Tuberculosis and Malaria.

Corruption is recognized by the global community as a threat to development generally and to achieving health goals, such as the United Nations Sustainable Development Goal # 3: ensuring healthy lives and promoting well-being for all. As such, international organizations such as the World Health Organizations and the United Nations Development Program are creating an evidence base on how best to address corruption in health systems. At present, the risk of corruption is even more apparent, given the need for quick and nimble responses to the COVID-19 pandemic, which may include a relaxation of standards and the rapid mobilization of large funds. As international organizations and governments attempt to respond to the ever-changing demands of this pandemic, there is a need to acknowledge and address the increased opportunity for corruption.In order to explore how such risks of corruption are addressed in international organizations, this paper focuses on the question: How are international organizations implementing measures to promote accountability and transparency, and anti-corruption, in their own operations? The following international organizations were selected as the focus of this paper given their current involvement in anti-corruption, transparency, and accountability in the health sector: the World Health Organization, the United Nations Development Program, the World Bank Group, and the Global Fund to Fight Aids, Tuberculosis and Malaria. Our findings demonstrate that there has been a clear increase in the volume and scope of anti-corruption, accountability, and transparency measures implemented by these international organizations in recent years. However, the efficacy of these measures remains unclear. Further research is needed to determine how these measures are achieving their transparency, accountability, and anti-corruption goals.

Social capital and public health: responding to the COVID-19 pandemic.

BACKGROUND: As countries continue to respond to the COVID-19 pandemic, the importance of ensuring that fair and equal access to healthcare for all is more urgent than ever. Policies that promote social capital building along all levels of society may offer an important avenue for improved healthcare delivery and health systems strengthening in the COVID-19 response. MAIN BODY: In reference to the established and emerging literature on social capital and health, we explore the role of social capital in the COVID-19 health policy response. We analyse current research with respect to mental health, public health policy compliance, and the provision of care for vulnerable populations, and highlight how considerations of bonding, bridging, and linking capital can contribute to health systems strengthening in the context of the COVID-19 response and recovery effort. CONCLUSIONS: This article argues that considerations of social capital - including virtual community building, fostering solidarity between high-risk and low-risk groups, and trust building between decision-makers, healthcare workers, and the public - offer a powerful frame of reference for understanding how response and recovery programs can be best implemented to effectively ensure the inclusive provision of COVID-19 health services.

The Urgent Need for Transparent and Accountable Procurement of Medicine and Medical Supplies in Times of COVID-19 Pandemic.

The COVID-19 pandemic has unleashed unprecedented and complex public policy issues. One that has emerged as a challenge for many countries globally is how to ensure the efficient and effective procurement of quality medical supplies. Existing corruption pressures on procurement-everything from undue influence to the outright bribery of public officials-has been amplified by the pandemic, and thus demands commensurate policy responses. We argue that transparency and accountability in procurement are essential to preventing the corruption risks that threaten the health and well-being of populations.

Integrating pharmaceutical systems strengthening in the current global health scenario: three 'uncomfortable truths'.

The response to emergency public health challenges such as HIV, TB, and malaria has been successful in mobilising resources and scaling up treatment for communicable diseases. However, many of the remaining challenges in improving access to and appropriate use of medicines and services require pharmaceutical systems strengthening. Incorporating pharmaceutical systems strengthening into global health programmes requires recognition of a few 'truths'. Systems strengthening is a lengthy and resource-intensive process that requires sustained engagement, which may not align with the short time frame for achieving targets in vertical-oriented programmes. Further, there is a lack of clarity on what key metrics associated with population and patient level outcomes should be tracked for systems strengthening interventions. This can hinder advocacy and communication with decision makers regarding health systems investments. Moving forward, it is important to find ways to balance the inherent tensions between the short-term focus on the efficiency of vertical programmes and broader, longer-term health and development objectives. Global health programme design should also shift away from a narrow view of medicines primarily as an input commodity to a more comprehensive view that recognizes the various structures and processes and their interactions within the broader health system that help ensure access to and appropriate use of medicines and related services.

The risk of corruption in public pharmaceutical procurement: how anti-corruption, transparency and accountability measures may reduce this risk.

Background: The goal of the public procurement of pharmaceuticals is to purchase sufficient quantities of high-quality pharmaceuticals at cost-effective prices for a given population. This goal can be undercut if corruption infiltrates the procurement process. Good procurement practices can help mitigate the risks of corruption and support equitable access to affordable and high-quality medicines.Objectives: This paper aims to 1) examine manifestations of corruption in the pharmaceutical procurement process and key factors behind them, and 2) identify how to design and implement effective anti-corruption, transparency and accountability mechanisms within this process.Methods: This paper was informed by a narrative literature review from 1996 to the present. The search focused on publications that addressed the issue of pharmaceutical procurement and governance and corruption issues. Our search included peer-reviewed literature, books, grey literature such as working papers, reports published by international organizations and donor agencies, and some media articles. Some documents used in this paper were already known to the authors.Results: Procurement is highly vulnerable to corruption particularly in the health sector. What is more, corruption in the procurement process does not appear to be limited to any one level of government or type of health system. The better integration of accountability, transparency and anti-corruption mechanisms in the procurement process is needed to reduce the risk of corruption.Conclusions: Lessons learned suggest that anti-corruption, transparency and accountability mechanisms in the pharmaceutical procurement process, such as open contracting and integrity pacts are helpful towards reducing the risk of corruption.