Correspondence

Tackling corruption in apolitical. The political landscape— die annually because of corruption.1
ie, national histories, institutions, To eradicate this burden, we need
global health governing capacities, and the varying clear diagnoses and evidence-based
The Lancet Lecture by Patricia García1 nature of political institutions and research. We agree with Patricia García2
on the pervasive yet invisible hand political actors—shapes whether and that the notion of telling the truth
of corruption in global health pres­ how corruption can be prevented. Good should be the basis for a common
ents a compelling introduction to governance and strong institutions awareness concerning corruption in

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corruption and the various types that are good solutions, but what if those global health.
exist. Corruption truly is an “ignored democratic elements are not feasible? Governments and international
pandemic”2 and we have no doubt that What is left are the four walls of an organisations need to invest in research
awareness needs to be raised; however, empty health institution crumbling on corruption. Scientific methods, such
the Lecture does not present ways of as the bedrock of corruption shakes as randomised con­trolled trials, might
raising awareness or specify a starting beneath it. As such, anti-corruption be useful to measure specific effects,
point. The recommendations to expand solutions should start with a design that such as the influence of salaries on
funding and adopt an integrated is led by individuals and that is adapted corruption in health-care systems.
and multidisciplinary approach are and adaptable to cultural and political New technologies, such as block­
incommensurate with the problem contexts. chain, might also be used to guaran­
facing global health practitioners, the We declare no competing interests. tee the integrity and safety of health
research community, and the public. records. Transparency has to be the
Maimouna Bah, Ludmilla Charlier,
After identifying corruption, sub­ *Camilla Davila, Sophie Descousse, top priority of governing bodies. The
sequent challenges are deter­mining Benoît Frimon-Richard, effect and role of private funds, such as
the scale of targeted interventions, Sameh Hashem, Clara Leroy, foundations that finance an important
assessing their cost-effectiveness and Marie Minault, Violette Mouro, share of health programmes, should
deciding whether they guarantee Rajiv Nillameyom, Louise Schlüter, be clarified and citizens should have a
sustained improvement. Nonetheless, Manon Wailly say in the actions of these foundations.
the bottom-up approach discussed at camilla.davila@sciencespo.fr These issues require us to act now.
the end of the Lecture has proven to Sciences Po School of Public Affairs, Paris 75007, This global situation has to be
be a good starting point for designing France transformed into a virtuous circle
interventions. 1 This approach to 1 García PJ. Corruption in global health: the open in which both local and global anti-
corruption prevention is crucial for secret. Lancet 2019; 394: 2119–24. corruption policies will improve
2 Burki T. Corruption is an “ignored pandemic”.
empowering people via education Lancet Infect Dis 2019; 19: 471.
reciprocally. WHO has to be reinforced
and sensibilisation, with the ultimate to become a truly independent insti­
hope of engaging them in change. The fight against corruption, which is tution. The organisation’s funding has
Working at the individual level rather defined by the global anti-corruption to be clarified so that it can support
than the institutional level, nationally body, Transparency International, the development of defined criteria for For more on Transparency
or internationally, allows for solutions as “an abuse of entrusted power for transparency in governance systems international see https://www.
transparency.org
to be designed both by and for people private gain”, is a transversal theme of and can lead international research
and, via a knock-on effect, increased the Sustainable Development Goals into such systems. Eradicating both
citizen and civil society involvement that the UN member states aim to day-to-day and high-level corruption
will foster new solutions. However, for achieve by 2030. The health sector will reduce inequalities, given that
sensibilisation and education efforts is highly affected by corruption, for low-income and middle-income coun­
to be effective, they should be adapted reasons including the increasing tries have more corruption than high-
to the culture and cultural differences demand for health services, the income settings, and will allow the
of each context to strengthen the amount of public money spent on Sustainable Development Goals to be
salience of these efforts and guide these services, and the consider­ achieved. It is worth noting that the
them to success. able scale and complexity of this money lost as a result of corruption
The integration of culture represents sector, which has led to information globally exceeded the amount of money
all but one element in preventing asymmetry and entry barriers to that was needed annually to assure
corruption and creating solutions. accessing health care. The effects universal health coverage by 2030
Political contexts are an equally of corruption, although difficult to (Sustainable Development Goal 3.8).3,4
important element for combatting assess, are known to be extensive. At However, translating knowledge into Submissions should be
made via our electronic
corruption. With this in mind, the least 10–25% of global spending in the practice, and so to go beyond politics, submission system at
solutions proposed by García are health sector is estimated to be lost will need both courage and unity. http://ees.elsevier.com/
not flawed as such; rather, they are and a minimum of 140 000 children We declare no competing interests. thelancet/

www.thelancet.com Vol 396 July 18, 2020 161

Antoine Dugast, *Nathan Judais, of corruption. The development of Tranexamic acid for
Faith Nganyi, Huangjin Zhang transparent literature about corruption
nathan.judais@sciencespo.fr in health is essential. A specific focus on
traumatic brain injury
Sciences Po School of Public Affairs, Paris 75007, health when studying corruption is also The CRASH-3 trial 1 reinforces a
France important, which has been seen, for growing body of evidence (such as
1 Hanf M, Van-Melle A, Fraisse F, Roger A, example, in the UN Convention against the CRASH-22 and WOMAN3 trials)
Carme B, Nacher M. Corruption kills: estimating
the global impact of corruption on children Corruption. Sustainable Development suggesting a treatment effect for early
deaths. PLOS ONE 2011; 6: e26990. Goals can also provide an organising administration of tranexamic acid for
2 García PJ. Corruption in global health: the open framework for international action life-threatening bleeding scenarios.
secret. Lancet 2019; 394: 2119–24.
3 The World Bank. High-performance financing against forms of health corruption that Because the evidence presented in the
for universal health coverage: driving are multijurisdictional and require the trial could potentially change clinical
sustainable, inclusive growth in the
21st century. 2019. https://www.worldbank.
development of global ethics.5 Above practice, its landmark status as one of
org/en/topic/universalhealthcoverage/ all, global health needs to deal with the the few positive pharmacological trials
publication/high-performance-health- problem at its roots by working with in the acute setting of traumatic brain
financing-for-universal-health-coverage-
driving-sustainable-inclusive-growth-in-the- local stakeholders to progressively end injury cannot be overemphasised.4 Still,
21st-century (accessed Sept 28, 2019) corruption at all levels and to create some issues concerning the trial deserve
4 Jones B, Jing A. Prevention not cure in tackling
health-care fraud. Bull World Health Organ 2011;
a culture of integrity in the areas of attention.
89: 858–59. intervention. For example, in France, For moderate or mild traumatic brain
the Transparence Santé System has injury with intracranial bleeding, the
Patricia García1 underlines two main declared all links between health evidence for the use of tranexamic acid is
causes of corruption that are major companies and health professionals. less questionable, although the CRASH-3
threats to the future of global health. However, global health should be study was underpowered for that
First, the dependency mechanisms supported by a national and regional subgroup analysis (the 1·7% difference
between high-income countries and political will that can only be achieved would require 6742 total patients
low- and middle-income countries through other channels, such as with mild or moderate traumatic brain
enable corruption. Increased money improving education to increase citizen injury compared with the existing
leads to increased corruption and engagement and awareness. García’s 5615 patients), which increases the
developed countries have a major analysis shows that corruption has to be type I error risk and might inflate the
role in the corruption of health-care fought back by a multiscale approach treatment effect.5
services in less developed countries. and that we are all responsible. Patients, How should we interpret the sub­
This main idea originates from the doctors, organisations, and members of group analyses suggesting a null effect
concept of the so-called poverty trap,2 the political sphere all have a role to play for severe traumatic brain injury or
in which developed countries keep a in the fight against this global issue. altered pupil? It raises concerns, as the
dependency running by sustaining We declare no competing interests. higher the basal risk, the higher the
less developed countries. Second, expected absolute benefit (excluding
*Emma Jourdain, Elsa Cerino,
corruption is a structural issue that Zoé Delamare, Andréa Delestrade, moribunds). The severe traumatic brain
needs to be improved by systemic Margaux Françoise, Isabelle Lafaille, injury subgroup is too heterogeneous.
changes. Indeed, corruption is espe­ Héloïse Mahé, For example, should we consider it
cially observed in countries that have Lucile Prevost Sansac de Traversay futile to administer tranexamic acid to
substandard infrastructures and a emma.jourdain@sciencespo.fr a patient with anisocoria and a Glasgow
scarcity of political will, economic Sciences Po School of Public Affairs, Paris 75007,
Coma Scale score of 6–8? Although
means, coordination, and alliances France the general treatment effect was only
between national and global 1 García PJ. Corruption in global health: the open moderate, the risk of adverse events did
stakeholders. secret. Lancet 2019; 394: 2119–24. not seem to be increased. This finding
Thus, we believe that one of the 2 Samir A. Imperialism and unequal might enable a complacent prescription
development. New York, NY: Monthly Review
ways to best address corruption in Press, 1977. recommendation. Supplementary
global health is by creating systems 3 Ioannidis JPA. Why most published research post-hoc analyses might provide more
findings are false. PLoS Med 2005; 2: e124.
of accountability. Research findings3 information on this matter.
4 Larivière V, Macaluso B, Mongeon P, Siler K,
depend on financial interests in the Sugimoto CR. Vanishing industries and the Equally informative are the imaging
scientific field. Coupled with the issue rising monopoly of universities in published results to be revealed by the nested
research. PLoS ONE 2018; 13: e0202120.
of funding by industry laboratories4 in 5 Mackey TK, Vian T, Kohler J. The Sustainable
CRASH-3 intracranial bleeding
applied research and potential conflict Development Goals as a framework to mechanistic substudy6 regarding the
of interests, these questions seem combat health-sector corruption. haemorrhagic progression of injuries.
Bull World Health Organ 2018; 96: 634–43.
important when dealing with the issue Confirmation of the mechanistic

162 www.thelancet.com Vol 396 July 18, 2020