Questions/Answers

The project presented by AGENAS, delivered from 2014 till 2018, is aiming to three goals: 1) Implementing and strengthening processes to fight corruption in the Health System in Italy, in order to improve the capacity to deliver equitable Health services in all Regions and areas of the country and reduce the menace of corruption in Health Purchasing and other areas having impact of the availability of good health services for all the citizens; 2) Ensuring a systematic cooperation among all the public bodies involved in anticorruption and transparency: the National Anticorruption Authority, the 21 Regions and all the Italian 232 Hospitals and Health Local Organizations; all the Health Managers and General Managers; 3) Developing effective and accountable processes to guarantee full transparency and ethics in the Health Sector, including impact on Healthcare Quality and Safety, Procurement processes, relationship with external suppliers, conflict of interests at the level of Health professionals and managers, personnel and managerial recruitment and assignment processes. The implementation of empowering processes for Health professionals and managers, of Health specific grids to constantly monitor transparency and zero-corruption, led to an increasing commitment of “ the Health people” to safeguard Health Service delivery from corruption and corruptive practices.

The initiative aims at contributing to the 3rd SDG (Health) of the 2030 Agenda, in order to improve Italian citizens’ lives and rights to change the Italian “unhealthy Health system” (see the 2013 Report Transparency International Italy Report on Corruption and Waste in the Health System) and reduce inequality due to the risk of corruption. This burden is heavier in the least developed areas of the country, leading to a reduced access to high quality and safe Health services for citizens, to the highest Italian maternal mortality premature mortality ratio (Southern Regions), to a reduced health coverage, to higher risks.

By 2020 the four-year program is already reaching the following targets related to the 3rd SDG “Good Health and Well Being”: “Achieve universal health coverage, including financial risk protection, access to quality essential health-care services […] for all” “Substantially increase health financing and the recruitment, development, training and retention of the health workforce in developing countries […]”.The initiative has already increased in 2017 and 2018 the financial and human resources available for high quality Health Services, reducing the heavy burden of Corruption on waste, misuse and disruption due to corruption practices on Procurement, Manager’s selection and assignments.

Transparency International suggested at the end of its 2013 Report 15 proposals to help the Italian “unhealthy health system”: “Immediate application of these solutions would reduce the risk of corruption in the health sector, free up resources and lower costs without affecting the services provided. The proposals touch on all the sensitive issues in the health system: medical negligence, transparency of information, management of tenders and purchases, spending control, private health, executive appointments and the risk of the infiltration of organized crime”. Corruption practices are quite relevant in least developed Countries and Regions and the AGENAS initiative might be a best practice to learn how to reduce the waste of resources due to corruption and maximize the financial and human resources available for HealthCare Quality and Safety. Financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and devices are slowly improving, as the 2017 EU Commission comparison on National Health systems shows (see 2018 EU Eurobarometer and 2017 HSPA Report ).

The initiative is very innovative on three aspects: the innovative participative multilevel governance; the innovative methodology based upon “health specific” indicators and tools; the innovative use of structured Planning for measuring and controlling Anti-corruption and transparency. Since 2014, the Italian anticorruption model is carried out through an innovative multilevel and participative governance, (Government, Agenas, ANAC, Health General Managers, Managers and 232 RPCT) and through the innovative process of the National Health Anticorruption Plan since 2015, where each entity plans actions to reinforce integrity: tailor-made measures were diffused to help prevention of corruption, monitoring of the rules for transparency, as well as control of the Health procurement.

Original new tools and indicators were designed to detect risk factors and enhance transparency in the Health sector. Working-groups involving more than 130 experts from all the Regions and Health Organizations set up to identify measures aimed at enhancing the Health institutions to tackle corruption. Some results: a section of the National Anticorruption Plan has been focused on Health; Anticorruption actions have been linked to the Health Systems Performance Assessment and to the Management evaluation; risk factors and Health specific indicators were implemented; data and experiences have been shared, key areas have been put under control, such as: Conflict of interest and Code of conduct, Job Assignments/rotation and management selection, Public Procurement processes (regulations for bargaining and purchasing in the Health sector, central Agencies for Public Procurement, loan for use and testing phase, Selection and management of Professional External Contractors).

The capability to involve Health professionals and managers at local level in each single Region and area of the country, through the selection, training and continuous support to the local roles of “Anticorruption and transparency Representatives “has been one of the first experiences in Europe. This lesson has been already shared and learned in Europe, and recently followed by other European countries, such as Austria, France and Romania, which presented their 2019 strategy in the 18th EPAC/EACN annual conference last October 2018, where the Italian “Multilevel governance model for Anticorruption and Transparency” has been presented.

The program includes a development stage (2014-2016) and a full diffusion stage (2016-2018, on). During the development stage seven technical “tables” including 130 Health experts from the NHS were involved in the creation of “Health specific” indicators and grids. The financial resources which were used to implement the initiative were limited to journeys of AGENAS leaders in the Regions. AGENAS implemented in 2016 a web solution to support and collect declarations of Conflict of Interests from the Health Managers and Professionals in the NHS. The involvement was of 13.886 participants in 2016, 18.947 declarations in 2017 and 24.491 in 2018.

The 2016 Anti-corruption Plan (adopted in August 2016) further developed the methodology, to share "organizational solutions to preserve the National Health Service from the risk of corrupting events (...) and to raise the global level of integrity, competence and productivity (...) starting from increasing the effectiveness and efficiency of individual operating units in which it is articulated ", presenting "a framework of intertwined interventions, whose implementation necessarily requires a strong investment on training " (page 79). The structured framework includes risk factors, indicators, control measures, criteria for dealing with risks, suggested actions which are easily managed by all the Health Managers and Professionals in different regions and local entities. Procurement is a strategic area: measures were adopted to avoid conflict of interests (prevention procedures, information, self-assessment), private funding, authorization procedures and professional counseling involving doctors and medical personnel. Worst practices’ indicators were used, such as: Frequent contract extensions, lack of requirements and planning, mismatching of vendor proposals /requirements, frequent rush orders and exceptions, fractionated purchases, lack of communication to the central purchasing bodies (both Regional and National), weak or missing reporting (contract /vendor evaluation, compliance, savings).

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The project’s result has been regularly monitored by ANAC in the Annual Relations, since 2015 and represents a best practice in the Italian and European Anticorruption models. AGENAS collects and evaluate Conflict of Interests declarations and the adoption of indicators at local level. Major results include the strengthening of key processes to fight corruption in the Health System in Italy, in order to improve the capacity to deliver equitable Health services in all Regions and areas of the country and increase integrity, transparency and sustainability in Health Purchasing and other areas having impact on the availability of good health services.

Here the list of key areas and indicators which have been codesigned, applied and monitored yearly at national, regional and local level: • Procurement • Control, monitoring and inspections • Revenue and Asset Management: full utilization and dismissal – • Role of the RPCT • Conflict of Interests Assignments • Job rotation • Relationship with external suppliers • Clinical trials • Loan for use and phase test • Waiting lists and intramoenia

General and specific Risk factors have been mapped and put under control by more than 75% of the Health organizations (see Audit Report) Risk factors have been monitored and put under control by 75% of the Hospitals and 72% of the HealthCare organizations. Purchasing processes and vendor accreditation have been monitored by 29% of the Hospitals and 64% of the HealthCare organizations HTA, clinical trials, Loan for Use and phase test, sponsors have been monitored by 71 of the Hospitals and 74% of HealthCare organizations Deaths for inter-hospital activities have been put under control by 45% of the Hospitals and 54% HealthCare organizations.

The initiative successfully changed the approach to anti-corruption in the Italian Health system, thanks to a significant involvement of health professionals and managers at all the level of the health organizations, aiming at increasing transparency and sense of personal commitment to live into ethic health organizations, capable to deliver equitable health services in all regions and areas of the country and reduce the menace of corruption in health purchasing and other areas having high impact of the availability of good and safe health services for all the citizens. A strong commitment to cooperate and share goals, efforts and actions has been shown by all the participants, as proven by the ANAC acknowledgements; by the letter of thanks that a team of anticorruption and transparency representatives sent to sustain AGENAS eligibility to the award; by the high quality methodology and “Heath specific” tools designed by the 130 Health experts in the technical tables; by the commitment of the 232 Representatives of Prevention of Corruption and Transparency in all the Health Organizations through the last four years; by the 24.491 individual declaration of existing conflicts of interests made by Health professionals and managers at all levels.

Lesson 1. INVOLVING PUBLIC EMPLOYEES AND MANAGERS ON TRANSPARENCY AND CORRUPTION PREVENTION GIVES LONG LASTING RESULTS ON CULTURAL CHANGES, ETHICS AND TRANSPARENCY IN THE PUBLIC SECTOR The capability to involve health professionals and managers at local level through the newly selected decentralized roles of “anticorruption and transparency Reps” has been one of the first experiences in Europe. Lesson 2 - LONG TERM CONTINUITY AND STRUCTURED PLAN-DO-CHECK APPROACHES GUARANTEE SIGNIFICANT PUBLIC SERVICES IMPROVEMENT FOR CITIZENS A structured approach was adopted in all the 232 Italian Health Entities, through the Yearly National Plan, whose results have been monitored by ANAC and AGENAS.