How does corruption influence health system efficiency? A case study of two counties in Kenya

Objective Efficiency gains are one potential pathway to unlocking additional resources for the health sector. Given that corruption has been cited as a key cause of inefficiency in the health sector, the objective of this study was to examine the influence of corruption on the efficiency of county health systems in Kenya. Design, setting and analysis We conducted a qualitative case study in two counties in Kenya. We developed a conceptual framework from a literature review to guide the development of tools and analysis. We collected qualitative data through in-depth interviews (n=26) with county, sub-county, and health facility level respondents across the two counties. We analyzed the data collected using a framework approach. Results Corrupt practices reported in the case study counties included non-merit-based recruitment and training of health workers, supply of substandard goods, equipment and infrastructure; theft, embezzlement and misuse of public funds and property; and informal payments. These practices were perceived to impact negatively on health system efficiency by leading to a direct loss of health sector resources, increase in operational costs, poor quality of care, reduced staff motivation and productivity, and reduced access to healthcare services. Conclusion The efficiency of county health systems could be enhanced by implementing anti-corruption strategies to tackle the identified corrupt practices. Strengths and limitations of this study ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This work was funded by a MRC/FCDO/ESRC/Wellcome Trust Health Systems Research Initiative grant no MR/R01373X/1. Additional funds from a Wellcome Trust core grant awarded to the KEMRI-Wellcome Trust Research Program (#092654) supported this work. The funders had no role in study design, data analysis, decision to publish, drafting or submission of the manuscript. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Ethics review and approval (KEMRI/SERU/CGMR-C/154/3814) for this study was obtained from the KEMRI Scientific and Ethics Review Unit (SERU). Approvals from other relevant authorities were also sought prior to commencement of the study. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes The datasets generated and/or analysed during the current study are not publicly available due to participant confidentiality but are available from the corresponding author [EB] on reasonable request.