Abstracts

75 lack of prioritization to support the public health care that largely supported nonwhites. This resulted in substandard medical care for those relying on an underfunded and under- resourced system. Hospitals designated for black, mixed race, and Indian citizens often were overcrowded, poorly equipped, and understaffed compared to hospitals reserved for whites. For example, in 1981, there was 1 physician for every 330 white South Africans, whereas in contrast, there was only 1 physician for every 91,000 black South Africans (Kon & Lackan, 2008). The poorest quality of medical care was in the homelands, where black patients sometimes were assigned to white army conscripts learning to be hospital corpsmen. Instances of sick or injured people being turned away by hospitals or refused transport in ambulances due to race also were prevalent (Wren, 1990). In 1994, the new democratic government, spearheaded by the African National Congress, began to address the disempowerment, dis- crimination, and underdevelopment that weakened the health system. The new constitution established access to health care as an inalienable human right, guaranteed regardless of race and socioeconomic status. As apartheid was dismantled, the health system underwent major restructuring involving the desegregation and consolidation of health services: 14 health administrations merged into 1 national and 9 provincial health departments, which currently make up the South African health care system. The National Health Act of 2003 elaborates on this promise by providing a framework for the health system, accounting for the priorities of the South African constitution and laws on the national, provincial, and local health departments (Republic of South Africa, 2004). Currently, the National Department of Health (NDoH) coordinates health care delivery at all three levels. The national level focuses on policy, the provincial level on managing and allocating budget funds, and the local level on public health safety and primary care. All levels share responsibility to create conditions for the general population to be as healthy as possible. Although the democratization of South Africa has decreased overall state vulnerability to corruption by redistributing power from the elite few, the expansion of state services provides new opportunities for corruption and hampers the nation’s progress toward overcoming the sheer disparities in the health care system. While the South African Constitution states that access to health care services is a right for everyone, good governance, accountability, and transparency are necessary to safeguard universal health care for all. The current government claims to provide substantial investment in health care, yet corruptionpersists inSouthAfricangovernance and politics, resulting in mismanagement and inefficient use of resources. South Africa spends about 8% of its GDP on health care, almost twice the World Health Organization recommendation of 5%, yet the nation is ranked 176th in the world in terms of health care outcomes per capita spending (de Beer, 2018), with worse outcomes in the public compared to the private health sector. This only encapsulates how their funding may be misallocated or siphoned due to corruption. Overview of Corruption The characteristics that make the health care sector susceptible to corruption include the large amount of public money involved, the numerous actors and complexities between their interactions, and asymmetric information. These vulnerabilities, accompanied by lack of accountability and transparency, present themselves in the South African provincial health departments, the procurement process, and poor stewardship of health officials and workers managing the system. Corruption in Provincial Health Departments Just as Willie Sutton robbed banks because “that’s where the money is,” the same principle applies to the South African health sector. In an interview, a key public health expert claimed that because “provinces are the level where services are delivered and because of the requirement to manage large budgets and complex systems, there is a greater potential for fraud and corruption” (Rispel et