by Daniela Cepeda Cuadrado
There is a wealth of research demonstrating that corruption — the abuse of entrusted power for private gain — has contributed to weakening health systems and worsening public health globally. Corruption is associated with a higher infant mortality rate, the rise of antimicrobial resistance, and the diversion of key resources to invest in strengthening health systems. Corruption’s impact on health systems is well documented – that is if we see health systems only as the structures in place to cater to people’s physical health needs.
But the discussion on corruption and health rarely includes mental health. And when it has, research has mostly focused on the experiences of developed countries. This is a massive blind spot, as mental health problems are a growing concern worldwide. The experience of COVID-19 is estimated to have led to a 27.6% increase in major depressive disorder and a 25.6% increase in anxiety disorders globally in 2020.
Low and middle-income countries (LMICs), home to 80% of people with mental illnesses, should prioritize strengthening their mental health systems. Yet, funding for mental health is grossly inadequate. According to the World Health Organization, “annual [global] spending on mental health is less than US $2 per person, and less than US$0.25 per person in low-income countries.”
The mental health sector is further burdened by systemic discrimination and human rights violations. The 2017 UN Report of the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health concluded that discrimination influences policies, laws and practices, preventing patients from exercising their rights to refuse treatment, to legal capacity, and to privacy, among others.
In this context of limited resources and overwhelming demand, coupled with a lack of transparency, two crucial questions emerge: How does corruption manifest in mental healthcare systems? Could it be exacerbating the mental health crisis, particularly in LMICs?
Through my research, I’ve found three nefarious ways corruption impacts the mental health sector:
- Corruption compromises the effective utilization of funds in mental health systems.
My research found that corruption in the mental health sector can operate much like it does within health systems overall. Although evidence is scarce, we can still uncover cases of procurement corruption, fund embezzlement, and corruption that foster the proliferation of counterfeit mental health medications. For example, in Latin America, poor procurement practices have characterized the purchase of medications for mental health disorders. Between 2017 and 2021, the Peruvian, Chilean, Guatemalan, Uruguayan, Mexican, and Argentinian governments awarded the purchase of such medicines to single suppliers without a public tender or in favor of companies with bad corporate practices.
In West Africa, corruption contributes to the proliferation of counterfeit psychotropic medicines, which are related to higher substance abuse and worsening mental health disorders. Transnational networks smuggle Tramadol to countries including Niger and Nigeria. Tramadol, an opioid-based drug that has a calming effect, has been increasingly misused, leading to addiction and overdoses. Corruption has exacerbated this crisis, especially in countries with weak supply chain regulations, where state officials often engage in bribery and corruption during the importation, sale, and distribution processes.
Embezzlement is also common. Last year, a former purchasing manager at the Honduran psychiatric hospital “Mario Mendoza” was found guilty of embezzling approximately $9000 that was earmarked for improving the hospital’s sewage system. This diversion prevented psychiatric patients from accessing a safe and sanitary environment.
- Corruption contributes to the violation of patients’ human rights.
In the health sector, we say that corruption can mean the difference between life and death. This statement is even more poignant in the space of mental health.
In 2018 in South Africa, health authorities in Gauteng province moved 1700 mental health patients from Life Esidimeni — a cluster of private mental health facilities — to unlicensed care homes, many of which had no qualifications or infrastructure to provide quality care. The Guardian has reported that 144 patients died as a result of experiencing hunger, dehydration, cold, and abusive treatments in the new facilities. Their fundamental rights to life, a dignified standard of living, and physical and mental health were utterly disregarded.
Although the authorities claimed that they aimed to cut down costs, the actual expenses told a different story. The state paid a total of 47.5 million rands (£2.7m) to these unlicensed care homes. These payments continued long after their closure and patients’ deaths, indicating a potential mismanagement of funds. Additionally, the relocation plan was only possible through the falsification of licenses for many of these facilities.
- Mental health systems’ overmedicalization thrives on grand corruption
Pharmaceutical companies’ undue influence and policy help explain the rise of overmedicalized mental health care, supported by the biomedical model. This model advances the notion that mental health disorders are the result of “chemical imbalances.” Yet, many psychiatrists believe that this theory lacks sufficient evidence. This model also fails to recognize the socioeconomic, political, and cultural factors that shape mental health. Far from reducing any stigma associated with mental health, the biomedical model has isolated mental health patients from their communities and contributed to their overmedicalization.
Despite its harmful effects, the biomedical model’s reliance on medications makes it very profitable for pharmaceuticals. In the US, the pharmaceutical industry has been able to shape mental health policies and regulations through lobbying, exploiting conflicts of interest, and manipulating the results of clinical trials. The industry gave more than $14.2 million to almost 60% of the authors of the latest version of Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR).
Research on pharma’s undue influence on psychiatry in LMICs is starting to sprout. Last year, a journalistic investigation revealed that there are troubling conflicts of interest between the Psychiatric Association in Latin America and the pharmaceutical industry. Pharmaceutical companies such as Megalabs, Janssen and MK are key sponsors of their annual conventions.
Although having conflicts of interest is not corruption per se, not managing them properly can enable opportunities for abuse of power. The same investigation revealed that in Peru neither pharma nor doctors are required to disclose payments or gifts, making it difficult to track whether doctors’ relationships with pharma influence their prescribing patterns. Many psychiatrists in Peru offer patients samples from companies with which they have pre-established relationships and prescribe these medicines even when generic versions exist.
From undue influence to procurement corruption and bribes, falsified medical products, and cronyism, corruption has served to weaken mental health systems, divert resources, and enable the violation of patients’ human rights. Funding is allocated to advancing a biomedical model that perpetuates discriminatory practices and renders countries ill-equipped to deliver quality mental healthcare services. We need more systematic research on how corruption impacts mental health systems in LMICs: the millions of people living in these countries deserve accessible, quality mental healthcare.
Daniela Cepeda Cuadrado is an Affiliated Researcher with the Petrie-Flom Center’s Global Health and Rights Project.
Editor’s Note: English translation of Spanish language sources will be provided by the author upon request.
