MANILA: Election campaigns are a great thing for Joeje Tubal, a nurse's aide at a small government-run clinic here.

That's when local officials bring out the vaccines, vitamins and painkillers they have hoarded for just this occasion - to show their generosity to voters.

"They'll hold medical missions here and give things away," Tubal said. "Even health workers' allowances increase at election time. We get free meals. That's where the health budget goes, to elections. If there were no elections we'd get nothing."

Doctors say that some of these medications expire or lose their potency through lack of refrigeration as officials delay their release to clinics to achievemaximum political effect.

"It happens a lot," said Philip Paraan, information officer for the Council for Health and Development, a private health network. "It's everywhere. Everyone knows about it. Corruption here is overwhelming, and that includes the health care field."

The use of medications as political pork is just one of many forms of corruption in medical care that a recent study by Transparency International, an independent agency that tracks corruption around the world, showed was directly harming the health of Filipinos.

One of the authors of the study, Omar Azfar, said the picture in the Philippines was not unusual for developing nations. In the study, released in February, Transparency International compared indicators of corruption and health in a controlled study of 80 communities around the country.

It found that for every 10 percent increase in corruption, immunization rates dropped as much as 20 percent, waiting time in public clinics increased as much as 30 percent and user satisfaction dropped 30 percent. It also found that children were one-fourth as likely to complete their courses of vaccination.

"It does reinforce the idea that there's nothing you can do," said Michael Tan, a medical anthropologist at the University of the Philippines. "We are a poor country, but we do have resources. They just get swallowed up by corruption."

In its 2005 report on worldwide corruption, Transparency International placed the Philippines in 117th place out of 159 countries in a listing that ran from the cleanest down to the most corrupt.

The UN Development Program estimated in 2004 that $1.8 billion a year, or about 13 percent of the government's annual budget, is lost to corruption.

The Philippines is trapped in a cycle of corruption that has its roots in a culture of mutual help and obligation, family loyalties and political patronage. Poverty, low pay and a breakdown in services have led to a free-for-all of payoffs and pilferage.

People here say corruption has only grown in the 20 years since Ferdinand Marcos, the former dictator, found a place in the Guinness Book of Records for squirreling away as much as $10 billion of the nation's wealth.

In a recent survey, according to Transparency International, 7 in 10 Filipinos said corruption had grown significantly worse over the past three years.

Accusations of electoral corruption are behind a swelling drive to force President Gloria Macapagal Arroyo to resign. Her predecessor, Joseph Estrada, was driven from office by a popular uprising that grew out of disclosures of presidential corruption.

The two most recent military coup attempts have been motivated in large part by a perception of pervasive corruption in the government and the armed forces.

Because it involves some of the country's most powerful people, efforts to combat corruption have not gotten far. According to a presidential commission in 2003, only 6 percent of cases taken to a special anti-corruption court resulted in convictions.

"These are prominent and wealthy people, and they hire the best lawyers money can buy," said Simeon Marcelo, a former government ombudsman who worked to improve the conviction rate and who reported that statistic.

He declined to comment on the role of corruption within the anti-corruption court itself.

In its report, Transparency International said corruption in the field of health care costs tens of billions of dollars a year around the world.

According to one estimate, it said, annual earnings from the sale of counterfeit drugs alone was more than $30 billion.

The report on the Philippines was based on data first published in 2001 byAzfar and Tugrul Gurgur, who are based at the University of Maryland, College Park.

The report said the corruption can take place in procurement, recruitment, the theft of money and supplies, absenteeism, induced demand for unnecessary goods and services and the solicitation of bribes for services.

"It can happen in many ways," Azfar said in an interview. "It is particularly pernicious if vaccines are pilfered and the refrigeration is not effective or if they are diluted and lose their power, in which case resistant strains of bacteria can develop."

 

In January, Health Secretary Francisco Duque told Congress that millions of pesos had been lost in expired vaccines and medicines purchased in just one government hospital.

In February, the national Bureau of Food and Drugs reported that 8 percent of medicines bought from pharmacies in 1999 were counterfeit. According to the World Health Organization, 6 to 10 percent of all medications on the world market are counterfeit, with estimated sales of more than $35 billion a year.

In the Philippines, corruption eviscerates a health care system that is already severely underfinanced, experts say.

One of the most widespread forms involves payoffs from drug companies to local officials who then pay them inflated prices for often substandard medicines. "It's the way of life of the politicians," said Dr. Merry Mia, 29, a general practitioner who has worked in both government and private clinics. As a result, she said, the prices often climb out of reach of poor patients.

In a country that lightens its burdens with wordplay, these payoffs are known as incentives, rebates, internal arrangements, standard operating procedures and love gifts.

Health workers say corruption, including deals with drug companies, has expanded in the past decade as many civic functions have been handed down from the central government to local mayors and governors.

An investigation by the Philippine Center for Investigative Journalism found that these kickbacks can now range from 10 percent to 70 percent of the contract price.

Another common practice is the renting out of pharmaceutical diplomas, together with academic transcripts, to untrained people who want to open a drug store, several health workers said.

"It's almost natural, it's almost an accepted practice, although it's illegal," Paraan said.

The devolution of services to local governments has added medical supplies to the repertoire of political manipulation. Not only do local officials hoard medications for distribution during election campaigns, health workers say, but they also sometimes withhold them from clinics in neighborhoods where the local vote goes against them.

This does have a downside for local officials because, as an accepted practice, people expect them to deliver.

"Our congressman gave us some medicine, but it wasn't enough medicine," said Salvacion Berza, 44, who works at a food stall and whose children have been patients at San Roque Health Clinic Extension, where Tubal works as a nurse's aide.

As with other forms of patronage, local officials are now in a position to appoint unqualified friends or relatives to jobs in health care or to sign up "ghost doctors" and "ghost nurses" to draw government salaries for nonexistent employees. "My father is friends with the mayor," Mia said, "and he'll tell him, 'Pal, do you want a job without working?' In many health clinics there are only a few people working, but they declare a lot more."

Tubal herself is a product of that system. She was a campaign volunteer for a local official and was given her job as an untrained nurse's aide as a reward.

"The neighborhood captain chose me because I know the area," she said. "My work as a volunteer was going house to house, so I know the people here."

Now she must deal with the shortages that are partly the result of that same system. In her one-room clinic in a Manila slum, she said, there are generally only about five courses of antibiotics available to serve a population of 5,000. Often the doctors, who visit twice a week, rely on drug company samples to treat patients."If we run out of syringes, we use donations from the patients to buy syringes," she said. "For tooth extractions they have to buy the anesthetic on their own."

In public hospitals, Mia said, interns who have not yet become hardened to these shortages sometimes pitch in from their own allowances to buy things like syringes, sutures and anesthetics for indigent patients. "It's very depressing," she said.

Tan, the medical anthropologist, told of a hospital that did not have gowns to distribute to women in its maternity ward. "The funds have been depleted and there has been pilferage of gowns," he said. "The pilferage is amazing; it becomes a dog-eat-dog world. And for it to happen in a sector that is supposed to be nurturing and caring I think says a lot about where we are today."

Next: Corruption comes under the spotlight as a new era of openness in Malaysia takes hold.