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Introduction

We have come to the situation where we are not asking whether corruption exists in Macedonia, but how to stop it or which measures to take in order to prevent from its spreading. This problem emerges in several sectors and the most frequently involved are the enterprise directors, customs officers, referees, doctors and teachers. The paper is primarily concentrated on the health sector and the corruption problem among doctors. In order to present a better view on corruption and bribery in the health sector and how widespread this practice is, I will use the results from the Macedonian empirical report¹.
According to this report, 28,20% of the examined in the sample, on the question: "If in the last year you were expected to provide something (cash, gift or favor) in exchange to the solution of a problem of yours, it was by:" gave the answer: "by a doctor". Just as additional information, this is the highest percent of all other civil servants mentioned in the survey². Therefore, I believe that this is a very important issue that deserves attention and in the paper I will try to emphasis several points regarding this problem:

• Definition of corruption in the health sector;
• Legislative in Macedonia: information about the law and its advantages and disadvantages;
• Negative effects of bribery in the health sector and how this impacts on the doctor ­ patient relationship;
• Suggestion on several structural modifications to the system in order to protect the patients from this practice.

Definition of corruption in the health sector

There are many definitions about corruption, but in order to define the corruption in the health sector I will use the following one. Corruption is defined as an abuse of power, economical or political, in order to satisfy personal or group interest and endangering the legitimate individual, group, social or state rights and interests³. If we accept this definition in its reduced form and talk only about the passive bribery, or the situation where a gift or a favor is expected by the doctor in order to provide the patient with the needed medical care, then we can talk about the doctor's abuse of power in order to gain material goods or money from patients, even though, by law, the service in the state sector should not be paid for. Hence, with the previously proposed definition, first, I would like, in a hypothetical manner, to distinguish the private from the state health sector. The sketch below is for the purpose of helping to define what and why something amounts to corruption in the state health sector, and what does not.

State Sector model	Private Sector model
Free at point of need	Private insurance
Funded through taxation	Funded by private insurance
Infrastructure held in trust by the state, paid for by contributions	Infrastructure invested in private clinics from private sources
Doctors trained partly at state expense	Doctors trained partly at state expense

With these models in mind we can identify that a principal problem of corruption in the state health sector impacting on patients is doctors' expectations of extra payment from patients in return for service. Why is this a problem? The problem emerges because we have a sector where the equipment, doctor's salary and all other facilities are paid by the state through taxation and other contributions given by the citizens and yet, the patients are asked to pay "extra costs". To better illustrate how this works, here is a small text taken from the "Nations in transit"⁴.

"...Patients must pay for better rooms, for their families to be able to bring them personal belongings or extra food and for access to the drugs allegedly covered by their insurance but which have somehow become 'scarce'..."

Legislative in Macedonia: information about the criminal law and its advantages and disadvantages

In this section I will point out and discuss about the Criminal Law and the "black holes" that the doctors might use in order not to get exposed or prosecuted. According to the daily newspaper "Dnevnik", Macedonia is one of the rare countries that still haven't ratified almost all international norms against corruption⁵. I also must emphasis that there is no anti-corruption law in Macedonia. The law exists only as a proposal and hasn't passed the Parliamentary procedure yet.

In absence of an anti-corruption law, there are certain sections of the Criminal Code where corruption is criminalized. I will present only the sections that are most important for solving the problem.

a). Accepting or asking for a prize, gift or any other personal belonging by a civil servant⁶; This act is criminalized with the article 357 of the Criminal code by the name "accepting bribery". There is a penalty for this kind of practice that varies from 3 months to 10 years of penitentiary according to the category of criminal attitude.

b). Giving or promising a gift, favor or personal belonging to a civil servant⁷; The article 358 condemns this criminal act by the name "giving bribery" and the penalty also varies from 6 months to 5 years.

Which are the disadvantages of absence of anti-corruption law?

Even though corruption is criminalized in these sections, we still experience its expansion. Primarily, in these specific cases where extortion of money is experienced, there is no basis of prosecution unless the doctor or any other official is caught with the money or the gift. And there are no special trained agents that can play the role of patient who is giving the extorted money. Therefore, without any evidences the doctor can't be caught. There is no witness protection program in the Criminal code or in any other law in Macedonia. This discourages the patients to cooperate with the police. Also, for most of the patients, in cases where small amounts of money or small favors are asked, consider that it is better to bribe the doctor than to inform the police or to get involved in police action of stopping the bribery practice.

Another problem is the citizen's mistrust in the police. If we look at the other corruption indexes, we will see that policemen are also subjects of bribery. Survey⁸ shows that only 13% of the examined believe that there is no corruption among the police officers, which means that 87% believe that either almost everybody is involved or most are involved. With these results we can't expect patients to cooperate with the police.

Most countries hold liable both the persons giving and receiving the bribe, so there are difficulties in determining the culprits of these crimes because, as people say "a raven doesn't peak another raven's eyes"⁹. We can look this problem from another aspect. It is true that the person that is giving the bribe should be prosecuted, but what is happening with the patients who are forced to pay extra money. They won't go to the police since, as the survey results showed, they don't believe them. And patients know that they might be held responsible, as the person that is offering bribe, because is their word against the doctor's. So, the victim silently accepts this practice and pays the money, if that is possible.

Negative effects of bribery in the health sector and how this impacts on the doctor ­ patient relationship

On macro level, from an economical aspect, this practice brings negative effects since produces flow of money. Even though everything is paid from the state resources, through citizen's contributions, there is a certain amount of money that goes directly in doctor's pockets.

On micro level, destructs the doctor ­ patient relationship, since the doctor is not completing his duties, plus he asks for additional payment. This leads to into a situation where lack of professionalism exists and in that case, patients are loosing confidence in doctors. The category of medical insurance becomes an imagination since is useless although comes from every month salary.

Another negative effect from this practice is the construction of a privileged group of patients. This group emerges on the basis of its economical power. For this group of patients there is no problem in paying a certain amount of money or providing the doctor with a "small favor". They are always subject of a good medical service. But, what will happen with the citizens with the average salary? They only have one option ­ either pay the money or don't get the medical care. And because of the "black wholes" in the law and lack of evidences, can't do more.

The problem goes further where a situation of brain drain emerges. According to Mrs. Ljubica Macevska Ruben, the economic damage goes in direction where produces another more frightening event as leaving of intellectuals out of the country. Precisely, the young and professional people who are not included in the scheme of bribing simply have no access to the money as an object of implementing of their projects so they find a solution in leaving abroad¹⁰. Young intellectuals are either excluded from the "cake" so they leave the country, or they get involved in this network, so there starts the real problem since the practice becomes inheritable and spreads in the sector.

Suggestion on several structural modifications to the system in order to protect the patients from this practice

After defining the corruption, pointing out the problems with legislative and the emphasis the negative effects, I would like to propose several possible solutions to this problem. Corruption must be treated equally in all sectors because it is impossible to fight against it in one sector and to leave another untouched. For example, we can't fight corruption in the health sector if the police and judicial sector is corrupted. This gives doctors the courage since they know that in a situation like that there is a much smaller chance to be prosecuted or being caught.

The Law on the Prevention of Corruption must be put in force immediately. Without any anti- corruption law the problem can't be solved efficiently because there is no legislative background to prosecute the culprits, so the police can't act.

The problem in stopping these kinds of criminal activities also lies is the deficiency of money, equipment and well-trained agents. Without any legal and constitutional background for phone tapping, police following, secret audio and visual recording and other technical devices the police are powerless in dealing with these criminals because of the lack of evidences. In order to do the opposite, coordinate action between the police and the public prosecutor is needed.

The problem with corruption and bribery should be put on a transparent level. In that direction, more projects, surveys and analyses must be made in order to resolve the problem. More campaigns should be present in order to draw patient's attention not to support corruption and bribery, but to fight against it. With these campaigns in the future public trust in civil officials should be returned.

With all these procedures and measures, which should be taken in a very near future, there is a possibility to stand a chance against this practice. Until then, we can hear every day how much money, how many packages of cigarettes, how many bottles of whiskey are needed in order to force the doctor to do his job and get the needed medical service.