Reducing corruption in a Mexican medical school: impact assessment across two cross-sectional surveys

Data operators entered data twice with validation, using Epi Info software. Analysis relied on CIETmap open source software [23] which incorporates an interface to the widely used public domain R software. We examined the change in unofficial payments between 2000 and 2007 and factors related to making unofficial payments in 2007. Bivariate and then multivariate analysis was based on the Mantel-Haenzsel procedure [24]. Multivariate analysis began with saturated models including all variables potentially associated with the outcome, and stepped down to final models including only variables that remained significantly associated with the outcome. The significance of associations is described by the adjusted Odds Ratio (ORa) and the 95% confidence interval (CI) around the ORa.

To compare reported payments in 2000 with reported payments in 2007, we converted the figures into equivalent days of work according to the average official minimum wage for the geographical zone of Acapulco city: 33.33M$ in 2000 and 46.09 M$ in 2007 [25].

After each survey, focus groups of students discussed the key quantitative results, mechanisms of bribes transfer, priority problems in the medical school, what should be done to reduce corruption in the school, and who should lead the effort to achieve solutions.

We distributed the results from the 2000 survey to students and university workers, and presented the final report of the survey to the University Council, the highest governing body of the university, framed in terms of the need for institutional reforms to improve academic quality at the university.

The questionnaire asked for suggestions for how corruption in the medical school could be reduced. In 2000, some 53% of students (377/712) said those teachers who ask for a bribe should be dismissed from their employment. Administrative sanctions (such as salary penalties) were suggested by 24% (174/702) of students; 14% (101/712) wanted public disclosure of the teacher’s name; and 8% (60/712) said nothing could be done. In the 2007 survey, 44% of students (185/424) believed dismissing the teacher involved was the way to stop bribes. The other suggestions in 2007 were: administrative sanctions 31% (130); disclosure 19% (79) and 7% (30) said nothing could be done.

Student focus groups in 2000 considered the frequency and types of corruption in the medical school revealed by the survey were realistic. They noted that political harassment and poor preparation of classes by teachers were also a form of corrupt behaviour. They felt that poor preparation of classes by teachers was the most important problem and suggested this should be prioritised by the university authorities. They felt excessive demand for admission to the school was the main reason students paid for their registration. They said the most common administrative procedures for which students had to make unofficial payments were: obtaining a student identification card and certificate of enrolment, registration for a re-examination, and fast access to ones grades. They said some teachers were notorious for demanding bribes to pass examinations, even establishing ‘tariffs’ for different examinations. Some teachers linked political harassment and selling of grades. Bad behaviour by teachers, who usually have two or three jobs in addition to teaching in the medical school, was fostered by lack of administrative controls and sanctions. The students were optimistic that the medical school could improve the system and reduce corruption and they considered students could support this action if they simply stopped bribing.

After the results of the 2000 survey were presented to the University Council, the Faculty of Medicine introduced three relevant policy reforms in 2002: reduction in the number of students, an independent evaluation for selection of new students, and collective examination of students by department heads rather than by individual teachers.

We conducted our survey during an ordinary class day at the medical school and administered the questionnaire to all students who were present during that morning session. The number of students who participated in the survey was less than half the total student body in each survey. However, most of those not included were not present in the school at the time of the survey because they did not have classes in the school, so this is not likely to have introduced a bias. There was a lower proportion of “habitually absent” students in 2007 compared with 2000. These habitual absentees may well be students who expected to be able to complete their course by paying a bribe to pass examinations, so their absence in the sample may have led to an underestimate of the level of bribes, with this being more apparent in 2000 than 2007 because there were more of them in 2000.

We asked students if they had ever paid a bribe to pass an examination. We did not ask when they last paid such a bribe. The finding that a higher proportion of students in year four (or of those who had been in the medical school for five years or more) had paid to pass an examination does not necessarily mean that, in a given academic year, those students in their fourth year paid bribes for examinations more than students in lower years. It could simply be that students in their fourth year have had more opportunities to pay for examinations than those in their first to third year. It could also reflect a decreasing trend of paying for examinations over time. However, there is reason to believe that students have more incentive to pay for passing their fourth year examinations, which play an important part in determining their future. Hrabak reported that advanced students were more likely to use improper influence or to pay for passing an examination [9].

Little has been reported about unofficial payments in medical schools and reported rates from the few published studies [8, 9] might be only the tip of the iceberg. We focused on unofficial payments by students. These probably involve extortion on the part of the teacher, but the mechanisms of these corruption processes still need to be clarified.

In public universities the position of the teachers and administrative workers is similar to that of official government workers; in fact they are public workers. In this sense, the definition of corruption “the use of public position for personal gain” [26, 27] applies to teachers and administrative workers in medical schools where corruption exists.

Considerable amounts of money may be involved in some of these corrupt transactions in the medical school. According to Kumar, in India, admission to medical school is so profitable that the transactions are patronised by politicians who take the enrolment payments as a source of income [20]. In Kenya the amount paid for bribes in public universities appears to be on the rise: those reported in 2003 were seven times higher than the previous year [28]. In Mexico, according to a newspaper report referred to earlier, each aspirant to a medical residency paid 80,000M$, the equivalent 1,580 days of work at the 2007 minimum wage, for the purchase of the admission test [11]. In our 2000 study, the average payment for admission into medical school was the equivalent to 149 days of work. We were unable to find comparable studies from other countries to compare the occurrence of corruption in the process of admission to medical schools.

Our questionnaire did not ask about attitudes of the students toward unethical conduct although this was touched on in the focus groups. Other authors have found students’ attitudes to be a predictor of serious dishonest behaviour [9]. However, particularly in transactions where money is involved, the teacher shares responsibility. Probably the greater culpability is on the side of the teacher who, as a role model, is under greater obligation to avoid corrupt behaviour. Corruption is said to thrive where there is a monopoly of services, discretion in the application of the rules and low accountability [29]. All of these conditions could exist for medical school teachers. Particularly in small and medium-sized schools, like the one in our study, a specific subject is taught by only one, or a very few, teachers, creating an effective monopoly. The teachers determine the final grades and there is room for discretion. Teachers are accountable only to the head of the department or the school principal and that accountability is generally limited to their academic performance.

Our results showed an increased perception of corruption as an academic problem in the medical school in the second survey but without any increase in actual experience of corruption, and indeed a decrease in bribes to secure entry into the medical school. It is known that experiences of corruption tend to be under-reported because some respondents are reluctant to admit making unofficial payments [17, 18]. Reluctance by students to report misconduct has been reported by other authors [8, 9]. It is possible that students who completed the questionnaire in 2007 were more open to report (at least on the anonymous questionnaire) that they had paid a bribe than students in 2000, so there could in fact have been a reduction in the actual level of bribes for examination between 2000 and 2007, masked by this reporting difference. We do not know if this is so.

After the 2000 survey, the medical school implemented an admission test, conducted by an independent body, which all aspirants must pass in order to be admitted into the school. This is the main mechanism of control to avoid illegal enrolments. The proportion of students in the 2007 survey who reported paying for registration was indeed much lower than in the 2000 survey. The few students in the 2007 survey who paid for registration may have been deceived by corrupt staff members into believing they were enrolled by the influence of the staff member (who took their payment), when in fact they were admitted by the normal procedures. Only one first year student in the 2007 survey reported having paid for registration. The medical school plans to strengthen its information outreach about the official cost of the admission procedures and to emphasize that students should not make any other payments to obtain admission.

Collective examinations by department heads instead of by individual teachers were introduced in the medical school after the report of the 2000 survey was shared with the University Council. This was intended to decrease bribes to teachers for passing an examination. From our data, it is not apparent that this worked, although the low proportions of students in years one and two in 2007 reporting bribes to pass an examination are encouraging.

A study in the USA concluded that college students can play only a limited role in detecting teaching misconduct, and proposed strengthening of institutional codes of conduct and faculty peer sanctions [30]. Braxton and Bayer have argued for a formal code of ethics for undergraduate teaching [31]. Students’ focus groups in our study suggested disclosure, administrative penalties or dismissal for teachers involved in teaching malpractice. In another study, penalties for students for copying during examinations, including dismissal from the course, have been suggested [8]. However, given the disincentives for either party in corrupt transactions to report the event, it is likely that few cases will be detected, so the approach of the Autonomous University of Guerrero of changing the system of enrolment and examinations in order to avoid bribes, rather than to focus on punishment, seems appropriate.