Health

Collective Action to strengthen integrity in healthcare? Americas Health Ethics Virtual Forum, 17-18 August

The Covid-19 pandemic has brought issues of ethics and business integrity in the healthcare sector into the public spotlight. Citizens everywhere are demanding well-governed, transparent healthcare systems and industries – not only to address the health consequences of the pandemic but as a backbone of resilient and sustainable economic growth. Health outcomes are better when government, industry, and civil society work together well. The fast development and roll-out of Covid-19 vaccines, as well as the provision of personal protective equipment PPE and emergency care, are in large part thanks to collaboration. This collaboration has been broad and intense, taking place between life sciences, medical technology and healthcare provider companies both among themselves and with regulatory authorities and governments towards a clear common goal. So is now the right moment to strengthen Collective Action for integrity in health? This is a question that Gemma Aiolfi, the Basel Institute’s Head of Compliance and Collective Action, will explore at the upcoming Americas Health Ethics Virtual Forum. About the Forum The Americas Health Ethics Virtual Forum on 17–18 August will bring together hundreds of government, industry and civil society stakeholders from across the Americas. Over two days of major announcements, presentations and panels, the Forum will showcase advances in ethics and business integrity, transparency and good governance in health since the 8th Summit of the Americas hosted by Peru in 2018. It aims to catalyse progress in preparation for the upcoming 9th Summit of the Americas to be hosted by the United States. Broadcast live in English, Spanish and Portuguese, the Forum will feature speeches by government ministers, industry leaders and experts. It is free and open to public registration via the event website. The Basel Institute on Governance is pleased to support the event as Forum Partner alongside the Inter-American Development Bank, International Federation of Pharmaceutical Manufacturers and Associations IFPMA , and more than a dozen other leading organisations concerned with fostering integrity in health. Spotlight on Consensus Frameworks for Ethical Collaboration Speaking at 8:45 EDT 14:45 CET on Wednesday 18 August, Gemma Aiolfi will share insights on the role of Collective Action in bringing together all stakeholders of the healthcare “ecosystem” to foster common goals of integrity and transparency. A special focus of her presentation is Consensus Frameworks for Ethical Collaboration. First launched in 2014, these are mechanisms for national health stakeholders to discuss and align on ethical practices and to build mutual capacity. Tailored to the specific needs and contexts of the implementing country, Consensus Frameworks may be championed by government agencies, the private sector, health professionals and/or patient and consumer organisations. The Brazilian Consensus Framework for Ethical Collaboration will be launched at the Forum the previous day, in a session led by Brazil's Minister of Health. It is the ninth country in the world to formalise a Consensus Framework. Australia, Canada, Chile, China, Japan, Peru, the Philippines and Vietnam all have formal Frameworks at various stages of maturity. One lesson from countries’ experiences so far is the importance of clear governance structures, a prerequisite for all successful Collective Action initiatives. Speaking alongside Gemma Aiolfi, Héctor Valle Mesto, Executive President of the Mexican Foundation for Health Funsalud will share observations on the importance of Collective Action initiatives and the opportunity to launch a Mexican Consensus Framework for Ethical Collaboration. More Find out more about the Forum in English, Spanish and Portuguese and register for free: Americas Health Ethics Virtual Forum. See a quick overview of Collective Action initiatives in the healthcare sector in: Pandemic highlights the potential of Collective Action for integrity in healthcare, a guest blog by Andrew Blasi and Katherine Nunner of Crowell & Moring International. Learn about a Collective Action initiative in 2020 led by Norges Bank Investment Management to co-develop a set of indicators for healthcare companies to consider using to report on the effectiveness of their anti-corruption efforts to external stakeholders. Find out more about anti-corruption Collective Action on the B20 Collective Action Hub, a resource and guidance centre hosted by the Basel Institute since 2013.

How to enhance integrity during crises: lessons from behavioural science

The following summary reflects key messages emerging from the Harnessing the intangible: enhancing integrity during crises Knowledge Partner session on 25 March 2021 at the 2021 OECD Global Anti-Corruption & Integrity Forum. Hosted by the Basel Institute and moderated by Claudia Baez Camargo, Head of Public Governance, the event explored how practitioners could tailor approaches to strengthen integrity during an emergency response to counter recurrent social norms and informal practices. The panel incorporated a wide range of perspectives from health, anti-corruption and behavioural research, featuring Dina Balabanova and Eleanor Hutchinson of the London School of Hygiene and Tropical Medicine, David Jackson of the U4 Anti-Corruption Resource Centre, and Ruth Persian of The Behavioural Insights Team. Why aren’t traditional approaches to tackling corruption and promoting integrity working? A key takeaway from the session is that mainstream anti-corruption interventions focusing on accountability, transparency and law enforcement measures have not been as effective as we would like in combatting corruption. Could this be because we don’t make enough effort to understand the local context, social networks and power dynamics in the target countries as well as individual actors’ experience and motivation? A growing body of evidence suggests so. For example, recent research carried out in Nigeria by the London School of Hygiene & Tropical Medicine reveals that the causes of absenteeism among Nigerian health workers are much more complex than one might expect. They encompass economic pressures, structural inefficacies and managerial/organisational dynamics, with the research also emphasising that these are shaped by sociocultural factors and political relationships. Without a more nuanced analysis of how and why people behave as they do and the context in which they make decisions, laws and rules alone are unlikely to change the drivers of corrupt behaviour. Initiatives are increasingly focusing on improving health system governance, but thinking about the “upstream” social and political factors is essential. Exploring social norms can offer insights into the drivers of unethical/corrupt decision-making. For instance, the Basel Institute’s current research project in Tanzania under the GI-ACE programme shines a spotlight on, among other things, social norms related to returning favours or serving family members first. Health workers are put under pressure to make special concessions to their kinship or those who offer gifts. If people follow these informal rules, merely changing or strengthening laws or rules will not get rid of the underlying drivers of corruption or violations of integrity. The message is clear: when designing interventions, it is critical to first understand the context, including what social norms are at play and which behavioural and structural barriers to behaviour change the different actors face. Are we less rational than we think – and even worse in a crisis? Traditional economic thinking has assumed that human beings are rational agents acting according to an analytical, cost/benefit analysis. In his best-selling book, Thinking, Fast and Slow , Daniel Kahneman referred to this as slow “System 2” thinking. In contrast, System 1 thinking is fast and automatic, and more susceptible to environmental influences and biases than we think. However, policies and systems are often designed with only System 2 in mind. Furthermore, in situations where decision-makers act under a lot of pressure and stress – as is the cases in crises – evidence shows that System 1 is most likely to take over when making decisions. This has to be taken into account when designing interventions. In the context of the Covid-19 pandemic, interventions could support medical staff and policy makers by simplifying how information is displayed and framed. For instance, a study showed how changing how prescription instructions are framed can lead a significant reduction in prescription errors in UK’s National Health Service NHS . It seems likely that this finding can be generalised: by providing information at the right time and an easily accessible format and by simplifying decision-making, people working under a lot of stress are supported to take the right course of action. Do crises amplify integrity issues? Or is “crisis” mode quite normal? The pandemic has merely exacerbated the fact that health systems around the world are in a constant state of crisis, with regular shortages and understaffing. This generates different pressures on staff workers, with a direct link to integrity issues. One issue relates to the political economy of a country. For instance, sanctioning health workers for corrupt behaviour if they enjoy political protection may lead to severe consequences – like job losses – for head of departments. An intervention that does not take this into account would do more harm than good. Gendered norms and expectations also drive behaviour. In the case of absenteeism among Nigerian health workers mentioned above, for example, female nurses are often expected to juggle their shifts with family care and contribution to the household economy e.g. farming . Merely changing rules or management without understanding people’s behaviour and the expectations they face in a complex system will not yield the expected results. As for political power, understanding how social and family networks are structured and operate is key to designing effective anti-corruption interventions. Harnessing behavioural insights to drive change A solid political economy analysis will help build understanding among anti-corruption practitioners – but what should they do with that understanding? The next step is to understand how to use these insights into different networks to design more effective interventions. This is the idea behind another GI-ACE project led by the Basel Institute on Harnessing Informality: Designing Anti-Corruption Network Interventions and Strategic Use of Legal Instruments. To continue with the example of absenteeism among health workers, individuals who are negatively affected by this more working hours, more pressure due to the added activities related to the Covid-19 responses may be more likely to support an intervention to address the issue. So, clearly identifying networks of allies with a reason to support a change in favour of integrity should be an essential step of any intervention. How social norms affect behaviour – for better or for worse Another interesting point raised during the session was how we all belong to different reference groups which form part of our identity. Social norms stem from these reference groups and influence our behaviours in different ways. We follow descriptive norms because they relate to common behaviour, whereas we respect injunctive norms because we think that others think these behaviours are socially appropriate. For example, assisting our family materially because we think that others perceive this as the right thing to do. These last norms generate social pressure as we are scared by the social sanctions we would incur by violating them. Social norms become particularly salient during crises when, as mentioned above, System 1 thinking is likely to take over in stressful situations where actors need to make fast decisions under a lot of pressure. Rather than changing social norms, perhaps the objective in the Covid-19 crisis and more generally should therefore be relieve individuals from the pressures generated by the norms. Norms of elites need careful consideration. Cases of decision-makers violating social distancing norms may make it permissible to violate health guidelines in the eyes of the public. However, research shows that trend-setters – i.e. people within groups leading by example by adopting virtuous behaviours associated with social norms like respecting social distancing – play an equally important role in changing undesirable behaviours associated with social norms. Revealing information about these virtuous behaviours within reference groups can incentivise others to change their own behaviour vis-à-vis a social norm. Another option that requires careful consideration and handling – and a deep understanding of political economy, behaviours and norms – is for governments to publicly condemn corrupt behaviour using normative interventions, for example naming and shaming individuals who violated covid-19 regulations. Can social norms be changed? So: relieving individuals from the pressures generated by social norms is one avenue for intervention. Another common form of intervention aims to correct people’s incorrect perceptions of social norms. More drastically, perhaps some norms need to change in order to form the basis of a stronger, healthier and more resilient society. Is this possible? The short answer that emerged at the session is yes. Three elements must be present: People need a reason to change. People must trust each other. A mechanism must be in place to let change occur e.g. a civic space . This implies that changing social norms to encourage integrity is a collective effort. It is also an immensely challenging one – but nonetheless essential if we wish to enhance integrity during crises as well as during “business as usual”. Learn more Read more about our Public Governance team’s research on social norms and related factors here. Learn more about the UK-funded Anti-Corruption Evidence ACE programme and its two components: SOAS-ACE led by SOAS University of London and GI-ACE led by Global Integrity . Read a publication on the London School of Hygiene & Tropical Medicine LSHTM website by Dr Dina Balabanova LSHTM , Professor Obinna Onwujekwe University of Nigeria and Dr Eric Umar University of Malawi on Understanding and eliminating health sector corruption impeding UHC at district level in Nigeria and Malawi: institutions, individuals and incentives. Watch a video recording of the session on YouTube.

OECD blog: new report on responsible business and anti-corruption compliance in Southeast Asia

An illuminating new report by our OECD partners on Responsible Business Conduct and Anti-Corruption Compliance in Southeast Asia illustrates three points we have long emphasised at the Basel Institute. First, how corruption, environmental, human rights and other elements of sustainable and responsible business conduct are increasingly being integrated within company-wide risk management frameworks. Second, that companies are at very different stages in terms of compliance and risk management – and that's OK. The point is to keep strengthening systems and adapting to new risks, such as those posed by covid-19. Third, the huge potential for Collective Action. Companies in the same sectors or geographical areas can help each other close weaknesses in compliance and sustainability risk management systems and thereby raise standards across the board. Collective Action will feature in the OECD's broader South East Asia Regional Outlook publication, due to be launched at the OECD Global Anti-Corruption and Integrity Forum in the week of 22 March 2021. Meanwhile, the report's authors Sofia Tirini and Leah Ambler have summarised the main findings in this short guest blog: The OECD, in partnership with UNDP, conducted a survey and analysis to better understand how corruption and other sustainability risks affect businesses and entities in Southeast Asia. The aim of the project was to assess current practices companies operating in the region employ in internalising anti-corruption and business integrity issues within their policies. Additionally, the project sought to evaluate the effects of the covid-19 pandemic on anti-corruption compliance and responsible business conduct RBC across businesses and entities operating in the region. The Responsible Business Conduct and Anti-Corruption Compliance in Southeast Asia provides inputs for recommendations that can form the basis for shared learnings across the region to support businesses in implementing RBC and business integrity standards. Scope of the survey Open for a total of five weeks ending on 7th July 2020, and available in six languages, the survey was shared with over 400 potential respondents across 10 countries in Southeast Asia: Brunei Darussalam, Cambodia, Indonesia, Lao PDR, Malaysia, Myanmar, Philippines, Singapore, Thailand and Vietnam. The survey obtained 229 responses, including multinational companies, SOEs and SMEs. The sample was well-distributed across business sizes, ownership type and business functions production and extraction, manufacturing, services . The most common sectors were: consulting and professional services, education, consumer goods manufacturing, sales and distribution , construction and engineering, agriculture and seafood production, energy. Corruption is the biggest concern One of the main findings that the survey showed is that being associated with corruption 58% is the most cited risk that companies face, followed by environmental issues and transparency issues. Association with corruption can be both direct and indirect through contractors, subcontractors and business partners. In light of these risks, almost all respondents in the sample 95% have a formal written policy in place setting out expectations for the management of various risks. Those without such policies are overwhelmingly micro-enterprises with fewer than 10 employees. The most commonly reported risk management policies are for anti-corruption, responsible business conduct and ethics. However, over a third of companies still do not have a policy explicitly addressing corruption within their company. For those companies that extend their policies to contractors, subcontractors and business partners, the majority do not cover anti-corruption. It is nevertheless encouraging to see that many businesses take risk management seriously and have at least the beginnings of a robust set of policies . Risk management policies When asked why businesses set up risk management policies or a broader risk management framework, the most common reasons are that: it is an obligation under national legislation; it is the right thing to do for people, the planet and society; to address the risk of reputational damage. National legislation or guidance seems to have the greatest influence on business risk management policies. Doing the “right thing” and avoiding reputational damage are also important factors. All this points to an already established track-record of awareness and engagement with business risks , especially corruption, even if much of the sample is made up of businesses already exposed to the OECD’s efforts in these areas. The pandemic effect Considering the survey was conducted between May and July 2020, when Southeast Asian countries were in various stages of “lockdown” due to the covid-19 pandemic, it is possible that the context may have shifted their vision and priorities regarding business risks . Although over half of respondents reported increased environmental, social and/or governance risks during the crisis, only a third are planning to make changes to their business integrity and/or RBC framework to reduce the impact of covid-19. An additional quarter of respondents report that they are unsure whether they will be making changes . Upcoming report: South East Asia Regional Outlook A larger version of the report will be published by the OECD containing more interesting findings on anti-corruption risks and challenges in South East Asia. In this broader publication, the OECD will provide information on other issues such as gender policies, risk areas for businesses and the impact of technology among others. The “South East Asia Regional Outlook” is expected to be launched in 2021 in the framework of the Global Anti-Corruption and Integrity Forum.

Clean procurement in times of covid-19 – transparency and the High Level Reporting Mechanism

As aid, donations and recovery packages are deployed to cope with the pandemic, the risk of corruption is surging in many countries. Funds for emergency healthcare procurements are flooding in. These fast procurement processes often have limited corruption prevention measures in place and therefore present an increased risk for both governments and businesses. In his recent publication “It’s Only the Beginning: COVID-19, Public Procurement, and Corruption”, anti-corruption expert Nicola Bonucci emphasises the lack of oversight of Covid-19 aid funds and the related surge in fraud and corruption. Procurement processes are far from perfect in many countries and will take time to adjust. Yet the nature of the pandemic means that urgent tenders which present increased risk exposure are unavoidable for the time being. That’s not the only problem: Current research by Claudia Baez Camargo, who leads the Basel Institute’s Public Governance team, points to added difficulties in procurement when governments declare a State of Disaster or State of Emergency. This can allow the bypassing of existing safeguards due to the urgency of the situation. Another increased corruption risk lies in the lack of policy and control mechanisms on donations to public facilities such as health facilities. There is also a lack of clarity around the role of anti-corruption authorities when it comes to emergency public procurement. Anti-corruption authorities could potentially help in identifying loopholes and safeguarding Covid-19 related resources. Transparency through collaborative action Now available in English, a Recommendation Guide jointly developed by Global Compact Network Brazil, Transparência Internacional - Brasil, IBGC - Instituto Brasileiro de Governança Corporativa and Instituto Ethos with the participation of Alliance for Integrity includes a specific section on procurement and contracting. It recommends the adherence to active transparency mechanisms and includes additional recommendations related to emergency public procurement. How to achieve this? In a nutshell: through collaborative approaches between government, the private sector and civil society. There is evidence from all over the world that multi-stakeholder engagements, if granted enough power, can offer a robust response in preventing corruption in Covid-19 procurement and beyond the pandemic. Any systematic framework for reporting allegations of possible bribery and corruption needs buy-in from all parties in order to work. It must also be supported by whistle-blower protection regulations. Applying the HLRM to Covid-19 procurement The High Level Reporting Mechanism HLRM is one powerful transparency mechanism which could be deployed rapidly to address Covid-19 procurement challenges for the benefit of citizens, governments and businesses. The Basel Institute on Governance, OECD and Transparency International jointly developed this tool to meet private sector demands for a fast, independent and effective mechanism to deal with alerts about suspected bribery or unfair business practices in public tenders. HLRMs offer an alternative to traditional judicial and administrative procedures. They enable the private sector to obtain a prompt and pragmatic response from the government and avoid further escalation. They are tailored to address a country’s specific risks. The result: more transparency, more efficient procurement of urgently needed essential supplies, a fairer playing field for bidding companies and stronger trust in government. A silver bullet? No. But a powerful and collaborative tool for those with the courage to take it forward. Learn more Find out more about the HLRM, including case studies from four countries. See this guest blog by our partners in the OECD Anti-Corruption Division, published on 24 September 2020: New OECD study on how to implement a HLRM for clean, transparent public procurement

Upcoming UK government webinars on Top Tips for Trading Responsibly During Covid-19

Integrity risks for businesses trading overseas have shot up due to the pandemic. Anti-corruption and human rights compliance approaches designed to protect companies during “business as usual” can come under strain in these unusual circumstances. How can companies – especially smaller companies with limited resources – protect themselves from integrity risks in these times of crisis? There are no easy answers, but it’s important to talk about the questions. Gemma Aiolfi, the Basel Institute’s Head of Compliance and Collective Action, will take part in a panel at two upcoming UK government webinars. The events are part of the UK Department of Trade’s COVID-19 Webinar series aimed at helping SMEs trade safely and responsibly during the covid-19 pandemic and its aftermath. The focus is on guidance and practical advice to support SMEs from any country – not just the UK – and help them overcome pandemic-related challenges and potential disruption. An open Q&A session will follow the short presentations. Webinar details and registration The two webinars are hosted by the UK Department for International Trade and Department for International Development. They will take place in English and feature presentations by UK government officials, but the majority of the advice will be relevant to businesses in other countries too. Attendance is free. Both events cover: Trends and opportunities in the sector Practical tips on sourcing and managing supply chains while respecting and championing human rights Protecting your business from integrity risks Complying with the UK Bribery Act. More information and registration: Consumer and retail sector: 16 June 2020, 11:00-12:30 GMT+1 Food and drink sector: 7 July 2020, 11:00-12:30 GMT+1

Local health governance in Tajikistan: accountability and power relations at the district level

Corruption, social norms and behaviours: a comparative assessment of Rwanda, Tanzania and Uganda