In East Africa, there are concerns over widespread petty corruption in some of the countries’ health and medical services. This makes access to them conditional on who you know or who you can pay, to the detriment of everyone else who doesn’t have the money or connections.
In Uganda and Tanzania health service providers are ranked as some of the most bribery-prone institutions in the country. By contrast, health and medical services in Rwanda are ranked as the least bribery prone.
We wanted to understand the behavioural drivers, such as the role of social norms and beliefs, in spurring petty corruption. To do this, we investigated the decisions of those seeking medical treatment and of health service providers that fuel petty corruption in Tanzania, Uganda and Rwanda.
We focused on these three East African countries, which share a common border west of Lake Victoria, because we wanted the opportunity to compare attitudes and experiences. All three countries have robust anti-corruption legislation and institutions in place but all yielded different results.
Our research found evidence that social norms and shared beliefs spur corruption. For example, people are swayed by social pressure to help relatives, share contacts or reciprocate favours received from their networks. Many also believe that corruption is normal.
This was very evident in Uganda and Tanzania, but to a much lesser extent in Rwanda. This highlights our findings on why this behaviour comes about in the first place: people engage in corruption when health services are less available or accessible.
In Rwanda effective government social programmes exist. For example Ubudehe provides targeted support to the poorest and most vulnerable groups. The programme has reduced the reliance of citizens on informal social networks by ensuring access to public services and social benefits.
We hope that our research provides insights into the importance of incorporating behavioural insights into anti-corruption policymaking that conventional measures have largely failed to address.
However, unless basic problems of accessibility and quality of public services are addressed, it will be extremely difficult to eradicate informal strategies to obtain the desired healthcare.
Social norms and networks
The research was conducted between January 2016 and August 2017 in Rwanda, Tanzania and Uganda.
For our research we carried out interviews, focus group discussions and surveys. Our target communities were providers and receivers of healthcare. For those seeking treatment, we targeted women of child bearing age, young men, and elderly and disabled people.
The evidence suggests that social norms and networks play a role in fuelling and reproducing practices of petty corruption. Users of public health facilities in Uganda and Tanzania often turned to their social network, family, friends, friends of friends, when seeking medical services.
When personal connections are absent, offers of unsolicited bribes and gifts are used to create a relationship with the provider. The expectation is that having a “provider friend” helps facilitate access to treatment.
Social norms even dictate how large a bribe should be. In both Uganda and Tanzania, for those that were close – like family members – it would be a small gift or bribe. But for those more socially distant, like friends of friends, they were asked to pay more.
Pressure from relatives
The research also illustrated how corruption was perpetuated by relatives working within the health industry. The duty to help and provide for one’s relatives was an essential, unquestionable premise of social life in the three countries.
A health sector district official in Tanzania explained that:
It’s not that we have a lot of money to help five or six relatives, but…whatever you get you share with others.
The imperatives of helping out, and sharing with, the family results in practices of favouritism as explained by a health provider in Kampala, Uganda, who observed that,
Your relative must be given priority if there is not an emergency. My mother, father, son or daughter come first.
In some cases, family pressures pushed public servants to abuse their positions and engage in illegal acts, such as embezzlement of public funds or misuse of public resources. For example, focus group discussions in Tanzania showed that the misuse of public resources was motivated by the need to contribute to family duties such as paying for children’s school fees, weddings and funeral costs.
Another big driver of corruption in Tanzania and Uganda was the belief that corruption is commonplace, and is expected and accepted. This stereotype is used to justify corrupt behaviours and those of the doctors, nurses and pharmacists.
Our research in Rwanda suggests that accessing health services by relying on networks is much less and limited to those very close to health staff.
This is predominantly associated with the fact that you don’t need special connections or money to have access to good quality health services. The East Africa Bribery Index illustrates this point: the least probability for the request or offer for bribery was recorded at Rwanda’s medical and health services.
Our research suggests that this is because it’s less socially accepted. And it is partially helped by authorities publicly shaming those caught engaging in corruption, preventing it from becoming a norm.
Conventional anti-corruption measures and approaches often seek to scale up penalties and, by so doing, increase deterrence. Some focus on better laws, regulations and education and awareness campaigns about the negative effects of corruption. But these aren’t necessarily effective in addressing root issues.
Integrating behavioural insights into anti-corruption programming can provide complementary avenues to strengthen these endeavours. They pay attention to social norms and beliefs that have supported the persistence of corrupt practices to begin with.
We are exploring this in detail by developing an intervention that works with social networks and community opinion leaders. It uses behavioural techniques – such as environmental nudges which would encourage a certain type of behaviour, like anti-corruption posters – to address the social norm of accepted use of bribery in the provision of health services.