Development aid is needed to counter the crisis; it must be safeguarded from corruption

The SARS-CoV-2 virus and the disease it causes – COVID-19 – might have emerged as a result of corruption (as WHO explains, SARS-CoV-2 is the name of the virus and COVID-19 is the disease it causes).

The ongoing outbreak is affecting developed and developing countries simultaneously. Following the onset of such a crisis, it is tempting to deprioritise the mitigation and management of corruption risks and upholding of sanctions against perpetrators of corruption. This pandemic will be seen by some as an opportunity to take advantage of the emergency to abuse their power for private gain. In this unique circumstance, it is critical that corruption not be ignored.

The importance of continuing and strengthening anti-corruption is, moreover, underscored by the fact that the best evidence we currently have of the origin of SARS-CoV-2 leads to a market in Wuhan, China, that engaged in the corrupt and illegal trade of exotic wildlife, whereby this zoonotic disease was transferred to humans.

Health systems in aid recipient countries suffer from chronic systemic weaknesses that will make it difficult to respond to this crisis. They will require a swift injection of financial and technical support. It is critical that existing investments, as well as any additional funds made available to tackle the disease are deployed strategically. Anti-corruption procedures and systems of accountability will ensure that development aid deployed to help fight the virus is used well and benefits those who need it the most.

The following text outlines emerging corruption trends associated with the disease outbreak and suggests priorities development actors can adopt to minimise the threat corruption poses to an effective response to the crisis.

Emerging corruption risks and trends

Throughout March 2020, there has already been a wave of corruption-related incidents, decreasing transparency and accountability, as well as manipulative political propaganda from all over the world.

Europe

At the time of writing, the European continent is the epicentre of the outbreak with Italy hit the hardest. An agricultural company won a contract to supply the government with face masks. The ICJ reports that the public procurement agency is now investigating the case and the bid has been blocked.

In Hungary, the Prime Minister, Viktor Orbán has wasted no time in securing his appointment to oversee the outbreak response, rather than the Minister of Health or Minister of the Interior. His government is pushing to extend an indefinite state of emergency and securing the power to make critical decisions without involving parliament.

Serbian President Aleksandar Vučić has publicly indicated that due to a lack of ventilators available on the European market, he was “forced” to acquire them on the semi-grey market. This raises suspicion for the integrity of the procurement procedure. Vučić is quoted as saying “you can prosecute me one day for providing respirators to the people.”

In Germany, evidence of petty forms of corruption have been reported, such as individuals posing as health personnel going door-to-door in neighbourhoods in Berlin providing SARS-Cov-2 testing kits.

There are also accounts of Russian oligarchs, whose wealth is often gained on the back of corruption, purchasing scarce ventilators, outfitting their homes with makeshift clinics, and arranging agreements with doctors to be on call to ensure that they can avoid seeking treatment in the state-owned hospitals responsible for treating victims of the outbreak. Suppliers of ventilators reported that private buyers constituted as much as 30% of their recent sales.

In Norway, some doctors are reported to be breaking the guidelines from the state medicines agency that has issued rationing on medicines that may help against COVID-19; they continue to write prescriptions for their families and friends.

South Asia

In the state Tamil Nadu in India, there is suspicion of failure to report the number of SARS-CoV-2 cases to authorities. And in Bangladesh, there are reports of an overall failure to properly screen those coming into the country. President of the Workers’ Party of Bangladesh, Rashed Khan Menon, indicated that this was at least in part due to the rampant corruption within the Ministry of Health, which he claims is “more dangerous than spread of coronavirus.”

North America

In the United States, there are concerns that those in positions of power will bend what is left of the regulatory, policy and legal institutions for their private benefit, or influence decisions for bailouts and stimulus packages for industries at the beckoning of special interest groups and at the expense of public interest. This could severely derail the country's efforts to respond to the crisis.

US Senators, representatives and senior aides have been found committing insider trading, off-loading stocks for travel companies, and investing in biotech companies during a time when they themselves were aware of the threat of the virus, but continued to reassure the American people.

Furthermore, criticism has been made against proposed relief packages to buttress the US economy that include specific mention of hotels, which raises concerns about whether or not the President’s own hotels stand to benefit from the relief.

Middle East and Northern Africa

Within less than weeks following the outbreak, Israeli Prime Minster, Benjamin Netanyahu has ordered the internal security services to secretly track citizens’ movements using mobile phone data, incapacitated the Israeli parliament and shut down the courts of justice, which were meant to begin the trial against him for bribery, fraud and breach of trust on 24 March but at the time of writing has been postponed until May. Critics are claiming that Netanyahu is using the outbreak to exercise an unprecedented power grab. Following the most recent 2020 election, the opposition leader Benny Gantz was given the mandate to form a government. Netanyahu is now urging that Gantz form an “emergency government,” but under his leadership.

In Iran, a country also hit hard with the pandemic, there are reports of a “well-connected network” controlling the distribution and prices of items needed for the country’s response. There are suspicions that the leaders of this network are closely connected to those in power.

Africa

The outbreak presents an opportunity for scammers and businessmen to defraud citizens, often with the complicity of government officials, as indicated by reports from Uganda. There are also accounts of citizens evading quarantine by bribing officials in Cameroon and Uganda, which will inevitably lead to further disease spread.

Finally, six million face masks ordered by Germany to protect health workers from the coronavirus went missing at an airport in Kenya. Investigations on how the masks ended up in Kenya and how they went missing are going on.

Health system corruption risks during disease outbreaks

There are a number of corruption typologies showing what kind of corruption occurs under normal circumstances in many low- and middle-income countries. During an outbreak, it is possible that attention and funding for other health operations are deprioritised. This can lead to a number of consequences, such as:

1. emergency procurement that increases corruption risks
2. pilfering available supplies, price gouging, and resale on the grey and black markets
3. increase in substandard and falsified products entering the market.

Procurement of goods and services for disease management

Evidence from audits of international aid spending during the 2013–2016 West African Ebola outbreak indicate that procurement procedures were widely disregarded. In the case of SARS-CoV-2, considerable funding will be required to procure the equipment and other infrastructure needed to provide intensive care. European countries are currently scrambling to acquire more ventilators to deal with the crisis through domestic production as well as outsourcing. The cost of a standard ventilator is US$25,000 and they require frequent maintenance. The scarcity and demand for ventilators and other equipment for intensive care will increase the risk of corruption in the procurement of these goods.

Opacity and corruption in health workforce governance, recruitment, and management

Strong and capable leadership, backed by a health workforce with the necessary expertise, is the cornerstone of an effective response to pandemics. However, in many developing countries, corruption and lack of transparency have led to the recruitment of people who cannot implement complex treatment protocols, reducing the ability to handle a crisis. This issue is pertinent at a time when health systems are under pressure to recruit as many workers as possible.

During the Ebola outbreak, audits of internationals development spending showed that funds for health and awareness raising efforts were fraudulently documented. There was also failure to provide healthcare workers’ salaries and monies destined for organisations were paid out to private individuals by those charged with distribution. From the Red Cross alone it was reported that 5% of total disbursements was lost.

Petty corruption at the service delivery level

Forms of corruption carried out by healthcare workers such as informal payments, over-prescribing, favouritism, and nepotism are likely to be exacerbated during an outbreak as the system experiences a greater patient load. These types of corruption can be driven by low wages and poor working conditions and contribute to poor patient perception of public services – affecting health-seeking behaviour.

Furthermore, other forms of low-level corruption perpetrated by patients can also contribute to further disease spread, such as bribing enforcement officials to evade quarantine. This has already been reported in Uganda, where foreigners that were supposed to be placed under quarantine were able to evade it through corrupt means. Similar incidents, of “connected” people evading quarantine, have been reported in Cameroon. This could have dire implications for containing the spread of the disease.

Opacity in research and development

There is a global call to advance research and development of diagnostics and therapeutics to address the SARS-CoV-2 outbreak and considerable amounts of public funding is being spent in support. In the best of times, pharmaceutical development is opaque and expensive and it can be expected that where possible, industry and market dynamics will be manipulated for the sake of higher profit.

Already the pharmaceutical company Gilead Sciences, which previously came under fire for excessive prices for the Hepatitis C cure, Sovaldi, has been granted FDA approval for the experimental drug, Remdesvir, to treat COVID-19 giving it “orphaned drug” status. Orphaned drug status comes with a number of financial incentives, such as tax breaks, waiving of fees and market exclusivity. Gilead Sciences has since rescinded the orphaned drug status following outcry, but demonstrates that it is critical during this time to:

• ensure strict adherence to regulatory procedures in research and development
• scrutinise decision making
• make the results of research publicly available
• see to that the prices for any final products reflect the public investment made and not company interest for profit
• secure equity in access for all nations without restrictions.

Recommendations for development actors

This emergency requires that corruption risk mitigation is built into the donor support provided to the response to prevent further damage to societies, and maintained in existing investments. Donors should leverage their aid and influence, wisely building on the experience of past crises.

Apply a sectoral approach to anti-corruption

Anti-corruption must remain a priority in times of crisis and in this particular case of the SARS-CoV-2 outbreak. It is comfortable to rely on traditional anti-corruption policies and programmes that focus primarily on financial management to identify and prevent corruption, but funds can be diverged and documents can be forged, and outbreak response requires haste – not bureaucracy. The Ebola outbreak demonstrates that such mechanisms in the face of an epidemic are insufficient. Instead, donors should prioritise a sectoral approach to tackling corruption that places achieving health outcomes as the top priority and builds anti-corruption into intervention design. This means including anti-corruption experts in the public health discussion and constructively working together. Donors also need to know the corruption risks they are facing, and implementers must design interventions accordingly. There are a number of risk assessment frameworks that can be applied, such as these examples from UNDP or WHO.

For example, in the case of an outbreak, dedicated personnel is needed to deliver health services. Donors can leverage their influence to ensure that strong and capable leaders are appointed to head responses at the country level. Despite widespread patronage in the appointment of public officials, developing countries such as DRC, Uganda, and Nigeria have been able to control the spread of Ebola by appointing experts with strong leadership skills to spearhead their epidemic response plans. A pandemic is therefore an opportunity for meritocracy to be prioritised.

The common corruption risk of informal payments in health facilities that can lead to poor health-seeking behaviour and distrust in health providers – and the public service more generally – is a significant threat that should be tackled urgently. To curb this, governments should ensure timely payment of adequate salaries and consider further incentives such as overtime allowances and bonuses. Civil society organisations can play an oversight role using various social accountability tools to deter informal payments and other corrupt practices at service delivery level.

Share risk and minimise compliance burdens

In a webinar on the international SARS-CoV-2 response held on 19 March 2020 by The New Humanitarian, Suze van Meegen, Advocacy Manager of the Norwegian Refugee Council, indicated that the increasing compliance obligations for financial management and anti-corruption placed on implementing organisations led to the burden of risk being carried by NGOs and restricted their ability to act. Such traditional compliance mechanisms have little evidence of success, are time consuming and expensive. It was suggested that donors reflect on their own policies to avoid stifling activity and prevent achieving outcomes.

Channel funding jointly and use existing networks

When it comes to anti-corruption best practice in health, the Global Fund is recognised as having robust policies to allow for prevention and management of corruption within grants, as well as sanctions enforcement. There are increasing amounts of bilateral donor funding being channeled through the Global Fund already, and the fund is considering grant making to combat the SARS-CoV-2 outbreak. This presents an opportunity for donors to join together for greater impact using a trusted grant-making entity with robust and established anti-corruption mechanisms. As recommended by a 2019 U4 Issue, donors channelling aid through multi-partner funds should aim towards a shared understanding of risk appetite and risk sharing between the stakeholders: the funding partners, the MPF administrator/trustee, the implementation partners, national authorities, and intended beneficiaries.

Rather than building new systems to safeguard funding, donors should identify and reinforce existing systems that have robust anti-corruption procedures. Again, the Global Fund has established a transparent open procurement system that could be used for procuring medical devices and other needed supplies.

Where possible, donors should support civil society organisations, journalists, and anti-corruption commissions to provide a watchdog function on grant disbursement and hold implementation agencies to account.

Safeguard the justice system and deter fraud

To the extent that it is possible, the justice system must be allowed to continue to function in order to enforce sanctions and rule on cases of corruption, thereby maintaining systems of accountability during a state of emergency. The relevant anti-corruption and criminal justice agencies should issue strong warnings against fraud and corruption in crisis response measures, and prepare to launch investigations against those who are abusing their public positions to profit from the crisis.

Low income countries have a long-standing problem with overcrowded prisons and there is a real threat of prisons becoming epicentres for the disease to spread. It has been reported that in Iran the government has been forced to release prisoners to curb the spread of SARS-CoV-2 in prisons. The prisoners released were those considered not to be a threat to society. Those convicted of corruption-related cases could fall into the category of “low security risk” prisoners. This is uncharted territory, and should be carefully planned and managed to minimise undermining and subverting justice.

Support civil society and community-based responses

There are important lessons to be learned from the HIV/AIDS epidemic that can be applied to the SARS-CoV-2 response. The response to HIV/AIDs was notable for its emphasis on the role of civil society. Governments worked closely with local community organisations and encouraged local programmes and practices. As a result, the HIV/AIDS epidemic did not have as devastating an impact on societies as had been anticipated.

During a natural disaster in Bosnia-Herzegovina in 2014, anti-corruption hotlines were implemented to allow for citizens to report instances of corruption. A similar approach could be applied to allow not only for reporting of corruption, but also to report proliferation of misinformation.

In times of crisis when demands for quick action are high, the important role of civil society for anti-corruption efforts can be forgotten. Civil society organisations can play a crucial role in public health systems both as supporting actors in that space or in a monitoring, accountability, and information sharing function. CSOs can help monitoring health outcomes and reveal issues that end-users can experience, can support budget tracking measures and monitor procurement systems. They can also provide crucial user feedback through community healthcare scorecards on issues such as informal payments, access to medicines, and so on.

Apply a rights-based approach

Human rights considerations should be prioritised in efforts to safeguard humanitarian aid from corruption. An integrated approach to corruption and human rights can ensure an effective response. Human Rights Watch says due attention should be paid to human rights principles such as non-discrimination, transparency, and respect for human dignity. This will ensure an effective response and limit the harm that can come from the imposition of overly broad measures.

This is the first time that the international community is facing an urgent public health crisis that affects every nation, and international guidelines to guide UN member states on what they should do within their own borders or how they should interact with each other are not well-known. As a result, countries have adopted varying responses to the crisis, with some countries implementing severe restrictions on freedom of movement and others taking a more relaxed approach.

The 1984 Siracusa Principles on the Limitation and Derogation Provisions in the International Covenant on Civil and Political Rights provide guidance on government responses that restrict human rights for reasons of public health or national emergency. However, these principles are decades old and it is not clear if they are being or will be adhered to. They might need to be re-visited and updated to bring them into line with twenty-first century realities in order to promote a more coherent and coordinated response that balances public interest and safety with human rights.

Apply a gender-lens

Combining a gender lens in anti-corruption measures is important to ensure that controls introduced to reduce disease or corruption risks do not further marginalise or disadvantage women and other vulnerable and marginalised groups. Pandemics affect men and women differently. Past pandemic responses (to SARS, Ebola, etc.) did not take gender into account – with disastrous consequences for women.

The risks to women arise in many ways. Firstly, the majority of healthcare workers are women. Second, social isolation increases their household burdens due to the larger role they play in child-care, food preparation, and other household tasks. Added to this is the fact that they are responsible for caring for the sick and the elderly, so if family members are infected, they will have to step in.

Another real danger is the diversion of public resources away from important health services such as maternity and obstetric care, vaccination, and other forms of primary health care – putting the lives of women and children at risk. In Sierra Leone during the Ebola crisis, maternal mortality likely increased.

Women are also over-represented in the informal sector and in temporary jobs. They will be hit hard by the loss of jobs and income.

The closure of schools and social isolation obligations puts girls in developing countries at risk of dropping out of school altogether – as also happened in Sierra Leone during Ebola. Teen pregnancies went up, as did domestic violence. Indeed, it has been reported that domestic violence increased in China and is increasing in other countries contending with social distancing and isolation, as families are forced to spend more time together under stressful circumstances that can trigger abusive behaviour.

Apply a social norms lens

Health workers and administrators – as well as public officials in general – will come under widespread social pressure from families, friends, colleagues, and the powerful to ignore official rules and official guidance, as is happening in the example of Norway described above. These pressures are likely to be systematic because they are rooted in social norms: shared understandings about actions that are appropriate in society. Such norms provide the unwritten rules of behaviour and in times of crisis the regulatory role and pressure to follow them can sharpen – overriding not just formal rules but even personal attitudes and beliefs. The presence of social sanctions for violators of these norms – from gossiping and disapproval, to physical punishment – i­ncreases pressure to conform.

These norm-related pressures fuelling corruption can be manifold in the health sector. Nurses may see it as perfectly legitimate or be under pressure to prioritise treatment to kin over those with more acute conditions because ‘putting family first’ is an essential norm. Doctors may seek increased bribes in the hospital because an internal code amongst medical colleagues tolerates it – being an outlier may result in social backlash. Public officials may as a favour issue fraudulent health certificates to those in the network because reciprocity underpins social relations. Political leaders may illegally allocate more funding to areas inhabited by their own ethnic group because loyalty to the group is more important than to the state.

The more these negative social norms play a role, the more they crystallise as alternative reference points to the formal rule, threatening to subvert the administration and treatment of the pandemic according to science and need. This ‘trap’ also makes attempts to build-up integrity in the health sector difficult: the issuance of new regulations, codes of conduct, or guidelines around integrity may have little ‘bite’ on behaviour or are trumped by the continued operation of the ‘unofficial’ norms.

Practitioners seeking to ensure and build integrity in the health sector require a thorough understanding of the social forces that perpetuate the corrupt practices. Moreover, conventional initiatives to health governance should be complemented with social norms strategies, the purpose of which is to relieve and shift social pressures so that other kinds of interventions – such as codes of conduct, salary increases, legal reform, enforcement, and civil society oversight – can be effective. These interventions will have to be developed according to the features of each case and the respective entry points.

Such strategies make use of methods such as:

• Finding people or mechanisms to coordinate behaviour so that norms can be collectively reinterpreted, for example through trendsetters who are ‘first movers’ who break free from established norms in a way that can inspire and mobilise others to follow suit.
• Construct social spaces for negotiations around norms through providing an infrastructure for normative dialogue in the health sector, for example through online portals or convening discussions.
• Building positive norms around integrity which can be done through connecting social status and prestige with integrity. Also important is supporting leaders at the top of hierarchies who are willing to initiate a flipping of norms in the network – a removal of corruption-inducing hierarchical norms and a cascade of pro-integrity norms.
• Negative norms may result from inflated notions of how many co-workers are engaged in corrupt acts. This is what social psychologists call ‘pluralistic ignorance.’ Addressing this collective ignorance requires providing credible information and reshaping perceptions about how much corruption is tolerated within an organisation. Compiling and disseminating information about how much, or how little, corruption actually occurs in peer organisations may be one way of overcoming pluralistic ignorance.

Actions for development actors summed up

The SARS-CoV-2 pandemic requires urgent action from all involved in national and global health response. What we do know from previous epidemics and global crises is that they provide a perfect environment for corruption to flourish and that this guarantees further loss of life, depreciation in public trust, and dysfunction in society that persists much longer than the crisis itself. In this moment, safeguarding corruption must be prioritised alongside the health response. At the same time, it is important to avoid premature or poorly-thought-out reforms that can do more harm than good, such as overwhelming a society’s capacity to absorb aid and put it to effective use.

As mentioned earlier, the health systems of many low income countries suffer from systemic weaknesses that could make an effective response to COVID-19 difficult. However, experience from the HIV/AIDS and Ebola crises shows that the challenges are not insurmountable. Development partners need to ensure that development aid is not misused or misappropriated. They can can do this by ensuring transparency in procurement, implementing civil society oversight of grant disbursements and service delivery, and encouraging integrity norms in the health workforce.

The crisis also provides an opportunity to strengthen leadership and governance in the sector, clean up ghost workers, and improve salaries and benefits for health workers. The COVID-19 crisis has shown that transparency should be strengthened throughout the medical private sector (medical devices, pharmaceuticals, life/science, medical supplies, drug trials, etc.), to ensure that profit-making does not override public interest.

The pandemic is also a reminder that the global community and governments should make sufficient investments in pharmaceutical management systems (warehousing and distribution). This is a good time to strengthen the WHO sub-standard and falsified medicines department and ongoing efforts to tackle pharmacueticals corruption such as the Good Governance for Medicines Initiative.

As governments all over the world pass emergency legislation to deal with the crisis, they should prioritise protecting the public interest by deterring those who seek to profiteer from crises through fraud and corruption. Legislation could, for example, allow for retrospective scrutiny of procurement and other official decisions made during the crisis by a specially established body staffed with reputable persons. This would also allow countries to learn lessons before the next pandemic strikes, as it most likely will.

For more information, see the U4 topic page on anti-corruption efforts in the health sector.

Forthcoming from U4 in April/early May 2020 is also an updated comprehensive guide to anti-corruption in the health sector.