Social Norms & Behaviors & Health – Tanzania

Addressing bribery in the Tanzanian health sector: A behavioural approach

Project Summary

In previous research, it was found that social norms of gift-giving and reciprocity are linked to patterns of bribery in the Tanzanian health sector. These norms are enacted and confirmed repeatedly by the interactions of individuals across their social networks. Failing to accept a gift or to reciprocate a favour is punished by means of gossip, criticism, and even social isolation, further enforcing the norms.

This project develops an anti-bribery intervention that works with health workers, as well as with trusted community-based social networks to deliver messages of attitudinal and behavioural change, aimed at addressing the social acceptability of bribery and gift-giving in the provision of health services in public facilities. The hypothesis is that effective and sustainable change can be yielded by (a) explicitly recognizing the role of social pressures in perpetuating practices of petty corruption, and (b) harnessing the power of social networks to promote better understanding about the hidden costs of corruption.

Policy and Programming Implications

In spite of adopting appropriate legal and institutional anti-corruption frameworks, many countries around the world suffer from the effects of endemic levels of corruption. This underscores the importance of developing new approaches that are directly grounded in the local realities of each context, addressing the motivations of social, political, and economic groups. This project aims to provide evidence on (a) the feasibility of using social networks as an approach to implement anti-corruption interventions, and (b) whether it is possible to work with social norms to promote better anti-corruption outcomes. Such evidence will yield critical insights for the development of context-sensitive interventions that take into account behavioural drivers of decisionmaking, which can make corruption difficult to eradicate solely by means of conventional legal approaches.

Research Questions

• How can behavioural insights inform anti-corruption practice?
• Can a social norms focus be useful in addressing entrenched patterns of corruption?
• Can delivering anti-corruption interventions through existing social networks help bolster the fight against corruption?

Methodology

Both providers and users of public health services will be engaged for the intervention. For the case of users, the methodology to map and engage with social networks involves identifying the right seed nodes (opinion leaders) in a network to disseminate the intervention, thereafter assessing how particular ideas and attitudes spread through their existing social networks. Plans for capturing the effect of the intervention on attitudes and behaviours include an exit survey in selected public dispensaries in Dar es Salaam. The impact will further be assessed through a rigorous evaluation approach, such as a randomised controlled trial.

ACE Impact

Findings

• A social norm behavior change approach is not a silver bullet, but it can help boost or reinforce other interventions.
• Social networks “lock in” social norms of obligation within a group, and health workers face strong pressures to exploit their positions for the benefit of the social network.
• Social networks are informal safety nets – social norms of reciprocity. Abiding by social norms is linked to reputation, status, and respectability. Those who amass and share resources are respected and beloved, even if the resources come from illicit activity. Those who abide by the formal rules in their job and thus fail to provide benefits are criticised.
• Based on the intervention in Tanzania, it seems one of the more salient results was a perceived change in the injunctive social norms among users, stemming from the presence of physical environmental cues. Attitudes towards bribery did not seem to change significantly, but the perception of injunctive social norms did.
• Regarding the network intervention, we saw a pattern of “clustered dissemination” (champions spoke to individuals, who also spoke with each other). Communication tended to take place within professional groups (and not so much across professions), and staff meetings were common venues for dissemination. Despite the clustered pattern, the intervention message traveled beyond the treated units.

Impact

• We completed a study with U4 and SIDA on small and medium enterprises in Moldova, and looked specifically at the role of social norms. This study and its recommendations have been picked up by the Swiss Embassy in Moldova, which has since committed to an 11-year intervention. Claudia is involved with local consultants in co-designing the intervention, with a participatory lens and focus on social norms.
• We presented on the Tanzania project with the World Health Organisation’s Global Network for Anti-Corruption, Transparency, and Accountability. Following that collaboration, we now have a panel on social norms and corruption at a conference for Health Systems Global to raise awareness of corruption in the community of healthcare practitioners.
• Collaborating with an Indonesian university (University of Medan), we are supporting them in developing a pilot intervention to tackle sextoriton. The intervention will, in principle, adopt a similar approach as our Tanzania intervention, establishing a peer-led (champion-led) network intervention and environmental cues.

Research Team Members

• Claudia Baez Camargo, Head of Governance Research, Basel Institute on Governance
• Richard Sambaiga, Senior Lecturer, University of Dar es Salaam
• Ruth Persian, Senior Advisor, The Behavioural Insights Team
• Matthew Howitt, Associate Advisor, The Behavioural Insights Team
• Tobias Stark, Assistant Professor, Department of Interdisciplinary Social Science, Utrecht University