Research study 1

February 2023

Targeting corrupt behaviours in a Tanzanian hospital: A social norms approach

How a pilot behavioural anti-corruption intervention succeeded in reducing 'gift-giving' in a Tanzanian hospital. It targeted deeply ingrained social norms while also leveraging the social networks of key staff members.

What's the problem?

Users of public health facilities may offer unofficial payments ('gifts') to health workers in order to develop a social relationship.

Based on social norms of reciprocity, they expect this will help them to jump the queue and obtain other privileges when accessing health services in the future. This exacerbates inequality and risks a dangerous situation where access to healthcare is dependent upon 'gifts'.

This is a common situation in which deeply ingrained social norms may fuel petty corruption. Traditional anti-corruption interventions - based on training or controls, for example are often ineffective in such situations.

Interventions based on social norms and behaviour change approaches show promise. Now we need to scale up and test these tools in new contexts.

What we did

Where?

A public hospital in Dar es Salaam, Tanzania

Who?

• Hospital users: → patients and their families
• Health workers: → doctors, nurses…

Why?

To explore possibilities to:

• target social norms → to promote better anti-corruption outcomes;
• leverage individuals' social networks → to increase the effectiveness of anti-corruption interventions.

How?

• Staff champions. → Using a peer-driven approach, we recruited and trained anti-corruption champions amongst health workers. These champions disseminated messages against accepting gifts through their social networks.
• Environmental cues. → Posters and desk signs showing messages that hospital staff do not accept bribes. The health worker-facing side of desk signs gave guidance on how to tactfully refuse 'gifts' and appealed to their professional ethics - endorsed by the hospital management and national medical association.

What we found

• After 8 weeks, our surveys measured a 14 - 44% reduction in gift-giving intentions, attitudes and positive beliefs among hospital users.
• A supportive hospital administration and skilled local facilitator helped ensure the intervention's successful implementation.
• Staff champions disseminated the messages at staff meetings and through personal conversations, where trust was crucial.
• Recruiting staff champions from a variety of professions within the hospital helped widen the reach of the messaging.
• The posters and staff champions appeared to be more effective than the letters and guidance on how to refuse gifts.
• The intervention was less effective in changing strongly held beliefs that it is acceptable to offer or accept gifts given out of 'gratitude' after the service is provided.
• The intervention appeared to work by raising awareness of the injunctive norm - that all forms of gift giving are considered corruption - and by highlighting the negative consequences. This contrasts with behavioural interventions that seek to change perceptions of the descriptive norm - that gift giving is a common practice at the hospital.

Why it matters

Our intervention shows that social norms and behaviour change approaches have real potential to tackle deeply ingrained patterns of corruption. It reveals important lessons for designing more effective interventions.

The next steps in taking these findings forward will be to: a) identify follow-up activities to lend sustainability to the intervention; b): test the scalability of the approach by applying it in other hospitals; and c) adapt the social norms and behaviour change learnings in order to address other corruption problems in different sectors.

Citizens shouldn't have to resort to corruption to access basic public services. Donors want their funded projects to achieve real positive impact on the ground. Social norms and behaviour change approaches can help.

Where to learn more

Lessons for practitioners - Working Paper

Developing anti-corruption interventions addressing social norms: Lessons from a field pilot in Tanzania

Claudia Baez Camargo

About the intervention - Technical Report

Using behavioural insights to reduce gift-giving in a Tanzanian public hospital: Findings from a mixedmethods evaluation

Claudia Baez Camargo, Violette Gadenne, Veronica Mkoji, Dilhan Perera, Ruth Persian, Richard Sambaiga,

Tobias H. Stark

Public governance research and assistance baselgovernance.org/publicgovernance

Keywords

behavioural anti-corruption interventions behavioural insights

healthcare social norms

social networks

About this Research Case Study

This publication is part of the Basel Institute on Governance Research Case Study series. It is licensed for sharing under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License (CC BY-NC-ND 4.0).

Suggested citation : Baez Camargo, C. 2023. 'Targeting corrupt behaviours in a Tanzanian hospital: A social norms approach.' Research Case Study 1, Basel Institute on Governance. Available at: baselgovernance.org/publications/research-case-1.

This research project was funded by the Global Integrity Anti-Corruption Evidence Programme (GI-ACE), funded with UK aid from the UK government. The project implementation was a collaboration between the Basel Institute on Governance, the UK Behavioural Insights Team, the University of Dar es Salam and the University of Utrecht. All results are freely shareable under a Creative Commons licence.