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Identify the ‘red flags’: reducing fraud and corruption during Covid-19 (Part 1 of 3)

Covid-19 offers a valuable window into tackling many forms of fraud and corruption.
21 May 2023
Decorative collage
Throughout the pandemic, U4 conducted research and published several reports on fraud and corruption in the context of Covid-19. We used this evidence to identify ‘red flags’ for corruption risks affecting pandemic responses and provided advice for policymakers and practitioners to help them spot, mitigate, and reduce corruption risks during health emergencies. CC BY-NC-SA

Amid the pandemic U4, with the support of Norad, conducted media analysis and in-depth research on identifying corruption risks and real cases of Covid-19-related corruption worldwide. This work is part of a larger movement towards mainstreaming anti-corruption in the health sector, spearheaded by the Global Network on Anti-corruption, Transparency, and Accountability (GNACTA).

This blog is the first of a three-part series that identifies several corruption risks and their drivers at every level of a health emergency response. It also discusses how governments, businesses, health personnel, and citizens in general may be involved in the response. The series offers a practical guide to help those involved in implementing responses to better deal with the ongoing Covid situation, as well as future emergencies.

The series offers a practical guide to help those involved in implementing responses to better deal with the ongoing Covid situation, as well as future emergencies.

Corruption in health: a deadly business

To date, the WHO has issued four editions of its Covid-19 Strategic Preparedness and Response Plan (SPRP) – a package focused on 10 pillars to guide the coordinated action of health stakeholders at national, regional and global levels. Our research highlights how corrupt actors can co-opt each of these pillars, draining health budgets and reducing the effectiveness of health responses. We focus on the ‘red flags’ that can alert us to corruption risks; and how to mitigate them.

Table 1. The World Health Organization’s 10 emergency ‘response pillars’

Pillar number


Pillar 1

Coordination, planning, financing, and monitoring

Pillar 2

Risk communication, community engagement, and infodemic management

Pillar 3

Surveillance, epidemiological investigation, contact tracing, and adjustment of public health and social measures

Pillar 4

Points of entry, international travel and transport, and mass gatherings

Pillar 5

Laboratories and diagnostics

Pillar 6

Infection prevention and control, and protection of the health workforce

Pillar 7

Case management, clinical operations, and therapeutics

Pillar 8

Operational support, logistics and supply chains

Pillar 9

Maintaining essential health services

Pillar 10


In this blog series, we will take a deep dive into Pillar 1 (blog 2) and Pillar 8 (blog 3). These pillars are important because of their cross-cutting nature, which means they can have cascading effects. If we identify and address a corruption risk with a high likelihood of occurring in a specific pillar of the emergency response (eg, coordination), this will help us make progress on mitigating corruption risks in all the other pillars mentioned above.

‘Red flags’ for corruption risks

‘Red flags’ are warning signs that efforts within a pandemic response may be vulnerable to fraud or corruption. These flags could refer to problems with a policy, institution, system, process, person, decision, supplier, contract, or any element along the response chain. The research, as published in bi-monthly newsletters and a final Issue on the U4 website during 2021 and 2022, uses media examples to draw out several red flags within each pillar – over 100 in total.

These red flags are key reference points for planners, programme managers, the public, and those tasked with oversight and ensuring health outcomes. They can be used as a checklist to spot potential fraud or corruption risks, and design mitigation strategies accordingly.

Figure 1, below, shows the dynamic nature of corruption risks between the pillars.

Figure 1. Examples of how the activities of Pillar 1 could open the way for risks to emerge in other pillars

GIF of a circular diagram. The circle is divided into 10 segments. Each segment represents one pillar of the WHO emergency response. As the GIF progresses it reveals one possible way in which between Pillar 1 could influence other Pillars in turn.  Pillar 1 is "Coordination, planning,  financing, and monitoring", and underpins responses in all other pillars.  Pillar 2 is Risk communication,  community engagement, and  infodemic management. Pillar 1 connects to Pillar 2: Decision makers collude with  vendors to set up unnecessary  or inflated community  engagement plans. No work is delivered, but payments are pushed through anyway.  Pillar 3 is Surveillance, epidemiological investigation, contact  tracing, and adjustment  of public health and  social measures Pillar 1 connects to Pillar 3: Control over the publication  of key data is limited to specific agencies, such that information  is delayed or blocked, disrupting monitoring efforts by civil society and aid organisations.   Pillar 4  is Points of entry,  international travel  and transport, and  mass gatherings. Pillar 1 connects to Pillar 4: With more official barriers to travel, or requiring the issuance  of permits for movement, scope  is provided for monopolistic pricing and procedures open  to conflict of interest.  Pillar 5  is Laboratories  and diagnostics. Pillar 1 connects to Pillar 5: Substandard labs with political links are given preferential access to apply to give services for diagnostic work.   Pillar 6  is Infection prevention and control, and protection  of the health workforce. Pillar 1 connects to Pillar 6: Through a conflict of interest, selection criteria are established that will permit a monopoly  to be granted on a vital  (and lucrative) antibacterial product. Kickbacks are paid to those appointed to evaluate other importers or manufacturers.    Pillar 7  is Case management,  clinical operations, and therapeutics. Pillar 1 connects to Pillar 7: Where public health services are weak or overwhelmed,  and central regulation is lax, selection of additional services from private health providers can open opportunities  to charge exorbitant fees.  Pillar 8  is Operational support,  logistics and supply chains. Pillar 1 connects to Pillar 8: Normal procurement practices  are set aside, on grounds of urgency, with fast-track and single-source decisions promoted, in lieu of expert-led and independent selection and review of contract terms.  Pillar 9  is Maintaining essential  health services. Pillar 1 connects to Pillar 9: Hospitals receive emergency funds at the Ministry’s discretion. Favouritism and conflicts  of interest mean funds are not fairly distributed.  Pillar 10 is Vaccination. Pillar 1 connects to Pillar 10: ‘Cash-for-vaccination’ schemes are vulnerable to corruption, such as registering non-existent recipients.

The World Health Organization’s emergency response is managed through its Incident Management System (IMS). This standardized but flexible approach applies regardless of the underlying hazard, scale, or context of the emergency. To assist WHO and Member States to respond, response plans are developed, and for Covid-19 this was set out as ten ‘pillars’ to adapt as appropriate for each country while retaining a common structure.

These pillars interact and affect one another, but they all depend on Pillar 1 (Coordination, planning, financing, and monitoring). This is where managers of an emergency response set the scope and terms of an emergency response. Decisions made at this stage can open the way for fraud and corruption to appear in other pillars. Fraud and corruption damage health and care outcomes for everyone. They prevent authorities from reaching their public health goals, increase public distrust, and undermine vital health messaging.

The lessons from the research, as set out in this blog series, are not only applicable to Covid-19. We hope that the findings can also support those involved in the decision-making processes for responses to other health and humanitarian challenges, so they can identify and address red flags for corruption early on.

A window into Covid-19 corruption – and a toolkit for addressing it

The pillars allow leaders and practitioners to plan and implement every level and stage of a health emergency. The pillars are also a useful framework to identify and categorise different forms of corruption and fraud during health emergencies. They are a useful way to compartmentalise a pandemic response.

The pillars are a useful way to compartmentalise a pandemic response.

By looking at real-world examples of fraud and corruption, and considering the spaces in which these cases could occur, we can make more effective recommendations for finding and addressing them.

The research

Table 2. A checklist of anti-fraud and anti-corruption measures


Red flag

Is red flag present? Y/N

Recommendations, if red flag is present

Lack of transparency

Are response plans published and regularly updated?

Are statistics and government spending data gathered and published regularly?


  • These should all be made public, and open discussion encouraged.
  • Observe guidelines for disclosure of public officials’ private sector interests.
  • Civil society organisations should also be involved as expert advisers and independent overseers.

Concentration of power

Is a single individual or small group responsible for more than one decision-making body?


  • Decision-making authority should be spread across at least two separate power centres, with control mechanisms and declarations on possible conflicts of interest in place.

Conflicts of interest

Do implementation managers hold a beneficial interest in potential suppliers or contractors, either directly or via their family or associates?


  • Ensure that core control mechanisms, such as the segregation of duties, four-eye principle, and declarations on possible conflicts of interest, are implemented and operating effectively.

Physical discrepancies

Do products have poor-quality packaging, misspellings on labelling, or exaggerated claims of efficacy?

Are there discrepancies in size, weight, quality, colour or packaging between specifications and products actually received?


  • Implement uniform surveillance mechanisms for data collection.
  • Conduct quality assurance benchmarking and statistical monitoring of relevant data for comparison against other populations and the identification of anomalies for further analysis.

Procurement irregularities

Are simplified procedures used without adequate justification or for extended periods?


  • Conduct special audits of Covid-19 spending and publish these separately from other audits of government spending.

Data anomalies

Are there discrepancies in data collected on the same topic from different sources (eg, hospital admissions figures differ between local and central data)?


  • Conduct quality assurance benchmarking and statistical monitoring of relevant data for comparison against other populations and the identification of anomalies for further analysis.

Whistleblower and public complaints

Have individuals reported that they have been asked to pay unexpected fees, facilitation payments or bribes to obtain health services such as testing, treatment, or vaccination, or to bypass infection control measures such as testing or quarantine?

Have healthcare professionals reported that they have not received specific compensation or incentives allocated for pandemic-related work?


  • Introduce simple mechanisms for health professionals and members of the public to submit complaints about irregularities they encounter.
  • Implement a system to monitor and triage reports that are submitted for efficient escalation and resolution.

The other two blogs in this series give specific recommendations for pillars 1 and 8. You can also find more recommendations from the Covid-19 pandemic in this Issue paper, which summarises the trends, drivers and lessons learned for reducing corruption in health emergencies.

Don’t forget the politics!

It is also important to tailor the framework to any specific setting and context. While these pillar principles may be consistent across the world, in reality, any ‘corruption system’ depends on the power relations and the political economy in a specific country. It is important to not only consider the technical aspects of the pillars but also the underlying politics and complexity at play.

    About the authors

    Daniel Sejerøe Hausenkamph

    Daniel Sejerøe Hausenkamph is a U4 adviser and public health professional with an interest in anti-corruption, health systems, and digitalisation.

    Daniela Cepeda Cuadrado

    Daniela is a Senior Adviser at the U4 Anti-Corruption Resource Centre and a public policy professional with extensive experience in the areas of anti-corruption, health, and sustainable development. She coordinates U4's health theme – working with donor agencies and multilateral organisations to mainstream anti-corruption efforts in the health sector and its human rights theme – connecting the human rights and anti-corruption agendas.

    Monica Kirya

    Monica Kirya is Deputy Director at the U4 Anti-Corruption Resource Centre and a lawyer. Kirya coordinates the themes on mainstreaming anti-corruption in public service delivery and integrating gender in anti-corruption programming.


    All views in this text are the author(s)’, and may differ from the U4 partner agencies’ policies.

    This work is licenced under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International licence (CC BY-NC-ND 4.0)