Many governments’ responses to the Covid-19 epidemic have been characterised by mistakes and missteps. It has become increasingly clear that most countries were not ready for this pandemic. This is despite repeated warnings from scientists and long-standing guidance from the World Health Organization (WHO) on pandemic preparedness. Meanwhile, the Global Health Security Index 2019 concluded, ominously, that ‘National health security is fundamentally weak around the world. No country is fully prepared for epidemics or pandemics, and every country has important gaps to address.’

Response plans fail to consider governance or corruption

An analysis by U4 of guiding documents and recommendations for making national pandemic response plans, prepared by the WHO and the EU, revealed that they give little attention to governance- and corruption-related matters. Some national pandemic response plans available on the web (USA, Jamaica, Italy) further illustrate the lack of consideration of governance and corruption challenges. For instance, suggestions for pandemic response national taskforces often do not propose the inclusion of integrity and anti-corruption or counter-fraud agencies. Nor do the plans emphasise the importance of transparency, accountability and participation in the preparation and implementation of the plan.

Of course, the medical and public health aspects of national pandemic response plans are paramount. However, as the current crisis has illustrated, the effectiveness of the response depends a great deal on the extent to which transparency, accountability, participation and integrity in governance are respected and upheld. Initial research on Covid-19 and corruption by U4 and others shows individuals and corporations – in collusion with public officials – disregarding procurement rules to profit from the crisis. Such abuses can mean that agencies waste scarce resources or procure insufficient or sub-standard drugs and equipment. This will make the response to the pandemic less effective.

Responses can be undermined by corruption

Corruption hampered the Ebola response. The Council of Europe Parliamentary Health Committee, in its resolution on how EU agencies and national governments responded to the H1 N1 2009 pandemic, noted several problems. These included:

• the wasting of large sums of public money;
• the lack of transparency of decision-making about the outbreak; and
• the suspicion of influence of the pharmaceutical industry on decisions taken during the pandemic response.

The Global Health Security Index 2019 report warns of the possible threat corruption poses to pandemic responses. It notes that more than half countries face major political and security risks that could undermine national capability to counter biological threats. Only 23% of countries score in the top tier for indicators related to their political system and government effectiveness.

Integrating anti-corruption into pandemic preparedness and response

The WHO Pandemic Influenza preparedness and response guidance document 2009 (updated 2014) emphasises the importance of ethical principles to assist policymakers in balancing a range of interests and protecting human rights. It notes that, ‘An influenza pandemic, like any urgent public health situation, calls for making certain decisions that will require balancing potentially conflicting individual interests with community interests.’ This should not only refer to issues of restricting freedom of movement and quarantine. Also crucial is the fact that government resources deployed for the pandemic response should be spent in the public interest and not for the (possibly) illicit enrichment of a few individuals or corporations.

The WHO guidance on ethical considerations in developing a public health response to pandemic influenza states that an ethical approach involves principles such as equity, utility/efficiency, liberty, reciprocity and solidarity. At the same time, the approach must consider local context and cultural values. These principles should be used as a framework to assess and balance different interests and overarching concerns, including human rights protection and the special needs of vulnerable and minority groups. The New Zealand Pandemic Plan is a good example of how these principles and values can be integrated into a plan. Preventing corruption and promoting integrity, transparency, accountability and participation should, similarly, be an cross-cutting concern in pandemic preparedness and response.

This crisis therefore provides an opportunity for all countries to strengthen anti-corruption and integrity as part of improving governance effectiveness – a crucial factor in pandemic preparedness. As countries now revisit their pandemic response plans and policies, it is vitally important that they integrate anti-corruption as an essential part of this. It must not be added simply as an ad hoc measure.

Measures to minimise corruption in a pandemic

The measures suggested below could contribute to minimising corruption in pandemic responses.

Include anti-corruption and counter-fraud agencies on the national committee or taskforce

Most guiding documents on preparing pandemic plans recommend the establishment of a multisectoral pandemic preparedness planning committee. They do not specify who should be on the committee as this should be decided on by each country. Including anti-corruption, ethics and integrity agency representatives on the national taskforce or planning committee is therefore an important first step to mainstreaming anti-corruption into the pandemic preparedness and response plan.

Identify and assess corruption risks as part of the situation analysis

The second step in mainstreaming anti-corruption is to thoroughly assess the governance and corruption-related risks that could derail the implementation of the pandemic response plan. This assessment must be part of the situation analysis that forms the foundation of the plan. The 2019 Global Health Security Index Report points to the importance of gaining a detailed understanding of the risk environment. Once the risks are well mapped, policymakers and practitioners can build mitigation measures that promote transparency, accountability and participation into the plan.

Specific actions to promote transparency, participation, accountability and integrity

Transparency

The 2007 WHO ethical considerations emphasise the importance of transparency, public engagement and social mobilisation. All aspects of planning should involve the public and relevant stakeholders. Authorities must share their policy decisions (and their reasoning) to enable public scrutiny, awareness and responses. In this way, the public can check that policies are reasonable, responsive, non-discriminatory, and in line with local circumstances and values. Public trust will follow as a result.

Transparency is also important to ensure that plans are legitimate and decision makers are accountable as they plan and implement the crisis response. The WHO guidelines do not specifically mention budget transparency; yet we can, and should, assume that this is envisaged as a necessary part of planning.

By comparison, the Global Health Security Index 2019 explicitly recommends that a specific, globally recognised entity tracks the finances for health security preparedness, and that it annually briefs the heads of state. It further recommends urgent increases in domestic financing for health security. Authorities must make this transparent and tie it to benchmarks within national action plans. The UN should track and publish outbreak-related costs and contributions.

In line with the above, donors, central and local government, NGOs and other stakeholders should always publish how much money they allocate to pandemic responses and for what use. In the current Covid-19 crisis, many developed countries have declared the enormous funding they are channelling into their domestic crisis response. The World Bank and UN have also published how much money they are providing – US$14 billion and US$2 billion respectively. A few countries have also released information on how much bilateral aid they give to crisis response in developing countries. However, much less is known about how much each country receives and for what purpose.

It is understandable that donor countries are overwhelmed with problems at home. However, disclosing how much they donate, and for what, is crucial to maintain transparency. Only in this way can the public monitor the efforts and hold authorities accountable.

Participation

The WHO Ethical Consideration Guidelines emphasise the importance of public participation. All aspects of planning should include public engagement and involve relevant stakeholders. For this to happen, the authorities must communicate effectively with the public and educate them about the issues.

Policymakers should establish a process for setting priorities and promoting equitable access that involves civil society and other major stakeholders in the decision-making. This will ensure that decisions about the criteria for allocating scarce resources are made in an open, transparent and inclusive manner. Promoting gender parity, diversity and inclusivity in pandemic response teams is a good idea, as this is known to have a positive effect on policy and organisational outcomes, including corruption control. It is important for policymakers to involve agencies responsible for women, persons with disabilities, ethnic minorities and other excluded groups on the national planning committee to ensure that the plan considers the views and concerns of these groups.

In a time of social distancing, it is hard for agencies to continue with the kind of meetings that usually gather actors for inclusive planning and budgeting. However, governments and others can use technology – where possible – and invite the public to participate by calling into radio and TV shows. Alternatively, civil society organisations can upload views and suggestions online to tailored platforms.

Such platforms can also be used for whistleblowing and budget monitoring for Covid-19 funds. A good example of such a platform is Kenya-based Ushahidi, which means ‘testimony’ in Swahili. It was originally developed to map reports of violence in Kenya after the post-election unrest in 2008. It has since gone on to implement various crowd-sourcing initiatives such as Making All Voices Count and the Resilience Network Initiative. In this Covid-19 Crisis, Ushahidi has launched a dedicated platform to crowd source information that can help governments and other stakeholders to achieve a more targeted and effective response to the crisis.

Accountability

The WHO guidelines on pandemic preparedness mention that decision makers’ accountability is crucial, both in the planning stage and during implementation. Although not specifically detailed in the guidelines, accountability in pandemic response and management should entail the following:

• Clarifying and publicising lines of responsibility for the planning, budgeting and implementation of the pandemic response plan. This must include provision for accounting and auditing, in liaison with the relevant agencies such as finance ministries and supreme audit institutions.
• Ensuring accountability in financial management and procurement through budget transparency and robust internal and external auditing.
• Integrating crisis-response fund auditing into the ongoing monitoring and evaluation of the activity plan. This will ensure that audits are not simply a matter of testing vouchers and receipts – which are easily forged in highly corrupt settings. Instead, it will be properly linked to outputs and outcomes. In line with this, the Global Health Security Index Report 2019 emphasises that domestic financing for health security should be tied to benchmarks within national action plans.
• Providing social-distancing appropriate whistleblowing and complaints mechanisms by expanding access to digital options, as explained above.
• Ensuring that national health sector regulatory mechanisms such as health professionals’ regulatory bodies, drug licensing bodies, etc. are adequately funded to do their jobs properly, even during times of crisis.
• Promoting merit-based recruitment, deployment and promotion of health workers and others with various responsibilities under the plan. It should also be ensured that they are adequately trained – not just on the technical aspects of the job, but also on the importance of upholding values, ethics and integrity.

Integrity

Re-emphasising integrity as part of pandemic preparedness is needed more than ever where resources are scare and health workers are under a lot of pressure. The Global Health Security Index emphasises the importance of a robust health workforce to an effective pandemic response. This strong workforce necessarily implies that health workers uphold integrity and avoid corruption. Capacity building for pandemic preparedness provides an opportunity to re-articulate professional ethics, including integrity and the importance of providing corruption-free services.

The World Medical Association International Code of Medical Ethics states a number of general principles that are relevant not just to discouraging corruption, but also to behaving with integrity. They provide, among others, that physicians shall:

• not allow their judgment to be influenced by personal profit or unfair discrimination;
• deal honestly with patients and colleagues;
• report to the appropriate authorities those physicians who practice unethically or incompetently, or who engage in fraud or deception;
• not receive any financial benefits or other incentives solely for referring patients or prescribing specific products; and
• strive to use health care resources in the best way to benefit patients and their community.

The International Council of Nurses has a similar code of ethics, one of whose provisions states that ‘The nurse demonstrates professional values such as respectfulness, responsiveness, compassion, trustworthiness and integrity.’

Monitoring and evaluation

In the aftermath of a pandemic, it is vital that the response is evaluated so that lessons can be learned for future pandemics. The evaluation should consider whether and how corruption hindered the pandemic response. It must also look at how transparency, accountability and participation were upheld or undermined. The evaluation should make recommendations for minimising corruption and upholding these principles in pandemic response implementation alongside public health-related ones.

Conclusion

Even though corruption has already marred many countries’ responses to the Covid-19 pandemic, development actors can ensure that we are better prepared to minimise corruption in future pandemics. They can do this through making mainstreaming anti-corruption a priority when countries revisit and revise their plans. The broad guidelines included here can provide a starting point and can be expanded upon and adapted to each country’s needs.

(U4 would like to know more about what countries are doing to strengthen anti-corruption measures in their pandemic preparedness plans and policies. Please email monica.kirya@cmi.no and share your country’s experience.)