Development efforts travel a complex terrain: where local needs and resources, political interests, power dynamics, and cultural history cross paths in exciting, but often confusing ways. Many vital services may fail to reach the people who need it the most due to a variety of factors in one or all of these areas. In Sub Saharan Africa, waste in supply chains is one common and known problem affecting the delivery of health services. In many countries, bribery in the healthcare sector costs a significant portion of government spending on health. Intentional absenteeism, slanted procurement practices, opaque institutional  associations, and a culture of impunity have created systemic dynamics and feedback loops that reinforce corrupt and wasteful practices at all levels of the public health sector. 

Even in the specific area of family planning where governments, with support from international donors, offer free family planning commodities to citizens, a combination of theft, bribery, and favoritism means that many women either pay for services that are ostensibly free or risk not receiving services at all. These outcomes have multiple causes, including disinterest and deprioritization of family planning within senior leadership, to a broad normalization of waste and the self-interested diversion of resources across citizen-government interactions. 

At the core of these causes, as with most of the development sector, are two inescapable factors: politics and behavior. Development funding and properties are political, and subject to the whims of the political climate. The success of this work, however, is determined by the behavior of a range of stakeholders, from practitioners themselves to government officials, the private hospital community, insurers, and the general populace. Palladium hired RTI, Busara and sistemaFutura, under the USAID-funded Propel Health project, to better understand the causes of this waste, and the opportunities for behavioral change in this messy, politicized environment.   

A complex approach for a complex problem

Given the multi-layered nature of the problem we began our approach by combining two two distinct traditions –  political economy analysis (PEA) and behavioral science (BeSci). PEA gave us the tools  to understand the power dynamics, incentives, and constraints within the political and economic environment. It also provided insight into how political and institutional structures shape decision-making, allowing us to identify entry points for change by mapping stakeholders and their relationships, and understanding how power and incentives affect development outcomes​. Behavioral science complemented this by focusing on the psychological and social factors that influence decision-making at the individual and group levels. This helped us better understand how individuals decide on, execute, and justify their actions, as well as identify opportunities for interventions. 

We brought the two together by weaving in tools from systems thinking: which helped  us analyze the interconnections of various factors and stakeholders in the development process. This encouraged a more holistic approach to problem-solving, where changes in one part of the system can have ripple effects across others. 

We worked in this way to develop a political economy analysis that is more deeply grounded in the specific contexts, decisions and actions of the participants. This, in turn, would facilitate the development of practical interventions that build on political economy analysis insights. Some of the tangible insights and artifacts this process provides include:

1. A traditional political economy analysis analysis of the stakeholders and their incentives, the insights that generates into the challenges at hand.
2. A causal system map showing the interplay between stakeholder roles and contexts, political and institutional constraints, and specific behaviors that drive negative outcomes. 
3. A set of interventions to improve the functioning of the system.

We started with the perspective that waste is a systemic challenge, which is expressed and experienced through the daily behaviors of individuals throughout the family planning supply chain. At a high level, the process was straightforward and built on our prior work in behavioral systems analysis: we identified key stakeholders from the sourcing, internal distribution, and public-facing delivery of family planning commodities in a country in Sub-Saharan Africa.  We consulted with them in a sensitive manner, to gain their understanding of the system, without direct confrontation about waste and the self-interested diversion of resources. We then synthesized the result into a set of practical recommendations for USAID and development partners.  

Dishonest environments breed dishonest people

A key lesson from research in behavioral science is that dishonest behavior, including the self-interested diversion of resources and waste, arises from two related but different sources: people intentionally being unethical, and people seeing themselves behaving morally in a bad environment. The drivers and dynamics of each behavior are significantly different.  For people intentionally being unethical, there is a trade off between the long-term desire to be ethical and the short-term desire to act in self-interest (Mead et al., 2009). Both situational and social forces explain this unethical behavior: especially perceived anonymity and a low perceived probability of being caught. 

However, a much larger group consists of people trying to behave morally but are influenced by their environment. These individuals self-justify unethical actions due to:

1. Ambiguity: The ability to rationalize behavior increases the likelihood to behave unethically. This is also referred to as elastic justification (Hsee, 2006)
2. In-group / out-group dynamics: Strong norms for unethical behavior within groups can lead to self-justification through group loyalty (Tajfel & Turner, 1986). 
3. Moral licensing: People are more likely to self-justify unethical behavior, especially in environments where others cheat or act corruptly (Gächter & Schulz, 2016).
4. Stressors: People are more likely to self-justify when the brain is tired, distracted, or otherwise stressed. Self-interest diversion of resources can be a non-deliberative in-the-moment response (System 1 thinking), and is more susceptible to loss framing (Kern & Chugh, 2009)– the sense that without the corrupt behavior, the person will lose something they feel they currently have.
5. Reciprocity: People are more likely to self-justify unethical behavior when influenced by both positive and negative reciprocity—especially in the form of gift-giving and favors, rather than outright cash or clear bribes; (Fehr & Gächter, 2000; Lambsdorff & Frank, 2011)
6. Objectivity Bias / Overconfidence bias: Failing to recognize one’s own susceptibility to conflicts (Bazerman & Tenbrunsel, 2011; Chugh et al., 2005). These biases help both moral individuals behave unethically and provide justification for those intentionally acting unethically. 

Using this understanding, and in talking with a diverse set of stakeholders, we identified four main areas in which waste (premeditated and semi-intentional) directly or indirectly affects the provision of free family planning supplies in the country. Each area is shaped by the broader context of the supply chain and the society in the region, and thus we have examined both the acts of waste themselves, and the broader system that enables and reinforces it.The four routes by which waste directly or indirectly affects the family planning supply chain are: Stock outs, as supplies are not available to patients; Negative patient experiences, as they are asked for bribes or fees for otherwise free products; Upstream obfuscation, which makes it difficult to identify large-scale waste; Downstream discouragement, which leads patients simply to give up, and stop seeking free family planning supplies or going without altogether. These are displayed in Figure 1 below.

Across each of the four effects of waste, we find common drivers: Kinship expectations that a person’s role in the supply chain should benefit others in their social or cultural group; a pervasiveness and normality of waste; a culture of denial and group protection; and a lack of information that makes it difficult to discern actual waste from structural problems with similar outcomes.

In each case, we identified specific, actionable opportunities for change: from addressing the health worker’s sense of being overwhelmed and thus justified in taking bribes to tackling the tribal and community-based incentive structures that leads to favoritism.  Key next steps include clearly communicating allocation guidelines and supply-chain processes to build transparency, establishing defined accountability protocols for delivery responsibilities, and promoting visible ethical leadership to foster integrity across organizational levels. These targeted interventions offer practical pathways to reshape behavioral norms, strengthen trust, and improve the overall effectiveness of the family planning commodity supply chain.

Waste in the supply chains of health systems is one of many challenges that the development sector addresses,  most of which also lie at the intersection of political economy and behavioral change. A behavioral systems thinking approach can help by providing ways for us to  understand institutional drivers as well as individual motivations and justifications. Recognizing these nuanced dynamics will increase intervention relevance, effectiveness, and sustainability – particularly in sensitive contexts where conventional analyses may overlook critical psychological and social influences.

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