A Systems Approach to Ethical Public Procurement in the Medical Sector

Abstract

Modern slavery is present in the supply chains of public health systems, including those of England's National Health Service (NHS), which sources medical goods from over 80,000 suppliers globally. Public medical procurers face the competing demands of cost reduction, clinical requirements, resource constraints, and increasingly stringent legislative obligations, which hinder effective action to address modern slavery in their supply chains, one element of ethical public procurement. This thesis asks: what prevents public health systems from procuring ethically, and how can a systems approach reveal and address those constraints? An interdisciplinary, exploratory, problem-oriented research programme is developed at the intersection of supply chain research, modern slavery research, Health Policy and Systems Research, and systems thinking. The DSRP (Distinctions, Systems, Relationships, Perspectives) Theory for systems thinking, alongside the Agent Based Approach (ABA) provide the analytical systems thinking framework and structure the inquiry. Data was generated through semi-structured expert interviews with 26 procurement and ethical buying professionals across six European countries, and a focus group with systems thinking researchers. Three original research contributions are presented. First, complexity, power, and responsibility are identified as being interrelated emergent properties of complex adaptive public procurement systems, which present the largest barriers to the implementation of ethical procurement. Second, the current NHS health system is under stress, and addressing modern slavery is hindered by the emergent properties of complexity, power, and responsibility as well as culture, information, resource, and capacity constraints. Third, ABA is applied to produce recommendations for improving NHS procurement to address modern slavery, and a preliminary methodological evaluation of ABA's strengths and limitations is offered. The overarching finding is that the NHS, as a health system of systems under stress with low procurement maturity, currently lacks the culture, capacity, and resources to address modern slavery in its supply chains. The thesis hypothesises that procurement maturity is the lynchpin for implementing mechanisms to address modern slavery in public sector supply chains: without sufficient maturity, the additional processes required for Human Rights Due Diligence (HRDD) cannot be conducted by NHS procurement teams. Implications for practice and directions for further research are identified, including the need for work assessing the tension between health systems ethical procurement responsibilities and the practicality of implementing HRDD in a resource-constrained sector, quantitative modern slavery footprinting, and participatory systems research to co-produce solutions with NHS stakeholders.