Determinants of Unethical Behavior by Stakeholders in the Medical Insurance Industry in Zimbabwe : An African Humanism ( Hunhu / Ubuntu ) Approach

There is a continuous decline in the performance of medical insurance companies in Zimbabwe resulting in these companies failing to meet their obligations to stakeholders as seen by failure to pay wages, policy holders’ medical bills and dividends to shareholders. While research shows Hunhu/Ubuntu as a requirement for ethical practices that bring about good business and moral practices, it does not show how Hunhu/Ubuntu influences stakeholders, employee behaviour and organizational performance. Due to this glaring gap, the study was designed to investigate: the causes of unethical behaviour in the medical insurance industry, the attributes of African Humanism and how it influences people’s behaviour in medical insurance firms. A case study research design was used where both quantitative and qualitative methodologies were employed. Closed and open-ended questionnaires, semi-structured interviews and focus group discussions were conducted. Chi-square tests were used for data analysis. Findings of the study show that Hunhu/Ubuntu moulds good behaviour and is essential for avoiding risky behaviour which curtails organizational performance.


Introduction
The research sought to investigate the causes of Hunhu/Ubuntu (African Humanism) decay in the medical insurance industry.Humanism is associated with a variety of methods, beliefs and philosophies that place emphasis on what it means to be human.The words African humanism, Hunhu or Ubuntu mean the same thing and are used interchangeably in this article.To be human means personhood or sense of grace and honour within an individual human being.The concept of African Humanism (Ubuntu/Hunhu) is not new and it has no one meaning.It has been described over the years to mean humanity, humanness, goodness of nature, true humanity, generosity, human politeness kindness personality, a feeling of wellbeing, to mention but a few (Mbigi, 2004).Nussbaum (2003) defines Hunhu/Ubuntu as a social philosophy, a way of being, a code of ethics and behaviour deeply embedded in the African culture.There is not only a sense of belongingness in Ubuntu but also togetherness.
In Zimbabwe all medical aid companies are required to comply with the provisions of the Medical Services Act Chapter 15:13.A medical aid society can have its operating license revoked for failure to comply with this act and Statutory Instrument 330 of 2000.The Medical Services Act requires the claims ratio for a public medical aid company not to be more than 60% of its total contributions.Activities of medical aid institutions expose them to various risks emanating from both internal and external factors.Risks from internal factors include misappropriation of financial and non financial assets by employees, erosion of the skill base, investments risks, liquidity risks and inadequate internal controls.Risks from external factors include the frequency and severity of claims caused by fraudulent activities from both members who give their friends and relatives medical aid membership cards for them to access free medical services.Service Providers on the other hand connive with relatives and close friends to sign claim forms for services not rendered resulting in escalating operation costs.Other external factors include compliance with legal and regulatory framework of the Societies' business, competition, and loss of membership, reputational risks and credit risks.
The Herald Newspaper of February 8, 2014 reported that the top management at Premier Services Medical Aid Society (PSMAS) gobbled at least US$1 million in basic monthly salaries at a time when the State enterprise was reeling under a US$38 million debt.The CEO was reported to be earning gross monthly earnings of US$230,000 with the annual wage bill rising from US$15,547,171 in 2011to US$33,413,373 in 2012, almost half of which was paid to the top 14 managers.The Chairman of the PSMAS board was also linked with the same scandal and was fired from her position together with the CEO.As at December 31, 2014, the Herald Newspaper reports that PSMAS owed service providers US$38 million in unpaid bills for medical services rendered to its members.
Unethical behaviour in the medical insurance industry is linked to failure by stakeholders to uphold the Hunhu/Ubuntu.The research sought to investigate the determinants of unethical behaviour and to formulate strategies to enhance the risk management process stemming from this unethical conduct.The hypothesis is that Hunhu/Ubuntu is significantly associated with people's behaviour and therefore significantly affects the risk management effort.Nussbaum (2003) defines Ubuntu as a social philosophy, a way of being, a code of ethics and behaviour deeply embedded in the African culture.There is not only a sense of belonging in Ubuntu but also togetherness.In the Nguni language cluster of Southern Africa, they say "Umuntu ngumuntu ngabantu" which means that a person is a person because of others (Gade, 2011;Mabovula, 2011).African culture teaches people to sympathize with one another and to empathize or feel for each other in times of sorrow or happiness (Gade, 2011).Thus, from an African's point of view, your pain is my pain, my wealth is your wealth, and your salvation is my salvation.This would be translated to mean that the little that we have we will share and can survive (Nussbaum, 2003).Drawing from the above definitions, what Hunhu/Ubuntu philosophy tries to teach us is that no one can be self-sufficient, and as a result, interdependence is a reality for all.It is noteworthy that Hunhu/Ubuntu is the pillar of human behaviour (Nussbaum, 2003;Mazrui, 2001).It is about ethics and society building.The exhibition of unethical conduct by stakeholders in the medical insurance industry is unAfrican; it is a manifestation of Hunhu/Ubuntu decay.

Conceptualizing of Ubuntu/Hunhu
According to Murithi (2007), some of the core values of Hunhu/Ubuntu are communalism, interdependence, compassion, empathy, respect and dignity.Mbigi (2004) further explained that one becomes what he or she is because of copying the good behaviour displayed by other people.Dziro and Rufurwokuda (2013) note that the package children should have includes training them in the African philosophy of Hunhu/Ubuntu.It can be argued that the community is like a spring board or foundation that gives the individual person an opportunity to express their personality.His means that one can live in a community where good things are done but still fail to uphold the Ubuntu culture, so it is up to the individual to accept or reject the good behaviour (Mbigi, 2004;Gyekye, 2002).Kempker (2009) talks of personal leadership as a position that one holds and it is about how you choose to act.So, this again can change how people behave because it is touching on personal.Mastrangelo et al. (2004) and Verrier and Smith (2005) concur that people have to uphold the principles of Ubuntu in order to remain honest, fair, dignified and excellent which helps leaders in performing their responsibilities professionally.Ncube (2010) asserts that a few African leaders have exercised Ubuntu as a doctrine of leadership and that is why there is corruption across the length and breadth of the continent.
Human factor decay is the absence of Hunhu/Ubuntu in people due to lack of mental, emotional, moral and spiritual connections to their respective countries and communities (Adu-Fabiri, 2013).According to Adjibolosoo (1995), human factor (Hunhu/Ubuntu) decay is caused by both external and internal factors.Human factor decay emanates from colonialism, which education system prepared Africans to serve as clerks, artisans and agricultural technicians instead of preparing them for high-level skilled manpower, while internal factors are caused by over-emphasis on personal wealth and excessive abuse existing welfare systems.
In his research on the human factor implications on the revival of indigenous food security at village level, Mararike (2001) points out that no organization or human activity can sustain itself without people who are reliable, committed, disciplined and have appropriate skills and qualifications.Researchers have come up with various reasons on the causes of corruption.As pointed out by Dong and Torgler (2010), corruption is caused by harsh economic conditions within a country.According to ISACA (2014), desperate times lead to desperate acts, which sometimes lead to unethical behaviour.If the punishment is severe, culprits would not engage themselves in corrupt activities.Committing of fraud by medical insurance policy holders, business partners and employees is another symptom of human factor (Ubuntu/Hunhu) decay.According to the Federal Bureau of Investigation ( 2009), healthcare fraud is a form of white collar crime that may be committed by employees, healthcare providers and suppliers of medical equipment, drugs and services.Duckert (2011) notes that an effective risk management is the one that builds up corporate culture which enables all personnel within the organization to realize that risk management is a mutual responsibility of all executives and employees at all levels.Culture in an organization clarifies the difference between what behaviour is acceptable and what is not.Some of the most spectacular corporate collapses of modern times-Worldcom, One.tel and HIH, for instance, have single-handedly elevated corporate governance and risk management to the top of the boards' agenda (www.riskmagazine.com).These collapses occurred when boards were responsible for significant lapses of corporate governance that led, ultimately, to the demise of their companies.The tone or culture these boards set for their companies was either flawed or, more likely, ignored by their management and staff.

Methodology
The case study methodology was utilized.A questionnaire, interview guide, focus discussion group and document analysis were used to gather data for the study.The population of interest in this research is all stakeholders in the medical insurance business that includes: policy holders, employees, management and medical practitioners.For questionnaires, a random sample of 164 respondents was chosen from a population of 2410 using a sample calculator.For interviews, 10 interviews were held with doctors, pharmacists and medical aid beneficiaries.
With the help of three assistants, questionnaires were distributed to three clinics and a laboratory in Harare.A total of 75 questionnaires were distributed to patients, targeting the planned sample estimate of 45 as discussed in the previous section.In addition, two focus groups comprising of seventeen and fourteen employees, three senior managers and six medical practitioners were also interviewed using a semi-structured interview guide in order to get a better insight on the views of some key stakeholders in the medical industry.Other important stakeholders such as Pharmaceutical companies, medical equipment suppliers and the Ministry of Health and Child Care officials could not be interviewed due to time constraints.The table below shows respondents of questionnaires.Table 1 illustrates that 75% of targeted patients, 75% of targeted senior managers, 52% of targeted ordinary employees and 30% of targeted service providers participated in the study giving an overall response rate of 61%.

Determinants of Unethical Behaviour by Service Providers; Summary of Interviewee Information
Managers interviewed were of the opinion that unethical behaviour by employees, medical insurance policy holders and medical and service providers is caused by economic hardships, unemployment, greediness and failure to uphold Hunhu/Ubuntu (African Humanism).The results are echoed by Dong and Torgler (2010) and Rock (2009) who concur that corruption is caused by economic hardships; however they do not mention Hunhu/Ubuntu decay of moral values and greed which are surfacing in this study as causes of unethical behaviour by stakeholders in the medical insurance industry.This revelation shows that lack of or decay of Hunhu/Ubuntu can cause declining performance in organizations through pilferage, a major problem in the medical insurance industry in Zimbabwe.
Interviewee A, just like interviewees B and C cited togetherness and good behaviour as the main attributes of Hunhu.This view is in agreement with what is in the literature (see Elogo, 2014;Gade, 2011;Nussbaum, 2003).Individuals with strong Hunhu attributes relate well with their colleagues in work places and are of good and positive behaviour which improves work performance.
On being asked how Hunhu/Ubuntu affects behaviour the respondents said Hunhu/Ubuntu moulds good behaviour and promotes a culture of hard work.According to Murithi (2007), some of the core values of Hunhu/Ubuntu are communalism, interdependence, compassion, empathy, respect and dignity.This means that the respondents are in agreement with the author that Hunhu/Ubuntu encourages team work and good behaviour.
Reflecting on our problem, unethical behaviour by stakeholders in the medical insurance industry shows lack of Hunhu/Ubuntu culture.
The respondents are also of the opinion that Hunhu/Ubuntu promotes law and order enhancing the risk management process.However, the Hunhu/Ubuntu philosophy embedded in African culture encourages respect for elder people regardless of their actions.In Shona Language we say "Mukuru mukuru hanga haigare pfunde".This means that bad decisions and activities by elders cannot be challenged.An example is the scandal at PSMAS where senior management salaries were gobbling millions of dollars per month.Whilst most of the attributes of Hunhu/Ubuntu are generally good, the idea that elders cannot be challenged is not in sync with modern society.To enhance the risk management process employees and other stakeholders must be educated and cultured on the positive attributes of Hunhu/Ubuntu.

Strategies to Reduce Unethical Behaviour
The respondents suggested the following strategies to curb unethical behaviour in the medical insurance industry: training of stakeholders to behave ethically, choosing board members on merit, adequate internal controls and economic growth in the economy.Mcclelland (2002) says training changes people's behaviour and Ahammad (2013) emphasized that for the companies to survive they need to train their employees and give them the appropriate knowledge and skills.Behavioural training and education moulds the required behaviour in individuals.Employees need to be trained to strengthen the attributes of Hunhu/Ubuntu in them.The interviewees also said growing the economy would lessen the hardships on the populace at the same time reducing acts of dishonesty and poor corporate governance.
Respondents were of the opinion that determinants of unethical behaviour by employees, service providers, management and customers in medical aid societies in the form of fraudulent claims, theft and corruption were due to economic hardship, family problems such as sick relatives who are not on medical aid, greediness, lack of strong Hunhu/Ubuntu or moral decay in individuals.It was also observed that people would have seen an opportunity of doing so undetected.Adjibolosoo (1995) echoed that human factor decay is caused by both external and internal factors.He further stressed that human factor decay emanates from the inherited colonial education system which prepared Africans to serve as junior officials such as clerks, artisans and agricultural technicians instead of preparing them for high-level skilled manpower, while internal factors are caused by over-emphasis on personal wealth and excessive abuse of existing welfare systems.Mararike (2001) believes that the failure of the Zunde raMambo Project is due to human factor decay just as in organizations.Dong and Torgler (2010) posit that corruption or human factor decay is also caused by harsh economic conditions.
The respondents cited the following as attributes of Hunhu/Ubuntu: respect for other people's property, togetherness and communalism in African society, a code of ethics with a base in African culture, a way of being of African societies and respect of humanity and freedom.These same attributes of Hunhu/Ubuntu were echoed by Gade (2011) andElogo (2014).Those who behave unethically are being unAfrican and therefore lack Hunhu/Ubuntu in them.
The majority of the interviewees are of the opinion that the influence of Hunhu/Ubuntu on people's behaviour is that it moulds good behaviour in individuals, encourages respect for elders and people in positions of authority irrespective of their actions.Dziro and Rufurwokuda (2013), Mbigi (2004) and Murithi (2007) asserts that one becomes what he/she is because of copying the good behaviour displayed by other people and that one becomes an individual by proper incorporation into the community they live.However, failure to challenge elders or people in positions of authority is like giving them the green light to do whatever they feel like doing, including doing corrupt activities or fraudulent transactions.
The interviewees feel that the effect of Hunhu/Ubuntu on risk management effort is that it promotes maintenance of law and order and discourages corruption, and that it moulds positive behaviour necessary for organizational success.Chivaura (1998) noted that no organization, society or country can sustain its development activities if its people are not patriotic, reliable, committed and disciplined.He further asserts that individuals are developed on how to have an appropriate human factor to run business institutions efficiently and effectively and this reduces risks that may affect business operations.Gyekye (2002) argues that one can live in a community where good things are done but still fails to uphold the Hunhu/Ubuntu culture, so it is up to the individual to accept the good behaviour or not to.Bad behaviour breeds corruption which is believed to have a detrimental effect on economic development and social welfare and may expose the organization to more risks if no mitigatory measures are taken to curb it.Therefore people should learn to uphold Hunhu/Ubuntu at all times.
Strategies suggested by the respondents are that stakeholders should be given behaviour modification training through the electronic and print media and in public gatherings, Integrate modified Hunhu/Ubuntu in education or school curricular, scenario planning, advocate for stiffer punitive laws on offenders.In addition, all stakeholders should be educated about the consequences of using their membership cards to get treatment for sick relatives, while practitioners should not be spared either.Another point that was raised is that medical aid firms should remove shortfalls on all medical bills and that older people who are above sixty years should be allowed to access the health insurance which they are currently failing to do.The medical practitioners further pointed out that this was the major cause of Hunhu/Ubuntu decay because people cannot leave their loved ones to die when they have the opportunity to talk to doctors and get their relatives treated.Ahammad (2013) asserts that training equips employees with the skills and knowledge required operating within the systems and standards set by management.Kalisa (2002) identified some management techniques which include shaping the behaviour of individual's as they grow through behavioural training.
Employees were interviewed in 2 groups of 9 and 8 respectively.Their views on the determinants of unethical behaviour in the medical insurance industry, the role of Hunhu/Ubuntu in influencing people's behaviour and its effects on the risk management process are summarized below.Strategies on how to curb unethical behaviour were also established.The main view was that Hunhu/Ubuntu moulds good behaviour and encourages team work in the process improving organizational performance.Besides advocating for deterrent penalties, Hunhu/Ubuntu should be integrated in the curricula of education, training and development.
The respondents in both focus groups were of the opinion that the role of Hunhu/Ubuntu in influencing people's behaviour are molding good behaviour and encouraging respect for elders and people in positions of authority.However, they were against the idea that Hunhu/Ubuntu inclines people to behave unethically, has no effect on people's behaviour and that it promotes a culture of laziness.

Effects of Hunhu/Ubuntu on Risk Management Efforts
This section focused on effects of Hunhu/Ubuntu on risk management and the group was of the opinion that the effects of Hunhu/Ubuntu on risk management on a positive note are: African code of ethics in promoting maintenance of law and order, moulds good behaviour necessary for organizational success.Adversely, Hunhu/Ubuntu as suggested by the group, is known to be encouraging dependency syndrome and corruption since individuals who are failing to take care of their health are waiting for relatives or the State through the Social Services Department to pay for their medical bills.That is a sign of human factor decay as echoed by Mararike and Chivaura (1998).
Drawing from the above results, the respondents were of the view that Hunhu/Ubuntu decay was caused by economic hardships and this was echoed by Dong (2011) and Rock (2009).Greediness was also cited as one of the causes of unethical behaviour in individuals.Other causes of unethical behaviour cited by the respondents were family problems such as sick relatives, inadequate measures to stem fraud, lack of stiffer penalties on all culprits and lack of strong Hunhu/Ubuntu in individuals.Hypothesis: Hunhu/Ubuntu is significantly associated with people's behaviour.
To test this hypothesis a chi-square test of association was carried out between the perceived attributes of Hunhu/Ubuntu and the perceived effects of Hunhu/Ubuntu on behaviour.The results are shown in Table 3 below.Table 3 shows that Hunhu/Ubuntu moulds good behaviour in individuals as the following attributes: African civilization, African code of ethics, togetherness and communalism and respect for humanity and freedom are significantly associated with behaviour since the P-values are less than 0.05.Hunhu/Ubuntu in general does not incline people to behave unethically but some attributes like togetherness and communalism may force people to shield friends and family in times of distress.It has been shown above that medical insurance policy holders sometimes use their cards to fraudulently assist sick relatives and friends, which is unethical in as far as business law is concerned but at the same time it is culturally a sign of love.From the society's point of view, saving life is a sign of togetherness and communalism and respect for humanity, whilst from the insurance's point of view the behaviour is fraudulent.According to Mbiti (1969), Nussbaum (2003), Gade (2011) and Mabovula (2011), Hunhu/Ubuntu represent togetherness and communalism which is respect for life.The question is, "Is it unethical to break the law and save a life"?This is an area that needs further research.
The respondents all believe that Hunhu/Ubuntu affects people's behaviour.Most attributes of Hunhu/Ubuntu, for example, togetherness and communalism, respect for humanity and freedom, African code of ethics and African civilization are associated with development of empathy in individuals.
The Chi-square test also shows that some attributes of Hunhu/Ubuntu are significantly associated with respect for authority.This becomes a major problem in that juniors cannot challenge superiors irrespective of type of actions."Mukuru mukuru hanga haigare pfunde".When superiors behave unethically, for example, if they breach corporate governance practices as in the case of PSMAS, their actions go unchallenged to the detriment of the organization.Whilst it is a good thing to respect authority, the aspect of not challenging bad behaviour is detrimental to organizational performance.Hence, there is need for cultural evolution to encourage positive criticism.Togetherness and communalism and strong family ties sometimes promote a culture of laziness.Extended families, in most cases depend on one family person to do the work for them.All in all, Hunhu/Ubuntu is significantly associated with people's behaviour.

Effects of Hunhu/Ubuntu on Risk Management Efforts
Effects of Hunhu/Ubuntu are: promotes law and order, moulds good behaviour, discourages individual thinking, deters challenging people in positions of authority and encourages corruption.The Table 4 shows responses on how Hunhu/Ubuntu affects the risk management efforts.The Chi-square test was then used to test the hypothesis that Hunhu/Ubuntu is significantly associated with risk management efforts (see Table 4 below).
Hypothesis: Hunhu/Ubuntu is significantly associated with risk management.
The chi-square test was used to test for association between the perceived attributes of Hunhu/Ubuntu and the perceived effects of Hunhu/Ubuntu on the risk management efforts.The results are shown in the table below: Table 4 shows that Hunhu/Ubuntu is significantly associated with risk management efforts.P-values less than 0.05 show strong association between perceived attributes of Hunhu/Ubuntu and perceived effects of Hunhu/Ubuntu on the risk management process.It is evident that Hunhu/Ubuntu promotes law and order and moulds positive behaviour.

Strategies to Reduce Unethical Behaviour in the Medical Insurance Industry in Zimbabwe
From the information gathered, it is the respondents' opinion that strategies that can reduce unethical behaviour in the medical insurance industry in Zimbabwe are: cultural evolution to encourage thought and invention, behaviour modification training on all stakeholders, integrate modified Hunhu/Ubuntu culture in education, scenario planning and advocate for stiffer punitive laws on offenders.
This section was a presentation, analysis and interpretation of data on the determinants of unethical behaviour in the medical insurance industry in Zimbabwe, how Hunhu/Ubuntu influences people's behaviour, how Hunhu/Ubuntu affects the risk management efforts and strategies that can be adopted to reduce unethical behaviour.The research findings were that Hunhu/Ubuntu influence people's behaviour and affect the risk management effort.One of the major causes of unethical behaviour is Hunhu/Ubuntu decay.Integrating Hunhu/Ubuntu in all facets of life would reduce unethical behaviour.

Conclusions and Recommendations
From this study, it can be concluded that interventions to reduce unethical behaviour in the Medical Insurance Industry are urgent.These could be in the form of behaviour modification training on all stakeholders and serious advocacy for stiffer punitive laws on offenders.
Government, medical aid societies and associations need to come up with a policy that encourages the integration of Hunhu/Ubuntu in all facets of education and training in Zimbabwe.Education and training curricula should have an element of Hunhu/Ubuntu embedded in it.The future focus of research should be to look at the influence of gender on Hunhu/Ubuntu and the relationship between age and Hunhu/Ubuntu.

Table 1 .
Response rate

Table 2 .
Chi-square test of association between Determinants of unethical behaviour and its rate of incidence

Table 3 .
Tests of association between attributes of Hunhu/Ubuntu and behaviour