Investigation of supply chain transparency practices of healthcare firms from modern slavery reporting Open Access

Modern slavery, broadly defined as exploitation that a person cannot escape because of threats, coercion, deception and abuse of power, continues to permeate global supply chains (ILO, 2025). Approximately 50 million individuals remain trapped in forced labour, child labour, debt bondage and other slavery conditions (ILO, 2025; Gold et al., 2015). Globally, 50% of sustainable procurement leaders consider their modern slavery management capabilities as immature (Gartner Research, 2023); in Australia, over 60% of companies fail to report forced labour as a form of modern slavery within their supply chains (Sinclair and Dinshaw, 2022). These governance failures have fuelled recurring scandals, from fatal gold mine accidents in Peru (Schleper et al., 2022) to the exposure of forced labour at Malaysian personal protective equipment (PPE) factories (Sinclair and Dinshaw, 2022).

Transparency has become foundational for exposing hidden modern slavery practices (Pinnington and Meehan, 2023; Bateman and Bonanni, 2019). Supply chain transparency (SCT) and modern slavery risk management are affected by supply chain complexity with interconnected activities spanning sourcing to consumption across multiple tiers of globally dispersed members (Pinnington and Meehan, 2023). Such complexity often undermines trust among supply chain stakeholders (Morgan et al., 2023). The growing reliance on outsourcing has resulted in supply chain fragmentation, further hindering organisations' ability to assess and report modern slavery risks (Pinnington et al., 2023). Consequently, the breadth, diversity and interrelationships of supply chain stakeholders affect the quality of the modern slavery reporting (McLaren et al., 2024).

To remediate modern slavery and strengthen SCT, organisations have introduced appropriate codes of conduct, whistleblowing mechanisms and dedicated governing committees (Han et al., 2024). Incorporating human rights requirements into an organisation's procurement practice helps in selecting suppliers with robust ethical practices (Wilhelm et al., 2025). However, unless procurement practices also include training and capacity development, suppliers may engage in mock compliance (Yagci Sokat and Altay, 2023). Such mock compliance may be reinforced by auditors and managers whose incentives prioritise reporting conformity over remedial action. Consequently, scholars urge closer collaborations and partnerships with multiple stakeholders to achieve more credible modern slavery remediation (McLaren et al., 2024).

Against this background, modern slavery in supply chains has been recognised as a multi-stakeholder governance challenge, prompting the proliferation of legislative frameworks globally (Pinnington et al., 2023). These include the United Kingdom Modern Slavery Act 2015 (UKMSA) and the Australian Modern Slavery Act 2018 (AMSA), which mandate companies to report slavery risks across their supply chains, aiming to enhance transparency (Strand et al., 2024). In parallel, disclosure-based studies have examined how firms communicate modern slavery risks. Stevenson and Cole (2018) analysed the modern slavery practices of United Kingdom fashion firms; Christ and Burritt (2023) investigated Australian organisations' reporting practices across commercial, public sector and not-for-profit entities; and Richards (2022) examined modern slavery practices in the Australian fashion industry. Although these studies have advanced understanding of corporate responses, they predominantly examine highly scrutinised, consumer-facing sectors with strong reputational pressures, leaving other critical industries underexplored.

The healthcare sector remains comparatively overlooked despite its global economic footprint, social importance and exposure to labour-intensive manufacturing risks. Australia's healthcare system, comprising both public and private hospitals, relies heavily on imported medical goods and services. Healthcare procurement is among the nation's three largest government spending categories, accounting for over 10% of gross domestic product with an annual procurement volume of $3.8 billion (Department of Health, 2024). The vulnerabilities of these supply chains became starkly evident during the COVID-19 pandemic, when hospitals struggled to secure PPE from regions known for high forced labour risks (Hughes et al., 2023; Trautrims et al., 2020). Utilising the modern slavery reports of both public and private healthcare organisations that are typically prepared at the organisational level and often involve input from legal, procurement and communication teams, this study aims to address the following research questions:

This study investigates how healthcare organisations ensure SCT and mitigate modern slavery risks, extending stakeholder theory through the lens of power dynamics and competing priorities. The research contributes to the literature on SCT and modern slavery by developing a transparency-driven modern slavery reporting (TDMSR) framework for the healthcare sector, which: (1) advances understanding of barriers in monitoring SCT within complex and disrupted supply chains, (2) reconceptualises the paradox of monitoring and reporting modern slavery risks, and (3) frames continuous SCT improvement as an evolving organisational capability.

The remainder of the paper is structured as follows: Section 2 reviews modern slavery disclosures and SCT literature and develops the conceptual framework for analysing disclosure. Section 3 outlines the study's research methodology, focusing on content analysis; Section 4 presents the empirical findings; and Section 5 discusses the key results. Section 6 concludes with the study's implications and provides directions for future research.

Modern slavery is an umbrella term encompassing coercive practices—including threats, deception and restrictions on freedom—that manifest in forced labour, debt bondage, child labour, domestic servitude and human trafficking (ILO, 2025). In supply chains, it can be understood as “the exploitation of a person who is deprived of individual liberty anywhere along the supply chain, from raw material extraction to the final customer” (Gold et al., 2015, p. 487). It is concentrated in export-oriented, labour-intensive and raw material sectors such as fishing, mining, electronics, garment, cotton and gloves manufacturing (Crane et al., 2019; Richards, 2022; Schleper et al., 2022; Sinclair and Dinshaw, 2022), where weak governance, corruption and cultural tolerance of inequality perpetuate these conditions (Crane, 2013). Migrants and ethnic minorities are particularly exposed because of limited education, language barriers and legal precarity (Hughes et al., 2023; Washburn et al., 2022). Meanwhile, downstream organisations in jurisdictions with strong labour enforcement mechanisms pose strict cost, delivery and compliance demands on upstream suppliers (Lotfi and Walker, 2024). For upstream suppliers already operating in resource-constrained regions with systemic governance failures, these pressures incentivise the concealment of abuses and the falsification of compliance data, exacerbating information asymmetries (Morgan et al., 2023) and creating opaque spaces in which modern slavery practices persist (Gold et al., 2015).

SCT refers to communicating and reporting to stakeholders to provide product traceability and visibility into supply chain flows, and to incorporate stakeholder feedback for improvement; it is increasingly recognised for addressing modern slavery risks (Marques et al., 2025; Morgan et al., 2018). At its core, SCT comprises visibility—the disclosure of salient information to stakeholders—and traceability—the ability to follow products and flows through verifiable data and enabling technologies (Sodhi and Tang, 2019). Some scholars portray SCT as tracing suppliers by disclosing identities, factory locations and working conditions (Egels-Zandén et al., 2015); however, as organisations face mounting pressure from external stakeholders such as governments, consumers and NGOs to report on modern slavery, SCT is increasingly framed as a broader set of governance mechanisms that extends beyond simple supplier identification. Moreover, SCT alone is not sufficient as a governance mechanism; it must be coupled with other tangible and intangible mechanisms.

Rather than a purely information-governance mechanism, SCT is an enabling governance mechanism that allows organisations to foresee, trace and render visible conditions in otherwise opaque supply chains (Montecchi et al., 2021; Morgan et al., 2023). Monitoring modern slavery typically includes tangible governance such as supplier codes of conduct, contractual clauses, third-party audits and certifications; and intangible governance such as supplier development, joint training and supplier integration, which foster trust, information-sharing and shared responsibility for monitoring risks (Montecchi et al., 2021; Morgan et al., 2023; Benstead et al., 2021; Cole and Shirgholami, 2022). Often underpinned by digital traceability tools, risk-based supplier screening, geographic heat-mapping and worker-voice technologies, these governance mechanisms strengthen supplier capabilities and enable continuous improvement (Strand et al., 2024; Christ and Burritt, 2018). Together, these governance mechanisms operationalise SCT by making product and information flows visible and traceable, enabling stakeholders to monitor and remediate modern slavery risks.

Over the past decade, multiple jurisdictions have introduced modern slavery acts, including the California Transparency in Supply Chains Act 2010, UKMSA, French Duty of Vigilance Law 2017, AMSA, German Act on Corporate Due Diligence in Supply Chains 2021 and Norwegian Transparency Act 2021. These acts share the objective of enhancing SCT and accountability, although they vary in design and scope. The UKMSA is widely viewed as a precursor to the AMSA, yet their institutional design diverges.

The earlier introduction of the UKMSA prompted empirical investigations into disclosure practices among government suppliers, FTSE 100 firms and sectors such as textile and mining. However, lessons from the United Kingdom may not be directly transferable to other jurisdictions because each country differs in political frameworks, cultural norms and import dependency, which shape organisations' approach to slavery risk management and reporting behaviours (McGaughey et al., 2022). The later enactment of the AMSA has led to underdeveloped research in Australia that focuses on investigating the construction (Liu et al., 2023) and fashion sectors (Richards, 2022). This gap constrains understanding of how Australian organisations respond to the AMSA, particularly in healthcare. Despite Australia's fundamental commitment to protecting public health, this area remains underexamined and scrutinised compared with the mining and textiles sectors (Han et al., 2024).

Existing research has exhibited shortcomings in modern slavery disclosures (Montecchi et al., 2021; Morgan et al., 2023; Pinnington and Meehan, 2023; Sodhi and Tang, 2019; Mai et al., 2023). Many statements remain symbolic, serving to protect organisational legitimacy rather than address systemic slavery issues (Pollach and Schaper, 2023; Meehan and Pinnington, 2021). Strategic ambiguity and limited upstream visibility remain recurring issues, and risk remediation has received limited attention (Stevenson, 2022; Flynn and Walker, 2021). Similarly, McGaughey et al. (2022) compare reporting frameworks across jurisdictions but remain oriented towards compliance rather than risk mitigation. Collectively, these findings expose a gap between disclosure and meaningful transparency, highlighting the need to interrogate how organisations operationalise governance to generate meaningful SCT and modern slavery risk mitigation.

The Australian healthcare sector's procurement diversity, intermediary reliance and import dependence position it as highly vulnerable to modern slavery (Sinclair and Dinshaw, 2022). Its procurement spans a wide array of products, including PPE, surgical instruments, medical electronics and textiles, each associated with unique supplier vulnerabilities (Sinclair and Dinshaw, 2022). Australia's island geography and import dependence further restrict sourcing flexibility and deepen reliance on geographically dispersed suppliers, third-party intermediaries, contract manufacturers and labour recruitment agencies, thereby weakening visibility into upstream labour conditions (Hughes et al., 2023; Washburn et al., 2022). These SCT challenges are evidenced by more than half of Australian healthcare organisations underperforming on modern slavery monitoring. For example, 52% of Australian healthcare firms that source PPE gloves from Malaysia failed to identify Malaysia as a high-risk region, despite extensive evidence of forced labour (Sinclair and Dinshaw, 2022). The COVID-19 pandemic also contributed to this issue by disrupting supply chains and accelerating vendor onboarding, weakening oversight and heightening exploitation risks (Cole and Shirgholami, 2022).

As both a major employer and a sector of substantial procurement expenditure on essential medical products, healthcare is acutely exposed to supply chain vulnerabilities. Australia's elderly population is projected to increase by 60% by 2030, intensifying reliance on healthcare services and infection-control measures, and substantially raising demand for PPE (Australian Institute of Health and Welfare, 2023). Government spending on PPE alone is forecast to exceed $1.1 billion, much of which is sourced from overseas suppliers operating in high-risk environments (Department of Health, 2024). This demographic surge in procurement magnifies exposure to upstream forced labour risks in PPE production while simultaneously heightening regulatory pressures on healthcare organisations to demonstrate ethical sourcing. These dynamics underscore the urgency for empirical research on how healthcare organisations disclose and address modern slavery risks.

Given the complexity of Australian healthcare supply chains that rely on dispersed actors, stakeholder theory offers a useful lens for understanding how buying organisations respond to disclosures (Freeman et al., 2021). Modern slavery and SCT are not isolated organisational concerns; they are wicked multi-stakeholder problems that demand ongoing engagement and negotiation among actors (Caruana et al., 2021; Crane, 2013). Rooted in an ethical commitment to balance stakeholder interests, stakeholder theory emphasises the importance of recognising the needs of employees, societal actors and suppliers to build sustainable relationships (Freeman et al., 2021; Hörisch et al., 2014). Importantly, these stakeholders exercise varying levels of power, legitimacy and urgency, placing pressure on organisations to divulge information about their supply chains (Yagci Sokat and Altay, 2023). In mediating these pressures, buying organisations play a pivotal role in assessing and remediating modern slavery (McLaren et al., 2024). Multi-stakeholder involvement becomes crucial for detecting risks early, improving operational management (Gardner et al., 2019), building trust-based relationships (Morgan et al., 2023), enhancing organisational learning and monitoring capabilities (Liu et al., 2023).

Realistically, stakeholder salience within supply chain governance for modern slavery remains uneven. At the upstream level, Tier 1 suppliers receive disproportionate attention in both practice and scholarship because their direct contractual ties make them more visible to buying organisations (Lotfi and Walker, 2024). In contrast, workers and lower-tier suppliers are often the most morally salient yet remain the least visible and empowered, lacking representation or formal mechanisms of influence (McLaren et al., 2024; Crane, 2013). Conversely, downstream stakeholders such as governments, NGOs, investors and consumers hold greater institutional authority but are often disconnected from the lived experiences of vulnerable stakeholders such as exploited workers (Christ and Burritt, 2018). Thus, modern slavery reporting serves as both a regulatory response and a reflection of stakeholder collaboration, shaped by governance structures and information asymmetries.

To align with the research aim, this study conceptualises modern slavery disclosure through three interconnected dimensions (see Figure 1). First, it examines the roles and practices of upstream supply chain stakeholders, focusing on supplier locations, working conditions, human resource practices and organisational culture, which all influence the prevalence and reporting of modern slavery risks. Second, it considers downstream buyer-led mechanisms for ensuring SCT, shaped by external stakeholder pressures and regulatory obligations under the AMSA, which institutionalise expectations for transparency and accountability. Third, it addresses the inherent challenges posed by modern supply chains, which are often fragmented, opaque and complex. As discussed in Section 2.1, these structural issues complicate efforts to monitor and report on modern slavery risks. Together, these dimensions reflect the information disclosures from a range of stakeholders, including government agencies, NGOs and the media, who increasingly expect ethical procurement practices. Figure 1 and Table 1 provide an overview of the key elements in the framework.

We adopted an abductive research approach that integrated both deductive and inductive reasoning, guided by Braun and Clarke (2006). The analysis was conducted collaboratively by three researchers, allowing for iterative discussion throughout the process. The first stage employed a deductive logic, drawing on existing literature to establish a theoretical foundation and develop an a priori conceptual framework (Ketokivi and Choi, 2014). This initial framework served as a lens for guiding data coding (see Figure 1). The second stage followed an inductive process, aimed at contextualising and validating the initial framework through empirical analysis of modern slavery disclosures. Following Elo et al. (2014) approach, we generated codes to identify meaningful patterns and relationships. First-order concepts were derived through open coding and organised into second-order themes via axial coding. These emergent themes were subsequently mapped onto the pre-established categories of the conceptual framework, ensuring coherence between theoretical constructs and empirical findings.

The analysis commenced with sample selection, using publicly available modern slavery reports of organisations as the primary data source. These reports provide unique insights into organisational SCT mechanisms and the complexities of identifying and mitigating modern slavery risks, which are often difficult to obtain through direct organisational engagement (McGaughey et al., 2022). Direct engagement with organisations is often limited by ethical sensitivities, fear of reputational damage and the risk of disclosing incriminating information (Pinnington et al., 2023; McGaughey et al., 2022). Unlike interviews, modern slavery statements are typically subject to institutional guidelines and internal review processes, thereby helping reduce bias and enhance data reliability.

Each organisation was treated as a case. In the preparation phase, we first identified healthcare organisations operating across Australia (see Figure 2). Then, modern slavery statements were retrieved from the Australian Modern Slavery Registry, a centralised platform that archives statements submitted in accordance with the AMSA. Table 2 shows that an initial pool of 111 healthcare organisations was reviewed; 78 of these had submitted modern slavery statements for the 2022–2023 Australian financial year (1 July 2022 to 30 June 2023). Details of the 78 organisations and their reports are shown in Table A of the supplementary file. The final sample comprised 40 public and 38 private entities, including hospitals, residential aged care facilities, specialist medical providers and allied health services (see Table 2).

Although the modern slavery statements analysed in this study are publicly available, the organisations' names were anonymised during the analysis and reporting stages. Each of the 78 healthcare organisations was assigned a pseudonym (e.g. Case1, Case2, Case3) to shift the focus from evaluating individual firm performance to uncovering sector-wide patterns and practices. The analysis began with a systematic content analysis of the modern slavery statements from 78 case organisations. The documents, in PDF format, were imported into NVivo12 software to facilitate qualitative content analysis. We read all 862 pages thoroughly. The analysis focused on sentence-level assessment for richer interpretative insights rather than on non-narrative elements such as images because sentence-level analysis offers greater analytical depth in socially sensitive topics.

During the organising phase, the reports were subjected to open coding in NVivo12. No predefined coding structure was used; instead, initial codes emerged inductively from the data itself. Examples of these codes include “auditing suppliers against code of conduct”, “employee training programs on modern slavery” and “whistleblower platforms to report modern slavery”. This method allowed the findings to emerge organically, minimising researcher bias. This process generated 350 initial codes (comprising both first- and second-order codes) derived from multiple readings of the texts related to SCT. These initial codes were reviewed, merged and grouped into broader categories according to conceptual similarities and relevance to existing literature. The iterative coding process resulted in a refined set of 83 codes. Conceptually related codes were further synthesised into 27 subcategories and 12 broader thematic categories, aligned with dimensions outlined in the conceptual framework. Specifically, 10 subcategories and two new subcategories emerged inductively from findings (see Table 3).

Table 3 illustrates how the subcategories were organised and aggregated into higher-order categories. Supporting data excerpts are also provided as coding exemplars (see Table B in the supplementary file). For instance, codes such as “modern slavery questionnaires” and “supplier selection” were grouped under the subcategory “risk assessment”, which was subsequently categorised under the broader theme of “supplier risk management”. Ultimately, these categories were clustered into aggregated dimensions, providing a comprehensive view of the findings. Figure 2 illustrates how the abductive approach guided this process, moving from data-driven codes to theoretical insights, by linking subcategories, categories and dimensions (Gioia et al., 2013).

To strengthen the study's trustworthiness, we systematically reviewed all reports in NVivo to avoid duplication. Three researchers conducted the content analysis and coding independently, to enhance credibility and dependability (Elo et al., 2014; Stevenson and Cole, 2018). Each researcher reviewed the definitions of categories and subcategories of themes (see Table 4). The first author initially conducted the clustering, which was subsequently cross-verified by the second and third authors using the same approach. This consensus-based procedure mirrors prior qualitative coding approaches used in modern slavery research (Stevenson and Cole, 2018). Disagreements were resolved through deliberation among the three authors, with reference to relevant literature and close examination of the contested codes until a consensus was reached. This process led to an inter-rater agreement of 92%, with concordance on 322 out of 350 codes.

This section analyses the information disclosed and the actions taken by Australian healthcare organisations regarding modern slavery.

Disclosures under the AMSA reveal consistent patterns across public and private healthcare organisations. On average, private entities produced longer statements (12.5 pages), devoting around 6.6 pages (52%) to supply chain issues. In contrast, public organisations produced shorter reports, averaging 9.6 pages overall, but devoted 5.9 pages specifically to supply chain disclosures, representing a higher proportional focus (62%). This variation suggests differences in how healthcare organisations communicate SCT, although similar disclosure themes were consistently emphasised across both public and private groups.

Thematically, corporate governance emerged as the most prevalent theme (91% organisations), typically framed around continuous improvement and process evaluation. This trend suggests that organisations view modern slavery reporting as a governance and compliance process rather than a direct human rights obligation. Supplier governance (88% organisations) and supplier risk management (92% organisations) were also widely discussed, reflecting the sector's reliance on formal mechanisms, codes of conducts and contractual obligations. However, 73% of organisations acknowledged persistent challenges in tracing indirect suppliers and subcontractors, highlighting limited visibility across multi-tiered networks. This constraint is particularly acute in high-risk segments such as PPE, textiles and medical consumables, whereby complex sourcing and pandemic-related disruptions exacerbate opacity and labour exploitation risks.

Healthcare organisations reference a diverse set of stakeholders in their modern slavery reports (see Table 4). The findings illustrate that stakeholder salience is unevenly distributed across reporting themes. Some groups engaged consistently, and others remained largely absent. Internal stakeholders were the most frequently mentioned, appearing in 58 reports. Procurement teams, audit and compliance committees, leadership, and human rights officers were positioned across all five themes, suggesting that organisations rely heavily on internal governance structures as the foundation of their modern slavery responses.

Upstream stakeholders, particularly local and tiered suppliers (Tier 1 to Tier 3), appeared in 60 organisation reports, mainly in discussions of information disclosure, governance and risk management. However, reporting was less consistent for PPE manufacturers, with indirect and overseas suppliers appearing in only 32 reports. A much smaller cluster of disclosures (26 reports) referenced vulnerable workers, including forced labourers, migrant workers, children and those in bonded labour. Information about them is typically obtained indirectly, through audits, NGO assessments or investigative reports, whereas little is reported on workers' access to remediation and grievance mechanisms.

Downstream stakeholders, including customers and retailers, were absent across all reports. As the healthcare sector does not deal with retailers of healthcare products, this omission reinforces the perception that modern slavery is primarily an upstream issue. Societal stakeholders were cited in 50 reports, encompassing NGOs, advocacy groups and international organisations such as the ILO and the Australian Catholic Anti-Slavery Network. Such stakeholders were portrayed as sources of legitimacy, risk frameworks and advocacy positions. Finally, market stakeholders such as EcoVadis were mentioned in 16 reports and positioned as providers of audit and supplier rating platforms, indicating limited integration of digital monitoring systems.

Australian healthcare organisations' disclosures on SCT encompass four key dimensions: upstream supply chain modern slavery information, mechanisms for assuring SCT, SCT monitoring challenges, and SCT monitoring through continuous improvement.

Supplier host-country environment: Most healthcare organisations (53%) identified the supplier host-country environment, mainly in Southeast Asia, as a key driver of upstream modern slavery risks, influenced by industry context, regulatory context and socio-economic norms. Around 29% of reports highlighted labour- and raw material-intensive healthcare production. For example, Case58 noted that “there is growing evidence that demonstrates a high occurrence of modern slavery in the sourcing of raw materials and in production of healthcare goods”. Weak labour regulatory context and socio-economic norms on migrant or low-skilled workers was noted in 44% of reports. For instance, Case40 observed that “countries with lower oversight … where there are vulnerable workers and in sectors … less transparent and formal”.

Modern slavery practices in supplier factories: Almost half of healthcare organisations (49%) referenced modern slavery risks in supplier factories, highlighting invisible workers affected by labour forms, recruitment practices and working conditions. Case62 noted that “PPE … in countries of the Asia Pacific region may be at risk of: forced labour, bonded labour, migrant labour exploitation”. About 19% of disclosures cited exploitative recruitment; for example, Case2 observed that “elevated incidences of … deceptive recruitment practices and debt bondage … arising from a heavy reliance upon low skilled workers from vulnerable groups.” Low-skilled and uneducated workers often enter employment with little knowledge of their rights and restricted bargaining power. Unsafe working conditions, excessive overtime and pandemic-related job insecurity further exposed workers to coercion and exploitation. These show how low-skilled and migrant workers face entrenched exploitation in healthcare supply chains.

Supplier modern slavery due diligence: Overall, 26% of disclosures highlighted deficiencies in suppliers' due diligence, driven by capability and motivation gaps. Limited supplier capability was noted in 15% of organisations. Case2 reported that “a number of our suppliers are smaller entities that do not have operational modern slavery due diligence or risk identification frameworks”. Time and resource constraints further compromised risk management processes (Case62). Motivational gaps were reported in 13% of cases; Case52 noted that one brand “knowingly profiteered from alleged forced labour”. These analyses show that structural capacity limits, coupled with deliberate exploitation, create blind spots in healthcare supply chains, allowing modern slavery risks and practices to persist in this sector.

Supplier governance: Supplier governance is the most widely adopted mechanism for addressing modern slavery risks in healthcare supply chains, reported by 88% of organisations. About 74% link governance to supplier codes of conduct and modern slavery policies. Some embed these internally; for example, Case40 noted that “our governance structure underpins our operations, with policies and procedures including a Supplier Code of Conduct, Modern Slavery Standard to support a transparent and accountable framework for internal and external stakeholders”. Others align with international frameworks, such as Case56's statement: “in line with the UN Guiding Principles … [our] human rights approach focuses on addressing [slavery] risks”. Governing committees cited in 79% of reports oversee cross-functional departments, highlighting the multi-stakeholder nature of modern slavery governance.

Supplier risk management: Supplier risk management is a core mechanism for addressing modern slavery, reported by 92% of organisations, encompassing risk assessment, information-sharing platforms and remediation efforts. Organisations conduct risk assessments during supplier selection using questionnaires and desktop reviews. Case74 noted: “we determined potential risks for modern slavery by using risk indicators provided by expert organisations such as the Global Slavery Index (GSI) … and identified the … supply chain categories as giving rise to medium to high-risk exposure”. Risk remediation includes whistleblower channels, corrective action plans and compensation for victims. Platforms such as EcoVadis, Informed365, OnBoard and SEDEX enhance visibility but may foster a “tick-box” compliance approach without engaging directly with vulnerable workers.

Supplier integration: Supplier integration is emphasised by 74% of organisations, focusing on collaboration with local suppliers through meetings and onsite visits to address modern slavery risks. Half of the reports (47%) highlighted constructive engagement and long-term supplier relationships. Case40 explained that they “maintain pro-active risk engagement with Tier 1 suppliers and implement the compliance framework for supplier onboarding protocols”. Case2 added that they “are interested in building long-term partnerships that ensures [their] modern slavery transparency”. About 27% emphasised joint decision-making, with Case6 observing: “Our approach is to maintain open dialogue with our suppliers … to improve their capacity to assess and address modern slavery”. Such practices foster trust, ownership and continuous improvement, treating suppliers as active partners rather than mere compliance actors.

Supplier development: More than half of the organisations (55%) highlight supplier development as a vital mechanism for promoting information-sharing, explicitly reference supplier education and training, and joint resources provision. Case29 noted: “To support our suppliers … our local teams personally interact with and visit our suppliers where possible to understand and evaluate their operations”. This face-to-face engagement recognises the importance of cultural and contextual understanding, enabling suppliers to learn, adapt and progressively embed due diligence. Some organisations also provide their suppliers with training tools and resources to strengthen modern slavery risk management, framing engagement as collaborative rather than punitive. However, the reports did not specify what these “tools and resources” entailed, making it difficult to assess whether the support was substantive.

Supply chain visibility: A primary challenge for addressing modern slavery, noted by 73% of healthcare organisations, is limited visibility across upstream supply chains, explicitly recognising information asymmetry and geographical distance. About 26% acknowledged information asymmetry, with Case1 and Case39 noting that “engagements with suppliers in high-risk countries, and upstream operations not currently visible”. Geographical distance compounds this issue; about 51% cited it as a major barrier. As Case48 explained, “products are generally manufactured offshore, making it more challenging to assess modern slavery risk through the supply chain”. These findings highlight how global sourcing, and multiple intermediaries weaken oversight and limit transparency across complex supply networks.

Supply chain complexity: Around 64% of organisations explicitly cite supply chain complexity as a core challenge, largely owing to multi-tiered and fragmented global networks. Case26 reported that “supply chains are complex and unauthorised subcontracting is hidden, which increases the complexity of tracing modern slavery”. Product diversity also amplifies this issue; 19% of reports cited goods sourced from multiple regions. As Case31 explained, “high-risk categories include PPE, uniforms, coffee and IT products sourced from China, Malaysia, India and other countries”. Such complexity creates blind spots, making it difficult for healthcare firms to trace, monitor or remediate modern slavery risks across their extended supply chains.

Supply chain disruption: Supply chain disruption, particularly during the COVID-19 pandemic, exposed weaknesses in healthcare SCT. About 58% linked disruptions to outsourcing and production pressures; 14% admitted that priorities shifted towards efficiency over worker welfare. Case36 noted that “due to the rapid sourcing of PPE, risks present regarding forced labour, poor working conditions and excessive working hours”. Some organisations increased outsourcing to meet urgent demand. For example, Case34 reported that “we were required to source outside of our regular suppliers, and due to the urgency, we were not able to undertake our normal investigation processes for modern slavery”. Such urgent outsourcing heightened the risks of modern slavery, revealing the fragility of healthcare supply chains under crisis conditions.

Corporate governance: Strengthening corporate governance was highlighted by approximately 91% of organisations to address modern slavery, focusing on organisational values and employee capability. Case49 noted that “the procurement of all goods and services is conducted in an honest, competitive, fair, transparent and ethical manner that aligns with [our] values and supports human rights”. This illustrates how commitments to fairness and accountability are integrated into governance and procurement processes. Specifically, they emphasised building internal capability through staff education, ensuring procurement teams are equipped to identify, assess and manage modern slavery risks within their supply chains.

Process improvement: About 68% of healthcare organisations highlighted strengthening due diligence and monitoring processes through periodic evaluations and future-oriented engagement with external stakeholders. Case15 noted plans to track “percentages of completed staff training, number of suppliers audits conducted, and number of remediation programs completed”; Case57 emphasised “continuous improvement” through reviewing and improving due diligence and risk management. Many also focused on collaboration and technology adoption, including the use of the EcoVadis CSR tool, signalling a shift towards more systematic, data-driven and partnership-based approaches to managing modern slavery risks across supply chains.

Drawing on the empirical findings, this study presents an integrated TDMSR framework (see Figure 3). Viewed through a stakeholder theory lens, the TDMSR framework highlights how SCT governance is shaped by asymmetric power relations among supply chain stakeholders. In particular, it reveals how the interests of powerful actors, such as regulators, healthcare buyers and investors, are prioritised over those of weaker stakeholders, including upstream suppliers and vulnerable workers, who are most exposed to modern slavery risks.

The TDMSR framework highlights the barriers healthcare organisations face in monitoring SCT, stemming from limited supply chain visibility, complex multi-tier supply networks and supply chain disruptions (see Figure 3). A central barrier lies in information asymmetries and geographical distance across upstream supply chains. Upstream suppliers and intermediaries, such as subcontractors and recruitment agencies in high-risk host countries, often withhold information on working conditions, recruitment practices and subcontracting relationships (Crane, 2013). Such behaviour arises from downstream cost pressures, in which healthcare organisations demand low prices, rapid delivery and strict sustainability compliance. Consequently, vulnerable suppliers have strong incentives to obscure exploitative practices to maintain contracts and market access (LeBaron, 2021). From a stakeholder theory perspective, these pressures reflect misaligned stakeholder expectations, where economic and reputational interests of powerful stakeholder from downstream supply chain dominate, while the social interests of upstream suppliers and workers are marginalised. This imbalance stakeholder expectations constrain suppliers' willingness and capacity to engage transparently, reinforcing information asymmetries rather than resolving them.

Supply chain structural complexity and diverse procurement compound these monitoring difficulties, forcing healthcare organisations to rely heavily on third-party audits that often provide a partial view of upstream modern slavery practices. The sector's reliance on a wide range of products—including medical devices, electronics, textiles and PPE—can blur buying organisations' understanding of conditions within supplier host countries. This limited visibility creates further opacity, as suppliers operate under conflicting expectations, balancing the demands of healthcare buying organisations with local, cultural and political pressures. In supplier host countries, economies depend on low-cost, labour-intensive and raw material industries (Crane, 2013). Such a permissive environment is accompanied by weak labour protections and an entrenched culture that normalises exploitative work, in which modern slavery becomes embedded in the society (Lotfi and Walker, 2024).

In the healthcare sector, COVID-19 supply chain disruptions prioritised production efficiency over social concerns and expanded outsourcing exacerbated modern slavery risks. The urgent demand for PPE weakened oversight, compromised supplier selection and limited modern slavery training, revealing gaps in transparency (Christ and Burritt, 2021) and the fragility of labour protections under the AMSA. Unlike sectors such as fashion, where suppliers suffered from collapsing demand (Richards, 2022), PPE manufacturers gained leverage, temporarily inverting traditional buyer–supplier dynamics (Christ and Burritt, 2023). Yet, increased profitability did not mitigate exploitative practices; it reinforced the structural entrenchment of modern slavery, showing how crisis conditions can enable suppliers to profit from vulnerable labour amid weak regulation and limited oversight.

Collectively, these findings highlight the contextual constraints of current SCT practices. Healthcare organisations must simultaneously manage supply chain complexity, geographic distance and systemic disruptions while navigating conflicting stakeholder expectations. Without collaborative proactive approaches, meaningful transparency and remediation of modern slavery risks will remain elusive.

Although the AMSA requires healthcare organisations to demonstrate progress on modern slavery, healthcare organisations face persistent tensions in monitoring SCT and fulfilling reporting obligations, typically manifested in two interrelated areas: (1) the gap between upstream SCT and modern slavery disclosure practices, and (2) the disconnection between monitoring and mitigation.

Modern slavery disclosures typically emphasise host-country conditions, suppliers' actual modern slavery practices, and suppliers' modern slavery due diligence efforts (see Figure 3). Healthcare organisations often rely on generalised risk assessments and public sectoral warnings rather than site-specific evidence, which restricts uncovering hidden practices such as debt bondage or deceptive recruitment that characterise modern slavery. This disjuncture illustrates how disclosure transparency can become performative: it signals compliance to downstream stakeholders (e.g. investors, customers) and societal stakeholders (e.g. regulators, NGOs), as highlighted in Table 4, while leaving unresolved the underlying opacity in supply chains (Morgan et al., 2018). Stakeholder theory helps explain these transparency disclosure dynamics. Reporting practices tend to prioritise the expectations of salient external stakeholders, such as regulators and the public, while the perspectives of less powerful stakeholders, particularly workers in supplier host countries remain largely absent. The imbalance is reinforced by the lack of due diligence among upstream suppliers, many of whom lack the financial, technical or organisational capability to impose anti-slavery and sustainability standards (Christ and Burritt, 2023). In disclosures, healthcare organisations increasingly recognise modern slavery risks in their supply chains, such as weak regulatory frameworks, low-cost labour markets and exploitative subcontracting; however, many stop short of examining how their procurement practices, such as cost-price compression and short lead times, exacerbate these vulnerabilities. Instead, responsibility is displaced onto less powerful suppliers, whose limited capabilities render them easy targets for buying organisations to transfer compliance burdens (Meehan and Pinnington, 2021).

Emergency procurement during COVID-19 further exposed the imbalance between the urgent demand of healthcare systems for PPE supplies to secure patient care and protect vulnerable workers in upstream factories (Sinclair and Dinshaw, 2022). Healthcare organisations relegated worker protections to a secondary concern, demonstrating that remediation of modern slavery is readily sacrificed during crisis conditions (Christ and Burritt, 2021). This neglect extended beyond healthcare organisations: governments and customers in developed economies also deprioritised the needs of modern slavery victims in favour of protecting themselves to survive. These dynamics cascaded across all supply chain stakeholders, reinforcing a hierarchy in which the protection of consumers and patients in developed economies outweighed the protection of workers in supplier host countries.

Consequently, the “transparency” communicated in reports does not equate to transparency in supply chains. History demonstrates that regulators have prioritised the interests of powerful, wealthy regulated organisations over society (Siems et al., 2023). The Australian healthcare context reflects this pattern: large organisations and regulators wield significant influence, while small upstream suppliers and workers remain largely voiceless. Transparency reinforced in modern slavery disclosures reflects a form of defensive accountability, in which healthcare organisations present an appearance of openness by reporting credible information to satisfy external stakeholders without resolving the systemic barriers that prevent meaningful visibility in upstream supply chains.

Modern slavery reports emphasise four primary mechanisms through which organisations monitor their supplier practices: supplier governance, supplier risk management, supplier integration and supplier development (see Figure 3). These mechanisms demonstrate procedural thoroughness, yet their effectiveness is limited by their reach to modern slavery victims and upstream suppliers, often confined to visible Tier 1, direct or sometimes Tier 2 suppliers, while retaining contractual and economic leverage without extending sufficient guidance, support or collaboration further upstream. Although stakeholder theory emphasises the need to balance conflicting interests (Hörisch et al., 2014), transparency mechanisms in practice tend to favour powerful stakeholders over those most affected by exploitation.

As in other sectors, supplier governance and supplier risk management are seen as crucial in healthcare supply chains to monitor modern slavery risks. Standard tools, such as supplier codes of conduct and modern slavery questionnaires, are widely adopted to assess supplier compliance and demonstrate accountability in meeting stakeholder expectations (Richards, 2022; Stevenson, 2022). These instruments' risks function as a tick-box approach rather than mechanisms that uncover labour exploitation (Benstead et al., 2021). Internal stakeholders and oversight bodies—including audit risk compliance committees, modern slavery working group, procurement teams and human rights officers (see Table 4)—are typically advisory, serving more as legitimacy-seeking gestures than as mechanisms capable of driving systemic reform.

Whistleblowing platforms are similarly constrained as remediation tools. Vulnerable workers often refrain from reporting abuses because they fear retaliation and have a limited awareness of remediation channels (Gold et al., 2015; Stevenson and Cole, 2018). Information-sharing platforms designed to support supplier risk management and real-time monitoring are resource-intensive and often encounter supplier resistance because firms may be unwilling to disclose sensitive operational data (Liu et al., 2023). This highlights a dilemma between transparency and confidentiality, reinforced by the United Nations Transparency Protocol, which warns that full transparency may expose sensitive information. Uniform standards of disclosure are rarely feasible across industries: transparency is indispensable in food supply chains for safety purposes, whereas defence industries face confidentiality and national security constraints that limit disclosure. Yet, when confidentiality is prioritised, disclosure risks minimum compliance-based reporting. Such surface-level disclosures reinforce existing power asymmetries and exclude the vulnerable modern slavery victims from meaningful remediation.

Supplier integration and development initiatives, such as supplier training and capacity-building programs, are increasingly promoted as mechanisms to enhance SCT. In cases of non-compliance, healthcare organisations signal their willingness to work with suppliers rather than terminating contracts. These practices foster sustainable and long-term relationships (Matook et al., 2009). Despite this rhetoric of collaboration, it remains unclear whether healthcare organisations implement these practices because contract termination remains the faster and lower-risk response to reputation threats. Consequently, healthcare organisations tend to prioritise satisfying the expectations of powerful external stakeholders (regulators, investors and the public) over those of marginalised groups such as smaller suppliers and vulnerable victims. This tendency risks reducing modern slavery initiatives to mere greenwashing rather than pursuing slower, more impactful practices.

Problematically, the AMSA privileges the interests of the healthcare sector while leaving victims' voices and interests unheard. Reporting risks is becoming a tool of reputational management, signalling accountability to regulators and investors while leaving the lived experiences of vulnerable workers unaddressed (Richards, 2022). The AMSA does not empower victims of modern slavery because it does not have a mechanism for them to follow and seek a remedy. The AMSA lacks substantive provisions to protect workers' rights and interests. Moreover, the regulation allows powerful groups to consolidate power and disregard the legislation's underlying moral principles (Pinnington et al., 2023). Even when healthcare organisations introduce mechanisms for assuring SCT (see Figure 3), they focus on building relationships with suppliers rather than engaging with workers. Addressing this imbalance requires recalibrated stakeholder engagement that centres weaker actors in transparency initiatives and redistributes responsibility more equitably across supply chains.

Notably, healthcare organisations are recognising modern slavery and SCT as an ongoing problem requiring corporate governance and continuous improvement (CI) (see Figure 3). This shift, driven by regulatory pressures from societal stakeholders such as the Australian Government and advocacy actors such as the ILO and the Slave Free Alliance (see Table 4), positions corporate governance as the foundation for strengthening SCT (McLaren et al., 2024). These stakeholders are driving reforms in governance and due diligence practices that reflect stakeholders' evolving expectations (McLaren et al., 2024).

Corporate governance is a foundation of CI; most healthcare organisations view corporate governance reform as central to strengthening SCT and addressing modern slavery. Embedding anti-slavery measures as a core organisational value rather than peripheral obligations further reinforces a culture of ethical awareness. Some healthcare organisations adopt defensive disclosure strategies, as noted by Meehan and Pinnington (2021), to reassure external stakeholders, without necessarily leading to meaningful remediation of modern slavery issues. Yet, those who build collaborative relationships with suppliers better reflect the shared responsibility. By institutionalising such mechanisms, healthcare organisations signal to stakeholders that modern slavery risk mitigation is an enduring governance priority. For instance, many organisations establish dedicated sustainability committees or appoint chief sustainability officers to oversee sustainability issues, which has been observed in previous studies (Meehan and Pinnington, 2021; Stevenson and Cole, 2018).

However, organisational commitments must go beyond formal reforms towards employee capabilities and CI culture. Training procurement managers and employees on modern slavery risks equips them to identify risks and to build relationships with suppliers to implement mitigation measures. Developing cultural competencies is equally critical because it can help organisations navigate differing societal expectations and regulatory contexts operating across supplier host countries (Matook et al., 2009). This approach echoes stakeholder theory's call for mutually beneficial relationships. Therefore, internal capacity building extends accountability beyond formal frameworks, enhancing credibility with external stakeholders.

Process improvement further complements these governance and training efforts. Healthcare organisations are recognising the value of due diligence improvement through the development of evaluation frameworks that incorporate key performance indicators to assess SCT and the effectiveness of existing mechanisms. These frameworks help organisations benchmark and identify gaps, refine procedures, and adjust governance practices over time. However, these measures often capture outputs (e.g. the number of audits conducted) rather than the actual influence on modern slavery risks, suggesting that further refinement is required to ensure key performance indicators address substantive risk remediation (Mai et al., 2023).

In essence, healthcare organisations begin to institutionalise CI in SCT by embedding ethical governance, investing in internal employee capabilities, and refining monitoring processes. These initiatives represent attempts to balance external stakeholder demands with meaningful engagement of weaker stakeholders, thereby moving beyond compliance towards continuous commitments (Christ and Burritt, 2018). From a stakeholder lens, this shift indicates a transition from compliance-driven stakeholder management towards a normative approach, where the interests of marginalised groups, particularly workers, are acknowledged.

This study analyses modern slavery disclosures by Australian healthcare organisations, focusing on SCT governance mechanisms, disclosure practices, and persistent barriers in upstream supply chains. Drawing on an analysis of 78 modern slavery reports, the findings uncover how Australian healthcare organisations disclose modern slavery information, implement governance mechanisms and commit to CI through the TDMSR framework. The study also identifies persistent barriers that continue to constrain SCT, with both theorical and practical implications.

This study advances theoretical understanding of SCT in the context of modern slavery, focusing on the underexamined healthcare sector and mandatory disclosure under the AMSA. This complements prior modern slavery studies, which largely examined disclosure quality, institutional drivers and the effectiveness of legislative frameworks (Christ and Burritt, 2018; Flynn and Walker, 2021; Stevenson and Cole, 2018; Meehan and Pinnington, 2021; McGaughey et al., 2022). In contrast, using the TDMSR framework, this study theorises how barriers within supply chains constrain the operational effectiveness of SCT as a mechanism for mitigating modern slavery risks.

Empirically, the framework shows that healthcare organisations structure their disclosure information around three dimensions: host-country conditions, modern slavery practices in supplier factories and modern slavery due diligence. The TDMSR framework indicates that, despite detailed Australian Government guidelines, modern slavery reports remain limited because of invisibility, supply chain complexity, and disruption challenges. Although similar patterns have been observed in the fashion, agriculture and construction sectors (Liu et al., 2023; Richards, 2022), this study demonstrates these dynamics in a new sector and regulatory context, showing that accountability under the AMSA is narrowly constructed and largely defensive.

Healthcare organisations tend to report credible information to satisfy external stakeholders without addressing systemic barriers. These practices reflect an uneven distribution of transparency: disclosures are detailed when firms have contractual control (Tier 1) and minimal when exploitation risks are highest upstream. This reinforces that SCT is inherently bounded; its depth and direction are shaped by geographic distance, power influence and regulatory visibility.

Healthcare organisations also emphasise tangible procedural monitoring, such as risk management and supplier governance as well as intangible mechanisms such as supplier integration and development to meet the expectations of influential stakeholders. However, tensions exist between procedural monitoring and genuine remediation of intangible risk, and between upstream SCT monitoring difficulties and modern slavery disclosures. Framed by stakeholder theory, the findings illustrate how power asymmetries shape which voices are heard and whose interests are prioritised. Focal firms exert strong influence over reporting agendas, whereas upstream suppliers often lack the capacity to challenge these expectations, and affected workers remain largely excluded from disclosure processes.

The study highlights that SCT should be treated as an evolving organisational capability rather than a series of one-off initiatives. The TDMSR framework conceptualises how Australian healthcare organisations are increasingly embedding modern slavery governance within their CI plans for SCT. Key drivers of improvement include developing organisational capabilities, aligning values with learning processes, and implementing systematic process evaluation.

Our findings highlight that stakeholder salience is fluid and context-dependent. In healthcare, volatile market shocks, such as the COVID-19 pandemic, temporarily shifted buyer–supplier power dynamics, exacerbating these challenges. Mapping the roles of government agencies, NGOs, investors, internal governance actors, suppliers and workers shows that these stakeholders have overlapping and reciprocal information needs: suppliers seek clarity, NGOs seek verifiable accountability, and workers seek empowerment. Yet, disclosures rarely reflect these shared interests. McLaren et al. (2024) portray stakeholder influence as relatively stable; however, our study reframes SCT as a negotiated process of selective visibility, in which modern slavery persists because vulnerable stakeholders lack power, and SCT capabilities are deliberately developed to prioritise powerful actors over those most at risk.

The study offers several practical implications. The TDMSR framework provides an approach to understanding how healthcare organisations report and remediate modern slavery. It enables policymakers, hospital administrators and similar organisations to assess their SCT monitoring and disclosure practices across identified key dimensions, such as supplier governance, risk management, supplier integration and supplier development. Detailed reviews remain necessary under the AMSA; however, the TDMSR framework offers a concise overview of SCT monitoring mechanisms, challenges and areas for improvement, helping policymakers track organisational progress over time.

Although developed in the healthcare context, the TDMSR dimensions are relevant to other high-risk sectors such as agriculture, construction and fashion, where multi-tier sourcing and complex supply chains are prevalent. Organisations in these industries can draw on these findings to further improve how modern slavery risks are governed across different tiers and refine their mechanisms accordingly. In healthcare, our findings suggest that organisations need to balance supply chain complexity, geographical dispersion and systemic disruptions while addressing often competing stakeholder expectations. Further, smaller firms can use the framework to understand the challenges larger organisations face in monitoring upstream supply chain information and the SCT mechanisms that are effective at scale. This understanding can help smaller firms to gradually build their own monitoring and mitigating capacity against modern slavery, steadily demonstrating a commitment to SCT.

Our findings also indicate that sudden changes in demand and capacity constraints, such as those experienced during the COVID-19 pandemic, can increase worker vulnerability. These insights can help organisations to recognise that disruptions can weaken modern slavery compliance. In practice, this means incorporating modern slavery risk assessments into planning, strengthening supplier communication and support during crises, and embedding mitigation measures such as contingency sourcing. The role of CI in monitoring and mitigating SCT within healthcare organisations is also critical for organisations to reinforce their organisational values, build internal capabilities, and enhance their monitoring process to track SCT and report to external stakeholders. In practice, this involves shifting to a learning-oriented approach that emphasises ongoing review, knowledge sharing and adaptive processes to enhance accountability.

The study has several limitations that suggest future research avenues. First, it solely focuses on responses to the AMSA within the healthcare sector. Future research could examine how healthcare firms in other jurisdictions respond to comparable legislation, such as the UKMSA, to facilitate cross-country comparisons. Second, our analysis draws on statements released by healthcare firms, reflecting only what they chose to disclose about their supply chains. Future research could incorporate multi-stakeholder perspectives—particularly those of suppliers, NGOs and survivors of modern slavery—to construct a more holistic understanding of risk remediation practices. Third, longitudinal research could examine how the content and depth of SCT disclosures evolve over time and whether improved transparency translates into measurable reductions in exploitation. Integrating complementary theoretical lenses, such as the relational view or resource-based view, could also illuminate how inter-organisational collaboration and capability building enable traceability and remediation. Nevertheless, we hope this study inspires future work in this new field at the intersection of modern slavery reporting and SCT in Australia. We have offered initial insights into a complex topic and strongly encourage others to continue this line of inquiry.

The author would like to acknowledge the encouragement provided by the International Symposium on Logistics (ISL) Best PhD Paper Award in 2024, the support of the RMIT College of Business and Law Research Publication Scheme, and the valuable and constructive feedback from the anonymous reviewers.

The supplementary material for this article can be found online.