Corruption in healthcare is an enduring problem in many countries across Europe. Iva Parvanova argues that while investing in institutional reforms can achieve results, even well-designed policies will fall short if they fail to address the social norms that sustain corrupt practices.
Corruption – the abuse of public office for private gain – is more than a nuisance in healthcare. It represents a global crisis bearing a heavy price tag. Globally, an estimated US $455 billion is lost to corruption in the healthcare sector alone. This burdens already overstretched health budgets by diverting scarce resources away from patients. In addition to this financial cost, corruption erodes patients’ trust in doctors and institutions and exacerbates inequality in access to care.
Informal payments and bribes – from cash and gifts to the use of connections and favours – remain a commonplace aspect of the doctor-patient relationship in parts of Europe. In 2024, one in ten patients in Bulgaria and Greece made such a payment for services they are entitled to – an increase since 2023. In Moldova, cancer patients are expected to pay up to thousands of euros “under the table” for care they are entitled to, while a group of oncology centre employees in North Macedonia were reported to be stealing life-saving drugs and selling them on the black market. Corruption in procurement resulted in diluted disinfectants leading to numerous unnecessary deaths in a Romanian burn clinic.
Despite some institutional improvements, such as spending more on healthcare and raising doctors’ wages, the persistence of corruption reveals a deeper challenge. The core issue, in many cases, is not just institutional weakness – it is social norms. That is not to say some people are inherently more corrupt than others. Instead, they might believe that the social groups they identify with participate in such behaviours (regardless of whether this belief is grounded in reality or not).
What we measure shapes what we fix
To address corruption, we first need to know how common it is and why it happens. In practice, the two questions are closely linked. Informal payments can serve different purposes: expressing gratitude, skipping the queue or ensuring safety of the treatment received.
International organisations and governments use large surveys to measure patients’ experiences with informal payments but sometimes fail to differentiate between types. Their effect might be the same: inequitable care, strained provider-patient relationships and a weakening of public trust in the system. However, this simplification creates a bias in our understanding of how often it actually happens and could lead to ineffective policy choices.
The cancer patients from Moldova would likely answer “no” when asked if they had made an extra payment expressing their gratitude. Similarly, a patient who brought a box of chocolates to their doctor would not equate their behaviour to a bribe. Policymakers would also choose their response accordingly. Measurement efforts should focus on collecting comprehensive information on the reason behind informal payments highlighting the underlying systemic deficiencies and informing policy responses.
The limits of structural fixes
Once we have a reliable measure of how often and why corrupt exchanges take place, appropriate policy instruments must follow. Under-resourced systems, long waiting times and low provider wages contribute to environments where bribery thrives. As a result, the notion that simply spending more will eliminate corruption in healthcare has become a recurring policy refrain, despite mixed evidence.
The results of a recent study of corruption across 33 countries show that structural shifts without cultural ones cannot drive results. A pattern emerges: perceived norms – not just institutional context – strongly influence patients’ choices. Corruption becomes less a matter of personal ethics or institutional setting and more a matter of social norms – what are others like me doing in this situation.
This result challenges a longstanding assumption in policy circles: that improving the material base and provider salaries will always lead to behavioural change. In reality, norms are much more rigid and they carry real consequences for the effectiveness of governance initiatives.
Tackling norms that drive corruption
Institutional reform remains essential. But without addressing the social norms that sustain bribery, even well-designed policies will fall short. The goal is not only to make corruption harder but to make integrity visible, credible and shared.
Research shows there are several potential approaches for addressing damaging social norms. First, they can be countered through network-based strategies. There is evidence that identifying respected “role models” among healthcare staff to model and diffuse new norms can trigger broader shifts in workplace culture.
Second, they can be tackled by designingnorm-sensitive messaging. This involves tailoring messages to local cultural norms and specific belief systems, rather than using generic anti-corruption slogans. Messages that resonate with citizens’ realities outperform abstract appeals to morality. Finally, championing physicians in public is likely to be beneficial given Europeans hold a deep distrust towards physicians. Amplifying and rewarding integrity and good practices could help reshape patients’ expectations about doctors
Fighting corruption by changing minds
Ultimately, reducing corruption in healthcare is not just about increasing spending. It is also about collective behaviour, sustained by shared assumptions and informal rules. Corruption becomes entrenched when people follow what they think is common practice – even in reformed systems.
Addressing this requires more than auditing and funding increases. It calls for sustained investment in social norm change, evidence-based policymaking and public trust. If people make payments “under the table” because they think everyone else is doing the same, then fighting corruption means changing minds as much as changing systems.
For more information, see the authors’ accompanying paper in Governance.
Note: This article gives the views of the author, not the position of EUROPP – European Politics and Policy or the London School of Economics. Featured image credit: PRIYA2025 / Shutterstock.com
