Compared to other EU countries, petty bribery in Lithuanian healthcare is quite common (see here and here). Though extortion seems rare, Lithuanians frequently make informal (and illegal) payments to doctors either to get better/faster treatment or as an expression of gratitude. When describing this practice, Lithuanians use the language of “giving a gift” or “giving a little envelope,” euphemisms that imply that these payments have come to be perceived as acceptable expressions of gratitude rather than bribes, despite the fact that the Criminal Code prohibits bribery and the Civil Code prohibits giving doctors any sort of gifts outside their private lives. Though formally bribery, giving money to a doctor in Lithuania seems to have developed a different social meaning—rather than implying that you are a dishonest or corrupt person, giving extra money to your doctor has come to be understood as something that reasonable people do in recognition that doctors work hard, are underpaid, and deserve gratitude. Offering gifts or money to a doctor has also become a way to express how much you care about the health of your loved ones who are unwell. So, in Lithuania, the practice of making illegal payments to doctors seems to have become a “social norm” – a shared understanding that such behavior is permitted or even obligatory. It has become a norm both in the descriptive sense (people make these payments because they think that everyone else does so) and in the injunctive sense (making an extra payment to your doctor is an appropriate expression of gratitude). That doesn’t mean it’s good, or something we should ignore or tolerate. But it’s something we need to take into account when thinking about how to combat this form of corruption.
Once we recognize that petty bribery has become a social norm, we should ask what tools could be used to disrupt that norm. Because the problem is so extensive and multifaceted, many of the solutions will require significant institutional reforms, changes in management style, budget reallocations, and the like. Without minimizing the importance of those more fundamental changes, it’s also possible that seemingly small, inexpensive, and non-coercive interventions might help disrupt this dysfunctional social norm. Back in 2011, when I was working for Transparency International Lithuania (TI Lithuania), we piloted one such initiative in collaboration with the Lithuanian Medical Students Association. Our objective was to disrupt social norms surrounding informal healthcare payments—not through loud or aggressive actions, but with stickers and smiles.
Our medical student collaborators who were leading the initiative emphasized the importance of finding ways to speak up against the current situation in a non-confrontational way, one that would emphasize a positive message instead of a negative one. The key part of our intervention was a publicity campaign with the slogan “The best way to say thank you to your doctor is to smile.” We distributed stickers with that slogan in cooperating hospitals, and suggested that doctors who agree with the goal of the initiative can voluntarily put those stickers on their office doors. The idea was to disrupt the social norm that showing gratitude to a doctor always requires a monetary payment or similar gift. We followed this up with a publicity campaign. Though only ten hospitals participated when we launched the initiative in 2012, that number had risen to a total of 71 by 2016. Eventually, the initiative earned official support of the Ministry of Health.
Admittedly, there is no quantitative empirical evidence on whether this initiative has, in fact, significantly decreased petty bribery in healthcare. I suspect that it did, but we do not have the data that would allow us to rigorously test that belief. Nonetheless, there are a number of other positive results that grew out of this initiative, which suggest its potential effectiveness in changing social norms regarding petty bribery in the health sector:
- First, the initiative helped medical personnel—and not only the young medical residents who pioneered the project—to start talking about the problem more openly and publicly by giving them a non-confrontational, positive medium through which they could declare their values. Getting doctors and other medical professionals simply to acknowledge that the problem exists—and is, in fact, a problem—was in itself a significant achievement. Up until then, the subject seemed to have been a taboo.
- Second, the leadership role of medical students—themselves part of the medical community—in this project helped reduce the insider v. outsider polarization that had dominated the conversation previously. It was no longer the anticorruption community alone that was talking about the issue, but rather voices from within the medical community who were raising concerns about these practices. This also made it more difficult for politicians to look away or deny the scale of the problem. The fact that the “messengers” were insiders had an effect of surprise, compared to the previous attempts to talk about the problem by the outsiders and, therefore, potentially making the message more effective.
- Third, the initiative helped to create a space for discussions about related issues. The Medical Students Association went on to develop other initiatives in the field. For example, the question about the salaries of the medical personnel is now being openly discussed, not only by doctors and hospital directors, but by the government. By disrupting social norms and taboos surrounding the compensation of healthcare providers, the initiative helped open up more space for deliberation.
This initiative is a useful example how thinking carefully about corruption’s social meaning in specific contexts can help us find new ways to fight it. This sticker initiative was low cost, did not require extensive resources or complex preparations, and was relatively easy to implement. Moreover, that same basic approach could easily be adapted for different sectors or issues. It would be naïve to expect that these sorts interventions alone could solve complex, entrenched problem like corruption—in the healthcare sector or elsewhere—but these kinds of small-scale norm-disrupting, conversation-starting interventions can be an integral part of a larger anticorruption strategy.
Thank you for sharing this unique strategy! Admiration and credit to you, TI Lithuania, and the Lithuanian Medical Students Association for coming up with such a creative and cost-effective way for combating the social norm of petty bribery.
Public education campaigns are key. But ensuring these campaigns are compelling is a difficult task. Yours is an incredibly creative and low-cost solution. I hope other countries learn of it and are able to implement it.
I am new to the anti-corruption field but recently had the opportunity to work on a research project regarding solutions for healthcare sector corruption. One of the greatest challenges was collecting solutions to combat the societal acceptance of providing bribes to healthcare providers. It is pervasive in many countries and can have devastating ripple effects (http://ti-health.org/content/bribes-for-better-healthcare-disrupting-the-sustainable-development-goals-in-unexpected-ways/).
The Updated Study on Corruption in the Healthcare Sector by the European Commission (https://ec.europa.eu/home-affairs/sites/homeaffairs/files/20170928_study_on_healthcare_corruption_en.pdf) proved to be an invaluable resource, and I would recommend the Updated Study as a fantastic launching point for those looking to address healthcare corruption.
In general, Lithuania appears to be implementing impressive measures to root out healthcare bribery. The country has implemented a multi-faceted approach through the establishment of measures geared towards patients, medical staff, and institutions (see Updated Study at 59–62). I am most eager to see the outcomes of the institutional-focused measures.
To incentivize institutions (i.e. hospitals) to prevent bribery, Lithuania has set anti-corruption standards and evaluates hospitals in accordance with these standards. The hospitals are then put into one of three categories based on their compliance: transparent institutions, candidates for transparent institutions, and institutions where not all criteria are in place and there is a higher probability of corruption (Updated Study at 61).
This strategy appears promising. It is a creative way to communicate explicit targets for hospitals to meet and to motivate hospitals to ensure mechanisms are in place to prevent bribery. Moreover, this labeling scheme is self-enforcing in a way. For instance, if the public knows that one hospital is transparent while another has a higher probability of corruption, the public would likely be inclined to choose the transparent hospital. These choices can lead to a de facto monetary punishment for the hospitals which do not implement sufficient anti-bribery mechanisms when patients choose to receive care from other institutions.
In sum, it is exciting and promising to see the many different approaches Lithuania is implementing to tackle healthcare bribery. The country could serve as an example for others looking to address this issue. I look forward to evaluations on the effectiveness of these strategies.