Framing effects in measurements of petty corruption in healthcare – a survey experiment

Informal payments in healthcare, a common form of petty corruption in Eastern European EU countries, raise significant measurement challenges. One in four patients reportedly engage in such transactions, which can involve cash or in-kind exchanges outside formal channels. The debate in health literature is divided: some view these payments as a corrupt practice, while others see them as a culturally ingrained, benign phenomenon reflecting the societal role of physicians. This ambiguity complicates measurement efforts at national and international levels. Media and policymakers often compare trends in informal payment prevalence over time or assess policy impacts using survey estimates (from Eurobarometer, Global Corruption Barometer etc), but the specifics of measurement nuances is seldom discussed. Our study delves into the influence of question framing on reporting informal payment experiences in healthcare, highlighting how survey question formulations can shape perceptions and reports of corruption. This study utilizes both secondary and primary data to examine framing effects in survey measures of petty corruption in public healthcare provision. We analyze Eurobarometer 397 survey data from 2014, focusing on 16,051 respondents who had interactions with the healthcare system. This analysis compares responses to questions framed neutrally (without mentioning words such as corruption or bribery) and those framed in a more loaded manner (asking respondents whether they have been asked or expected to make a bribe). Descriptive analyses identify associations between framing and self-reported informal payment experiences. To establish causal framing effects, we conducted an online survey experiment in Bulgaria and the UK, randomly assigning participants to respond to neutrally or loaded framed questions, paralleling those in the Eurobarometer. Additional analyses examine the differential effects of nationality and corruption-related social norms, assessed through Latent Class Analysis. Our findings indicate that question framing is significantly associated with differences in bribery reporting, with notable variations across countries. The Eurobarometer data reveal mixed framing effects on petty corruption reporting. In some countries, neutral framing correlates with higher self-reported corruption experiences, while in others, loaded framing elicits higher corruption prevalence. The experimental study confirms a significant, positive influence of neutral framing on self-reported informal payment experiences. Breaking down these differences by social norms, we find that respondents with a high-corruption social norm (beliefs about others like them making informal payments) are more likely to report informal payment experiences. However, this discrepancy between high- and low-corruption norm groups is significant only in the loaded treatment group. Our study underscores the profound impact of question framing on reported healthcare corruption experiences. It highlights the necessity for sensitivity in framing corruption measurement surveys and calls for a critical examination of measurement approaches in media and policymaking reports, especially when discussing trends over time and across countries.