Making Patients Pay: Informal Patient Payments in Central and Eastern European Countries

Informal patient payments are a key characteristic of nearly all Central and Eastern European health care systems (1–3). Apart from formal patient payments, which are regulated by national legislation (4) and quasi-formal charges, which are set by the health care provider in the absence of clear government regulations (5–7), there are also informal payments (also known as “under-the-table” or “envelope” payments), which comprise the unregistered patient payments for publicly funded health care services (7–9). In addition to this, there are also quasi-informal payments for goods that should be provided free of charge to the patient by the health care establishment but that patients are asked to purchase outside and bring for the treatment. Indeed, out-of-pocket patient payments are a major source of health care funding in Central and Eastern European countries (10). Informal patient payments warrant special attention as ignoring these payments causes an underestimation of total health expenditure and their hidden nature imposes a great challenge to the health care provision in terms of accessibility as well as accountability and transparency (2, 11–13). Informal payments constitute about 1.5–4.6% of total expenditure on health in Hungary, about 0.3–0.5% in Poland, and about 2% in Bulgaria (14). Furthermore, a few decades ago, informal patient payments were consideredmostly as “gratitudemoney,” or a socio-cultural phenomenon (5). Currently,multi-dimensional explanations, such as insufficient resources (low income of physicians) and inadequate governance (poor political-regulatory context) combined with the socio-cultural reasons prevail in the literature (15–17). These three dimensions are rather interwoven leading jointly to the existence of a specific pattern of informal patient payments in a country. Empirical studies on informal payments are one of the main sources of evidences on this multifaceted phenomenon; however, they comprise a variety of methodological challenges (7), including (a) the identification of a suitable sample unit (patients, citizens, providers, and/or officials), (b) a socio-culturally acceptable data collection mode (face-to face interviews or self-administrated questionnaires) (18, 19), and (c) adequate operational definitions of informal patient payments because some respondents find it difficult to distinguish between formal and informal payments (9, 20). The difficulties related to an adequate methodology design and implementation may explain the focus of most empirical studies on single countries and on the scale and determinants of these payments rather than on complex multi-country comparative studies (7). Still, a huge variety in the nature and patterns of informal patient payments is reported across countries (7). Studies provide evidence on the variation in the type of informal payments (cash or in-kind gifts given by patients or their families), timing (before, after or during service provision), subject (outor in-patient service), purpose (obtaining better quality or access), andmotivation (physician’s request or patient’s initiative) (1, 3, 8). Last but not least, the key characteristics of informal patient payments studied should also include the perceptions and attitudes toward these payments, which are the most indicative in a