Trends in Informal Payments by Patients in Europe: A Public Health Policy Approach

Abstract

Background: A new institutional approach toward informal payments in healthcare views informal payments as arising when there is a misalignment between values/norms (informal institutions) and the formal rules (formal institutions) of patients. However, less knowledge is available on the effectiveness of this approach in tackling informal payments in healthcare. This study aimed to fill this gap by evaluating the trends in the effect of institutional misalignment on informal payments made by patients.Methods: A quantitative study design with data extracted from the last three waves of special Eurobarometer surveys on corruption was used to model the propensity of European patients in 27 European Union countries and the United Kingdom to make informal payments. Multilevel logistic regression analysis was employed in order to test the relationship between the formal–informal institution misalignment and the likelihood to make informal payments. Sensitivity analyses were also performed to test the robustness of the findings.Results: The finding is that there is a strong association between the formal–informal institution misalignment and the likelihood to make informal payments for public healthcare services. Similarly, social norms play a pivotal role. When patients perceive that informal practices are widespread in the public healthcare sector they are more likely to make informal payments themselves.Conclusion: The outcome is a call for complementing deterrence measures toward informal payments in healthcare with measures aiming to reduce the formal–informal institution misalignment and to change the social norms. This can be achieved by improving the structural conditions at country level and by changing values/norms and beliefs of patients.

What Lies Behind Substantial Differences in COVID-19 Vaccination Rates Between EU Member States?

“…However, there are other battles to come, so it is essential to learn the lesson and prevent future escalations of the problem. In line with the findings presented in this paper, as well as from other studies on the misalignment between formal and informal institutions (27,34,36), the key emphasis must be on improving the integrity of public institutions. Among other things, this would require increased transparency, improved efficiency of administration, a decisive fight against corruption, and promotion of meritocracy in the public sector.…”

“…All coefficients have the expected signs, namely higher trust implies higher readiness to get vaccinated and vice versa. As already mentioned, there is a large body of literature identifying a weak psychological contract between the state and citizens as the key force behind the rising occurrence of informal practices in post-socialist countries (27,34). While less harmful forms of noncompliance commonly arise from formal institutions failing to deliver goods and services on time and/or under satisfactory quality, more serious offenses (e.g.…”

“…While less harmful forms of noncompliance commonly arise from formal institutions failing to deliver goods and services on time and/or under satisfactory quality, more serious offenses (e.g. undeclared work and akin tax evasion activities) are increasingly the result of rebellion against massive, ineffective, and over-intrusive state apparatus (26)(27)(28)(29)(30)35). Our findings suggest that similar mechanisms are probably in place when it comes to COVID-19 vaccination, meaning that many people in transition societies probably refuse it simply to defy the authorities.…”

“…trust in the authorities) and horizontal trust (trust in fellow citizens) (36). Previous studies have shown that nepotism, string-pulling, bribery and akin practices inherited from the socialist period still represent a substantial impediment to economic and social development in these "newer democracies" (26,27,34). Besides forcing many people to build their own informal networks of trust, weak rule of law has also nurtured the culture of obstruction of the ruling elites.…”

“…Notable examples of informal activities that not only stem from, but also contribute to, the state's failure to deliver high-quality goods/services on time are string-pulling, petty corruption in healthcare (i.e. gratuity and gifts to medical practitioners), and undeclared work(26)(27)(28)(29). The roots of detachment from the authorities trace back to the period of socialism, which was characterized by vast and inefficient public administration(30)(31)(32).…”