The Companion Pandemic to COVID-19: The Use of Informal Practices to Access Public Healthcare Services in the European Union.

Objectives: The objective of this paper is to evaluate the use of informal payments and personal connections to gain preferential access to public health services during the COVID-19 pandemic and to propose effective policy measures for tackling this phenomenon. Methods: Using data from 25,744 patients in the European Union, six different scenarios are analyzed in relation to making informal payments and/or relying on personal connections to access public healthcare services. To evaluate the propensity to engage in informal practices in healthcare, probit regressions with sample selection and predicted probabilities are used. Robustness checks are also performed to test the reliability of the findings. Results: For each scenario, a statistically significant association is revealed between the propensity to make informal payments and/or rely on personal connections and the asymmetry between the formal rules and the patients' personal norms and trust in public authorities. Conclusion: To tackle informal practices in healthcare, policy measures are required to reduce the asymmetry between the formal rules and personal norms by raising trust in public authorities.

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

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.

Institutional Determinants of Informal Payments for Health Services: An Exploratory Analysis across 117 Countries.

Healthcare accessibility and equity remain important issues, as corruption in the form of informal payments is still prevalent in many countries across the world. This study employs a panel data analysis over the 2006-2013 period to explore the role of different institutional factors in explaining the prevalence of informal payments. Covering 117 countries, our findings confirm the significant role of both formal and informal institutions. Good governance, a higher trust among individuals, and a higher commitment to tackling corruption are associated with diminishing informal payments. In addition, higher shares of private finance, such as out-of-pocket and domestic private health expenditure, are also correlated with a lower prevalence of informal payments. In policy terms, this displays how correcting institutional imperfections may be among the most efficient ways to tackle informal payments in healthcare.

Informal Payments by Patients in Central and Eastern Europe during the COVID-19 Pandemic: An Institutional Perspective.

Confronted with a global pandemic, public healthcare systems are under pressure, making access to healthcare services difficult for patients. This provides fertile ground for using illegal practices such as informal payments to gain access. This paper aims to evaluate the use of informal payments by patients during the COVID-19 pandemic and the institutions that affect the prevalence of this practice. Various measurements of formal and informal institutions are here investigated, namely the acceptability of corruption, the level of trust, transparency, and performance of the healthcare system. To do so, a logistic regression of 10,859 interviews with patients conducted across 11 Central and Eastern Europe countries in October-December 2020 is employed. The finding is that there are large disparities between countries in the prevalence of informal payments, and that the practice is more likely to occur where there are poorer formal and informal institutions, namely higher acceptability of corruption, lower trust in authorities, lower perceived transparency in handling the COVID-19 pandemic, difficult access to, and poor quality of, healthcare services, and higher mortality rates due to the COVID-19 pandemic. These findings suggest that policy measures for tackling informal payments need to address the current state of the institutional environment.

Drivers behind widespread informal payments in the Romanian public health care system: From tolerance to corruption to socio-economic and spatial patterns.

In order to explain informal payments in public health care services in Romania, this paper evaluates the relationship between extra payments or valuable gifts (apart from official fees) and the level of tolerance to corruption, as well as the socio-economic and spatial patterns across those individuals offering informal payments. To evaluate this, a survey undertaken in 2013 is reported. Using logistic regression analysis, the findings are that patients with a high tolerance to corruption, high socio-economic risk (those divorced, separated, or with other form of marital status, and those not working), and located in rural or less affluent areas are more likely to offer (apart from official fees) extra payments or valuable gifts for health care services. The paper concludes by discussing the health policy implications.

Rethinking informal payments by patients in Europe: An institutional approach.

The aim of this paper is to explain informal payments by patients to healthcare professionals for the first time through the lens of institutional theory as arising when there are formal institutional imperfections and asymmetry between norms, values and practices and the codified formal laws and regulations. Reporting a 2013 Eurobarometer survey of the prevalence of informal payments by patients in 28 European countries, a strong association is revealed between the degree to which formal and informal institutions are unaligned and the propensity to make informal payments. The association between informal payments and formal institutional imperfections is then explored to evaluate which structural conditions might reduce this institutional asymmetry, and thus the propensity to make informal payments. The paper concludes by exploring the implications for tackling such informal practices.