Informal payments for health care services present an important and challenging policy issue in most of the Central and Eastern European countries [1, 2]. These payments violate the transparency in the financing of the health care systems and jeopardize the accountability of the providers. They also lead to inefficient use of health care resources [1–3] and inequalities in access to health care services [4–6].
The definition of informal payments varies across the literature and reflects cultural differences in the perception of informal payments [2, 7, 8]. However, authors agree that these payments are unofficial, i.e. they are outside the official payment channels (not registered by the state and made without an official receipt of payment). Various types of informal payments can be distinguished based on who initiates the payments (the patient or the provider), who receives the payment (medical staff, institution), who makes the payment (patient or relatives), what the nature of the payment is (cash or in-kind), when the payment is made (given ex-ante or ex-post), what the purpose/motivation of these payments is (patient's gratitude, tip or fee for service) . Also the legal status of informal payments might differ across countries (whether it is explicitly forbidden by the law). They can be legal (not forbidden or even permitted by the law), or illegal (forbidden by law although sometimes condoned by governments) .
Overall, informal payments are seen as a rather complex phenomenon interrelated with different socio-cultural, legal-ethical and economic factors in a country. These factors have been extensively discussed in the literature [1, 2, 6, 7, 9–11]. According to the socio-cultural explanation, informal payments are considered as a tip and expression of patient’s gratitude (e.g. [4, 7]). Based on the legal-ethical considerations, the existence of informal payments can be explained by the lack of control and accountability of governance structures . The economic explanation mostly refers to the shortage of resources in the health care sector, low salaries of physicians and the existence of an informal market for services provided with better quality (e.g. [7, 12, 13]). However, the differentiation between these factors is rather difficult due to the “shadow” nature of the informal payments (i.e. the returns of informal payments cannot be measured and they are not compellable). Also, these factors might differ across countries. In low and middle income countries (e.g. Ukraine, Tajikistan, Armenia, Kyrgyzstan and Georgia), informal payments are an important source of health care financing [9, 14]. While in Central Europe (in Hungary for example), informal payments mostly contribute to the salary of health care personnel .
Most of the empirical studies on informal patient payments aim to estimate the magnitude of these payments and their determinants, while there is less scientific evidence on the perception of health care actors related to these payments [8, 16]. To be able to understand why informal payments are widespread, the perceptions and attitude of health care consumers towards these payments are one of the key factors (besides factors on the provider side). Thus, evidence on this issue may support policy making related to the eradication of informal payments.
In this study, we address the issue of informal payments, defined as unofficial cash or in-kind payments given to the health care personnel, in Hungary where such payments are widespread, especially in hospital care [6, 16, 17]. The aim of the study is to examine the perceptions of Hungarian health care consumers related to informal payments. For the analysis, we use data from a household survey carried out in 2010 in Hungary on a country-representative sample of 1037 respondents. We use cluster analysis to identify the main attitude groups related to informal payments. We also use multinomial logistic regression to examine the differences between these groups in terms of socio-demographic characteristics, as well as past utilization and informal payments for hospital services. Although we focus on Hungary, our results are relevant for other countries where informal payments are widespread.
Background: informal payments in Hungary
In Hungary, some authors consider informal payments as the heritage of the socialist system while others argue that these payments existed even before the socialist period . However, health care consumers are still regularly paying informally for health care services even 20 years after the fall of the communist regime. According to the results of a previous study, in 2007, 9% of the patients paid informally for their last visit to a GP (€2 on average), 14% paid informally for specialist care (€35 on average), and 50% paid informally for hospitalization (€58 on average) . Informal payments are most widespread in case of gynecology visits, delivery and for surgical admissions [17, 19].
The attitude of the Hungarian government towards informal payments has been rather controversial during the last decades. On the one hand, several Ministry Committees and policy measures have addressed the problem of informal payments in Hungary (including media campaigns against informal payments, the increase of the salaries in the public sector as well as the introduction of co-payments for health care services). However, despite these arrangements, there were no significant changes regarding the magnitude of these payments during this period [16, 17]. On the other hand, the national regulations do not explicitly forbid informal patient payments. Since July 2012, the Labor Code in Hungary prohibits receiving informal payments. However, the employer has the right to dispense the employees from this decree. Thus, in a way, the government tolerates informal payments in the health care sector. The reason for this tolerance might be that informal payments contribute to the system funding by complementing the income of health care personnel [2, 3, 9].
This idea is supported by the standpoint of the medical profession, as the Ethic Codex of the Hungarian Medical Chamber declares that “…one of the explanations of the existence of informal payments is the low salary of the physicians and the dysfunction of the health care system.” (, quoted in ). The studies show that indeed, in Hungary, informal payments are paid to the medical staff and contribute to their salary [16, 19]. According to the estimations of Gaál et al. (2006), physicians may have earned between 60% and 236% of their net official income from informal payments. However, they also point out that these payments are unequally distributed among physicians: 5% of them receive 60% of the informal payments . This can imply that beneficiaries of informal payments might have the power to block important changes in the health care system to maintain the status quo.
Regarding the consumer side, the literature on Hungary suggests that informal payments are not only the expression of gratitude of health care consumers, but a kind of “fee for service” to receive better quality, quicker access and more attention . More precisely, health care consumers pay informally because they are afraid that they will have less chance to obtain these services and benefits if they do not pay informally to the health care personnel [6, 7, 18]. Gaál and McKee (2004) consider informal payments as a reaction to the “declining” performance in the health care system . According to the authors, dissatisfied health care consumers, who have no possibility to satisfy their needs elsewhere or cannot openly complain, are using informal channels (such as informal payments) to obtain the care they desire.