The Hidden Costs of Healthcare: How 'Informal Payments' Undermine European Systems
"Uncover the surprising truth about unofficial fees in European healthcare and what it means for you."
In many countries, particularly those in Eastern Europe, patients often make 'informal payments' to healthcare providers—unofficial fees for services they're already entitled to. This can range from cash to valuable gifts and are often rooted in a desire for better treatment, fear of denial, or simply following local customs. These practices can severely undermine a healthcare system based on fairness and equal access.
While seemingly small on the surface, these payments can have significant consequences. They contribute to corruption, reduce equal access to care, and create a two-tiered system where those who can afford to pay receive preferential treatment. Understanding the dynamics of these informal payments is crucial for building a more equitable healthcare system.
This article explores the hidden world of informal patient payments in Europe, shedding light on why they occur, who is most affected, and what can be done to tackle this pervasive issue, drawing insights from institutional theory.
Prevalence Across Europe
In 2019, 5% of patients across European Union member states and the United Kingdom reported making an informal payment to healthcare practitioners, the same prevalence recorded in 2013. Research using data from the 27 EU member states also examines how institutional trust and institutional asymmetry relate to informal payments. Together, these findings indicate that informal patient payments remain a persistent governance issue rather than a short-term anomaly.
Limits of Current Approaches
Research on informal payments commonly combines patient-reported data with institutional and health-system analysis. However, the available evidence does not establish that existing approaches are consistently effective at reducing these payments. Results may also vary because informal transactions are difficult to observe and measure directly, so reported prevalence should be interpreted cautiously.
From Payments to Governance
Recent research treats informal patient payments as a multi-causal phenomenon in which health-system governance may play an important role. A comparative assessment identified shortcomings across governance domains, including inadequate legal frameworks, weak enforcement mechanisms, and poor execution in practice. The same research argues that both long-term strategies addressing root causes and short-term measures targeting the payments themselves are necessary.
Why Do Informal Payments Exist? The Institutional Asymmetry
Institutional theory suggests that informal payments arise when there's a mismatch between a country's formal rules (laws and regulations) and its informal institutions (social norms, values, and unwritten rules). When these systems are out of sync, practices like informal payments can take root.
- Formal Institutional Imperfections: Legal and ethical shortcomings, socio-cultural factors (tradition of gratitude), governance failures (lack of accountability), and economic factors (underfunding).
- Institutional Asymmetry: Disconnect between formal laws/regulations and informal social norms/values.
A Three-Country Governance Assessment
A 2026 article in BMC Health Services Research examines informal patient payments through gaps in health-system governance. The study is framed as a comparative assessment of health-system governance in three European countries. Its focus reflects a continuing shift toward explaining informal payments through institutional conditions rather than treating them only as isolated patient-provider transactions.
Why Solutions May Fall Short
Measures aimed at reducing informal payments may not work uniformly across healthcare systems. Their effectiveness can depend on whether legal rules, oversight mechanisms, and institutional practices are implemented consistently. Because informal payments have multiple causes, a single intervention may address visible transactions without changing the conditions that sustain them.
Formal and Informal Payment Mixes
A comparative study reviews the relationship between formal and informal patient payments across 35 European countries. It combines quantitative analysis of macro-level data with qualitative descriptions of selected country experiences. This design treats payment arrangements as country-level mixes shaped by multiple associated factors, rather than as a uniform European pattern.
Tackling Informal Payments: A Multi-Pronged Approach
Addressing informal payments requires a comprehensive strategy that targets both formal and informal institutions. Altering informal institutions involves advertising campaigns, normative appeals, and tax education to change perceptions and behaviors regarding these payments.
A Systemic Problem
Informal payments are best understood as a systemic healthcare problem rather than only as individual misconduct. Their persistence may reflect weaknesses in governance, enforcement, institutional trust, or access arrangements. A balanced assessment should therefore recognize both patient and provider behavior while avoiding claims that one explanation accounts for every setting.
From Diagnosis to Reform
Future work on informal payments in Europe is likely to focus on why they occur, who is most affected, and which policies can reduce them. The article’s institutional-theory perspective points toward examining the rules and relationships that shape healthcare exchanges. Progress will require connecting diagnosis of the problem with practical measures that address both access pressures and governance weaknesses.
Governance and Access
Informal payments can emerge where formal healthcare arrangements do not reliably meet patients’ expectations or needs. Weak oversight, unclear rules, and unequal access may create conditions in which unofficial transactions appear acceptable or necessary. These challenges suggest that reducing informal payments requires attention to the wider organization of healthcare, not only to individual exchanges.
Access Under Pressure
During the COVID-19 pandemic, informal payments and personal connections were examined as ways of gaining preferential access to public health services. Separate research analyzed trends in informal payments using representative data from 28 EU member states between 2013 and 2019. Together, these studies show how informal arrangements can affect patients’ ability to obtain timely or preferred access, especially when public services are under pressure.
For formal institutional changes, interventions include increasing health expenditure, improving service provision, modernizing governance, and shifting focus from curative to preventative care. These measures can reduce institutional asymmetry and the urge to pay informally.
By understanding the root causes and implementing targeted interventions, Europe can strive towards more equitable and transparent healthcare systems, ensuring that access to quality care isn't determined by the ability to make unofficial payments.