Explaining informal patient payments through gaps in governance – a comparative assessment of health system governance in three European countries

Abstract

Background

Informal patient payments remain a problem in many European health care systems, and poor health system governance is recognized as a key factor driving their persistence. This study aimed to assess health system governance in selected European countries, with a particular focus on factors relevant to informal patient payments.

Methods

To evaluate health system governance, an assessment instrument was developed based on the TAPIC framework, which covers five governance domains – Transparency, Accountability, Participation, Integrity, and Capacity. Available literature was used to identify aspects within the five governance domains that are relevant to informal patient payments. The content validity of the developed instrument was confirmed through a review conducted by external academic experts. The instrument was subsequently applied to three European countries, namely, Denmark, Greece, and Poland, selected for their differing prevalence of informal patient payments, with national legislation serving as a primary source of data.

Results

In Poland, and more prominently in Greece, where informal payments are more common, gaps in health system governance are more pronounced compared to Denmark. Shortcomings were identified across all governance domains, including both the absence of adequate legal frameworks and mechanisms as well as their poor execution in practice. These deficiencies are closely linked to informal patient payments or contribute to their underlying causes. They include poorly defined quality and waiting time guarantees, the absence of systems to monitor and incentivize quality of care, poor transparency regarding permissible patient payments, as well as weak accountability mechanisms that only penalize payments proven to be bribes.

Conclusions

While informal patient payments are recognized as a multi-causal phenomenon, effective health system governance may play a critical role in reducing these payments, though factors beyond governance cannot be neglected. Our results indicate that long-term and short-term strategies are necessary to target the root causes of informal patient payments as well as the payments themselves.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-026-14485-3.

Background

In all countries across the world, patients, to a lesser or greater extent, pay for health care services or goods out of their pockets, i.e., at the point of using health care [1]. Out-of-pocket spending has primarily a formal character, but in some countries, patients also make informal payments to health care providers [2, 3]. While formal patient payments have to some extent been rationalized and accepted, as they stem from the necessity for rationing health care and are considered an efficiency improvement mechanism [4], informal patient payments are beyond the control of tax offices and policymakers and are generally considered an undesirable phenomenon.

Informal payments can take different forms, i.e., in cash or in kind; given to individual health professionals or health care facilities, either before or after the provision of services; initiated by patients, or requested/hinted at by health care providers [5]. The value of these payments and their purposes can also vary greatly, e.g., they might serve as a means to reduce waiting time, obtain more services or medical professionals’ attention, or express gratitude [6, 7]. Often, it is also challenging to distinguish informal payments from formal ones when they coexist in the health care system. Payments that fall into the grey area between these two categories are sometimes called quasi-formal payments [8–10] and may not necessarily be illegal or unofficial in nature. All of this makes it difficult to formulate a definition of informal patient payments that would capture all the possible forms with sufficient precision [5, 7, 11]. For this reason, informal patient payments are commonly defined by the feature of additionality, regardless of their illegality or informality, i.e., informal payments are any payments made in addition to formal payments determined by the terms of entitlement [5].

Although public perception and attitude towards different forms of informal patient payments are not always negative [12], the possible adverse effects of these payments on households and health care system as a whole are numerous [13]. Informal payments are regressive in nature, meaning that low-income individuals are disproportionally burdened when they pay informally [14–16]. Like any out-of-pocket spending, they may also have catastrophic effects on household welfare, limiting their ability to meet other needs, or even pushing them (deeper) into poverty [17]. For households who are unable to pay informally, access and quality of care might deteriorate, thus resulting in an unequal use of health care [18, 19]. While the negative impacts on equity and household financial security can be present in any out-of-pocket payments, including formal ones, informal payments pose a greater threat because they lack protection mechanisms for vulnerable population groups, which are commonly found in formal payment schemes. Further, informal payments reduce transparency and hinder efficiency in the health care system as they might lead to the provision of inefficient services and suboptimal allocation of resources [14].

Informal patient payments are widespread in developing countries where there is a significant shortage of resources, and public health coverage is limited [18, 20]. In Europe, these payments are particularly prevalent in Central and Eastern European countries, where they flourished during the communist and post-communist transition periods (e.g. [13, 21–25]). Nevertheless, some countries in Southern Europe, particularly Greece [26–29], are also struggling with the presence of such payments. Even in Western European countries, informal patient payments also occur, as shown by the EU Eurobarometer survey [30].

The diversity of informal patient payments and their prevalence, which is not limited to one specific time in history or region, make it very challenging to point at the exact reasons for these payments. The literature indicates various hypotheses on why informal patient payments exist [6, 31–35]. At the macro level, their causes might be broadly classified into three groups, each playing some role and interlinking with the others. These include economic factors (lack of resources), governance shortcomings, and cultural norms in which informal payments are seen as token of gratitude deeply embedded in tradition [9, 36].

In this paper, we focus our attention on the role of governance in the presence of informal patient payments. Governance can be broadly defined as ”the process and institutions through which decisions are made and authority in a country is exercised” [37]. It is a multidimensional concept in social science that, although rooted in the term ”government,” extends beyond the role of government and its agencies [38–40]. It highlights the importance of other actors (e.g. private sector entities, non-profit organizations, and international organizations) and the interactions among them in public policymaking or, more broadly, in the pursuit of common goals. Governance of health systems has attracted growing attention due to the challenges health systems face today, the increasing complexity of these systems and their surrounding environments, and the shifting power dynamics among various (both new and well-established) actors [41–44]. It refers to “everything from the ability of policymakers to take evidence-based and relevant decisions to their ability to implement policies and create alignment between different actors” [45].

Although various studies have looked at the relationship between the quality of governance and informal patient payments [9, 31, 46], there is no in-depth and comprehensive analysis of what aspects of health system governance are relevant to informal patient payments. Thus, in this study, we developed an assessment instrument and aimed to assess health system governance in relation to informal patient payments across three European countries: Denmark, Greece, and Poland. These countries represent different health care systems, economies, and societies, and are heterogeneous in terms of informal patient payments. Denmark is the most economically developed country, with the highest indicators of overall governance quality [47], relatively high total health expenditure, and a low share of household out-of-pocket payments in health care spending [48]. Greece and Poland, being less wealthy countries with poorer governance indicators [47], are similar to each other in terms of health expenditure per capita, yet out-of-pocket payments play a substantially more significant role in the Greek health care system [48] (see Table 1).

Table 1.

Characteristics of analysed countries

	Denmark	Greece	Poland
Economic indicators (2023) [48]
GDP per capita, Purchasing Power Standards EU27 = 100	123.9	68.5	77.1
Current health expenditure (% of GDP)	9.51	8.39	7.10
Current health expenditure per capita, Purchasing Power Standards	4171.04	2191.20	2240.16
Out-of-pocket expenditure (% of current health expenditure)	13.98	34.30	15.85
Governance indicators a (-2.5 to + 2.5) (2023) [47]:
Governance effectiveness	2.02 (0.26)	0.15 (0.26)	0.42 (0.25)
Control of corruption	2.38 (0.17)	0.10 (0.16)	0.57 (0.15)

Note: ^a Governance effectiveness – the World Bank’s aggregate governance indicator that captures “perceptions of the quality of public services, the quality of the civil service and the degree of its independence from political pressures, the quality of policy formulation and implementation, and the credibility of the government’s commitment to such policies”. Control of Corruption – the World Bank’s aggregate governance indicator that “reflects perceptions of the extent to which public power is exercised for private gain, including both petty and grand forms of corruption, as well as capture of the state by elites and private interests” [47] The numbers represent the estimated value of the indicators along with their standard deviation

The available evidence indicates that informal patient payments for public health care are widespread in Greece [26–29, 49]. They appear at all stages of the treatment process, i.e., prior to, during and after service provision. They might be initiated by patients but are also often made upon providers’ request (e.g. according to the study by Giannouchos et al. (2020) [26] in 30% of cases). Greek patients pay informally to facilitate access to care, ensure that they will receive the necessary quality health care, and to express gratitude. In Poland, the scale of informal payments seems to have diminished over the years, though they are still present, particularly in hospital care [10, 50, 51]. They include under-the-table (cash and in-kind) payments to health care professionals, often initiated by patients to express gratitude and/or with the expectation of receiving better quality of care. Also, it has become common practice to pay in private practices to receive preferential treatment in the public system [52]. In the Danish health care system, informal payments are rare and mostly take the form of gratitude gifts.

Methods

We defined informal patient payments, following Gaal et al. (2006) [5], as any payments in addition to formal payments determined by the terms of entitlement for publicly financed health care. Thus, we considered a broad range of different forms of informal payments (including quasi-formal payments) indicated in Table 2. To conceptualize the notion of governance we applied the TAPIC framework that distinguishes five domains of governance, i.e. Transparency, Accountability, Participation, Integrity, and Capacity. This framework has been developed by the experts of the European Observatory on Health Systems and Policies, drawing on the rich literature on governance, to facilitate the assessment and improvement of health system governance [37, 45].

Table 2.

Types of informal patient payments for publicly financed health care

Forms of informal patient payments	Description
Under-the-table (cash or in-kind) payments to health care professionals	These payments are unofficial in their nature. They might be paid before or after the provision of services. The former are often considered a bribe to obtain better care, while the latter might be seen as an expression of gratitude, especially if they are in kind and of small value.
Goods and materials bought and brought to health care facility	These are goods (e.g., medicines) that are brought to health care facilities, often hospitals, by patients or their families, although they should be supplied by the health care facilities.
Cash payments to cover non-medical costs during health care utilization	These are usually official payments imposed by health care facilities (e.g., hospitals) for electricity, disinfectant liquid, etc., although these costs should be covered by the health care facilities.
Payments for “non-standard” health care services	These are official payments determined by providers, usually hospitals (e.g., for family childbirth, anaesthesia on request, individual nursing/midwife care) for (supposedly) better or extra services than the guaranteed ones, when in fact these services should be provided free of charge, or extra billing/balance billing for services/costs not covered is not allowed in the publicly financed system.
Donations by patients or their families	These are brick payments or donations to foundations established by health care facilities. Even if they are operating within a legal framework, they are considered informal payments if they can be linked to a particular episode of care. Also, they are not always fully voluntary as they might be hinted or requested by health care providers.
Overpayments on top of formal fees	These payments are often made unknowingly by patients, either because they do not know the exact amount of formal fees or are unaware of exemptions from formal payments. It is also possible that patients are aware that they pay more than is required, e.g., they do not ask for the change.
Payments for publicly financed health care when a patient mistakenly believes that the services are provided in the private sector	These payments might occur when health care facilities provide both public and private services, and the boundaries between the two are blurred. Health care providers may charge both the patient (privately) and the public payer (e.g., health insurance) for the same service.
Payments in private practices for faster access to/better quality of public health care	These payments might appear in countries where dual physician practice is allowed, and the private sector is used as a gate to (faster) access publicly financed health care and obtain better quality care in the public system. Hence, they are considered informal payments even if they are official and reported to the tax authorities.

In the first step of our study, called “item generation” [53], we developed a list of questions (questionnaire items) for each domain of the TAPIC framework. The questions reflect the aspects of health system governance identified in the literature as relevant to informal patient payments, particularly in the European context. The available systematic literature on informal patient payments and their underlying causes [3] was utilized to assist the authors in identifying relevant studies and information. The list of questions underwent multiple revisions to ensure comprehensive and coherent coverage until a consensus was reached among the research team members. In the second step, we assessed the content validity of the questionnaire through external expert review. Finally, after incorporating the reviewers’ feedback, the instrument was applied to the three European countries. The following sections provide details on each step.

Generating questionnaire items

The initial assessment instrument, developed by the research team based on the literature, included 23 questions, divided across the five TAPIC domains: Transparency, Accountability, Participation, Integrity, and Capacity.

Transparency refers to the availability of clear and public information on decisions and their justifications [45]. Poor transparency is widely recognized as a major driver of informal payments, especially when entitlements to publicly funded care – such as population coverage, service scope, quality guarantees, waiting times, and cost-sharing – are unclear [3, 22, 54–56]. To reflect this, the instrument includes items assessing the clarity of entitlements as well as the accessibility of information on provider performance, both of which influence patients’ empowerment and reduce incentives to pay informally for better or faster care.

Accountability addresses whether health actors are held responsible for their actions [45]. The literature points to weak legal frameworks and insufficient enforcement as key barriers to eliminating informal payments [3, 24]. Accordingly, we included items assessing the existence and application of penalties for informal transactions. We also considered accountability mechanisms related to roles and tasks known to impact informal patient payments, including the responsibility of public payers to ensure adequate funding for guaranteed services and of providers to deliver quality care [3, 36].

Participation is defined as the involvement of affected parties in decision-making processes [45]. Evidence suggests that engaging patients in collective health decision-making and service evaluation can strengthen their position and thus, reduce informal payments [3, 36]. We also included item related to the participatory and consensus-based policymaking on patient cost-sharing as lack of inclusive policy processes can undermine transparency and stability of the policy, fostering informal practices [9]. Moreover, the questionnaire assesses patient involvement in individual health decisions, such as shared decision-making with physicians or the ability to choose providers, which can help reduce power and information asymmetries linked to informal payments [3, 10, 13, 54].

Integrity relates to adherence to ethical norms, the rule of law, and anti-corruption principles, with informal payments and lack of commitment to combating them serving as an indicator of poor system integrity [37]. Integrity also involves clear allocation of roles and responsibilities across individuals and institutions [37, 45]. Hence, we included items assessing the separation between public and private health sectors, since unclear boundaries or dual practices can encourage informal payments, e.g. when private care is used to gain better access to public services [55]. Employment policies that reward health professionals based on their performances are also addressed, as evidence links informal payments to low salaries, job dissatisfaction, and perceived unfairness [3, 54, 55, 57, 58].

The final domain – capacity – refers to the resources and competencies needed for evidence-informed policymaking, including problem identification, policy formulation, implementation, and evaluation [37, 45]. In settings with widespread informal payments, capacity gaps, such as limited data availability, weak research infrastructure, and ineffective mechanisms for integrating evidence into policymaking, undermine effective responses [9]. To address this, the instrument includes items that assess the availability of data on informal payments, which are inherently difficult to capture due to their sensitive and hidden nature [7], as well as the extent to which research is integrated into policy processes.

Experts’ evaluation of the instrument

The main objective of the external expert evaluation was to ensure that the instrument reflected state-of-the-art knowledge by including all relevant aspects. We looked for experts with extensive knowledge of the topic. The experts were identified through the networks of the research team. Five experts from Denmark, Hungary, Lithuania, the Netherlands, and Ukraine were invited to provide feedback on the questions developed. They were all university academics and worked on the topic of informal patient payments as part of their research, education, or policymaking support, with a focus that extended beyond their country of residence. They represented different academic backgrounds, such as sociology, economics, public health, and health policy, ensuring a diversity in perspectives.

The assessment instrument was sent out to the experts via e-mail. They were asked to provide written feedback by indicating the relevance of each questionnaire item for informal patient payments on a three-point scale: not relevant (1), somehow relevant (2), and relevant (3). They could provide additional comments on each question (e.g., related to its clarity). For each dimension of governance, the experts were also asked to indicate whether any aspects, relevant in their opinion, had been omitted in the questionnaire.

Most of the questions have been evaluated by all five experts as relevant or somehow relevant. The Content Validity Index (CVI) [59], calculated as the number of experts rating the question as ‘relevant’ or ‘somehow relevant’ divided by the number of experts, ranges from 0.8 to 1. The average value of the index in the entire questionnaire was 0.9. As we have applied a very inclusive definition of informal patient payments, and the importance of some questions may vary across the countries in line with the types of informal patient payments being in place, we kept all questions even if the CVI was less than 0.9, which is the recommended threshold for the number of experts who evaluated our instrument [59]. Five additional aspects were suggested by the experts. However, after discussion among the research team, they were not added, as they largely overlapped with items already included (e.g., exemptions from formal patient payments are captured by the question on formal cost-sharing in the transparency domain) or fell rather beyond the concept of governance (e.g., having insufficient resources). Nevertheless, some questions were slightly modified to improve their clarity. The full results of the experts’ evaluation can be found in Additional file 1. Table 3 presents the final assessment instrument.

Table 3.

Health system governance assessment instrument

	YES	SOMEWHAT	NO
1. Transparency
1.1. Is the population entitled to services under the statutory health system clearly defined in legislation, and is it clearly communicated to the public?	Clearly defined and clearly communicated to the public	Partially defined and/or poorly communicated to the public	Not defined or very poorly defined/only in a few cases
1.2. Is the list of services, to which patients are/are not entitled under the statutory health system, clearly defined in legislation, and clearly communicated to the public?	Clearly defined and clearly communicated to the public	Partially defined and/or poorly communicated to the public	Not defined or very poorly defined/only in a few cases
1.3. Are quality and waiting time guarantees under the statutory health system clearly specified in legislation, and clearly communicated to the public?	Clearly specified and clearly communicated to the public	Partially specified and/or poorly communicated to the public	Not specified or very poorly specified/only in a few cases
1.4. Is the information on performance (quality, waiting time) of health care legal entities (e.g., hospitals, clinics, individual practices) collected and publicly available?	Regularly and comprehensively collected and publicly available	Partially collected and/or not publicly available	Not collected at all or only in a few cases
1.5. Is obligatory patient cost-sharing under the statutory health system clearly specified in legislation, and clearly communicated to the public?	Clearly defined and clearly communicated to the public	Partially defined and/or poorly communicated to the public	Not defined or very poorly defined/only in a few cases
1.6. Are patient payments under the statutory health system, other than obligatory cost-sharing (e.g., gratitude payments, payments to foundations, balance/extra billing), clearly regulated, and clearly communicated to the public?	All are clearly regulated and clearly communicated to the public	Some are regulated and/or poorly communicated to the public	None or almost none are regulated
2. Accountability
2.1. Are there any laws or regulations, and are they enforced in practice, to penalize individual health professionals for demanding or accepting informal patient payments?	There are laws or regulations, and they are generally enforced in practice	There are some laws or regulations, but they are occasionally enforced in practice	There are no laws or regulations
2.2. Are there any laws or regulations, and are they enforced in practice, to penalize health care legal entities (e.g., hospitals, clinics, individual practices) for demanding or accepting informal patient payments or for their employees demanding or accepting informal patient payments?	There are laws or regulations, and they are generally enforced in practice	There are some laws or regulations, but they are occasionally enforced in practice	There are no laws or regulations
2.3. Are there any laws and regulations, and are they enforced in practice, to penalize patients (or individuals acting on their behalf) for giving informal payments?	There are laws or regulations, and they are generally enforced in practice	There are some laws or regulations, but they are occasionally enforced in practice	There are no laws or regulations
2.4. Are there any mechanisms within the health system (e.g., internal whistleblowing, complaint mechanisms) to enable people to report cases of informal patient payments and be protected against reprisal?	There are mandatory/widely implemented mechanisms	There are some mechanisms, but they are partially implemented	There are no mechanisms, or they are very rarely implemented
2.5. Are there any watchdogs (e.g., committees, Ombudsman) at the national, regional, local or individual level, which are responsible specifically for protecting patients’ rights.	There are institutions at all or most levels of the system	There are institutions at some levels of the system	There are no institutions, or they are not specifically dedicated to patients
2.6. Are there established and effectively implemented mechanisms to hold health care legal entities accountable for providing adequate quality and access to care (e.g., accreditation, monitoring of errors and compliance with quality standards, quality-based payment mechanisms, etc.)?	There are mandatory/widely implemented mechanisms	The are some mechanisms, but they are partially implemented	There are no mechanisms, or they are very rarely implemented
2.7. Are there established and effectively implemented mechanisms to ensure adequate financing of the benefit package by public payer/s (e.g., cost-based price setting, population needs assessment, etc.)?	There are mandatory/widely implemented mechanisms	The are some mechanisms, but they are partially implemented	There are no mechanisms, or they are very rarely implemented
3. Participation
3.1. Is there a rule and practice of involving relevant stakeholders (including patients) in health care decision making at the local, regional, or national levels?	There is a rule which is always or almost always followed, and patients are involved	There is a rule, but it does not always apply or is partly followed, and patients’ involvement might be limited	There is no rule, or the rule is very rarely followed
3.2. Are there any monitoring and evaluation mechanisms in place that enable citizens to provide feedback on the quality of care?	There are mandatory/widely implemented mechanisms	The are some mechanisms, but they are partially implemented	There are no mechanisms, or they are very rarely implemented
3.3. Are there any mechanisms and policy initiatives to foster patient involvement in decisions regarding their health (allowing the choice of providers, promoting shared decision-making, patient empowerment, and person-cantered care)?	There are mandatory/widely implemented mechanisms as well as various policy initiatives	There are some mechanisms, but they are partially implemented, and policy initiatives are occasional	There are no mechanisms or policy initiatives, or both are very rare
3.4. Has the participatory and consensus-based approach been applied to policy on obligatory patient cost-sharing in the statutory health system?	Participatory and consensus-based approach has been applied (policy is accepted by all stakeholders)	Participatory and consensus-based approach has been partly applied	Participatory and consensus-based approach has not been applied
4. Integrity
4.1. Are there any specific missions, strategies, codes of conduct to fight/prevent informal patient payments, which authorities and institutions are committed to?	There are missions, strategies, codes of conduct, and authorities and institutions demonstrate commitment to implementing them	There are some missions, strategies, codes of conduct, but they are generally focused on corruption and/or authorities and institutions demonstrate little commitment to implementing them	There are no missions, strategies, or codes of conduct
4.2. Are the public sector and private sector well separated, i.e., are health care legal entities allowed to provide both public and private services, and are medical professionals allowed to work in both the public and private sectors?	They are well separated	They are partly separated	There are not separated or very poorly separated
4.3. Are there any regulations and mechanisms to take into account the performances of health professionals when hiring, promoting, and remunerating them?	There are regulations and mandatory/widely implemented mechanisms	The are some regulations and mechanisms, but they are partially implemented	There are no regulations and mechanisms, or they are very rarely implemented
5. Capacity
5.1. Are there any specific institutions that provide evidence and support health policymaking, including policy on patient payments (e.g., HTA agency, research institutes)?	There are institutions, and they provide evidence for policy making on a regular basis	There are some institutions, but they do not provide evidence on a regular basis	There are no institutions dedicated to this purpose
5.2. Is there a mechanism and practice of relying on evidence in health policymaking?	There is a mandatory mechanism and/or it is a common practice	There is a mechanism, but it is partially put into practice	There is no mechanism, or it is an uncommon practice
5.3. Are reliable data (e.g., from national household surveys) on informal patient payments systematically collected and available for policymakers?	Reliable (complete and accurate) data are systematically collected and readily available	Reliable data are collected but not systematically, or data are only partially reliable	Data are not collected, or they are not reliable

Application of the instrument

In the last step, we applied the assessment instrument to the three countries, i.e., Denmark, Greece, and Poland. We provided descriptive answers to the questions of the instrument for the countries. Through rounds of discussion among the research team, the responses were classified into one of the categories: ‘yes’ (indicating governance aspects that are likely to prevent informal patient payments, ‘somewhat’, and ‘no’ (indicating conditions that might be contributing to informal patient payments). We completed the third stage relying largely on countries’ legislation being in place at the time of our study (May 2023) and other sources (official government websites, and reports from national and international institutions). A full list of country information sources can be found in Additional file 3. When no literature was available (e.g. on how a given mechanism or regulation works in practice), we relied on the national expertise of our research team members.

Results

This section presents the results of the health system governance assessment in Denmark, Greece, and Poland, based on the instrument described in the methods section. Table 4 illustrates the main findings. Descriptive responses that provide greater insight into the situation in each country are provided in Additional file 2 and are summarized in this section.

Table 4.

The assessment of health system governance in Denmark, Greece, and Poland

	Denmark	Greece	Poland
1. Transparency
1.1. Is the population entitled to services under the statutory health system clearly defined in legislation, and is it clearly communicated to the public?	Y	Y	Y
1.2. Is the list of services, to which patients are/are not entitled under the statutory health system, clearly defined in legislation, and clearly communicated to the public?	S	Y	Y
1.3. Are quality and waiting time guarantees under the statutory health system clearly specified in legislation, and clearly communicated to the public?	Y	N	N
1.4. Is the information on performances (quality, waiting time) of health care legal entities (e.g., hospitals, clinics, individual practices) collected and publicly available?	Y	N	S
1.5. Is obligatory patient cost-sharing under the statutory health system clearly specified in legislation, and clearly communicated to the public?	Y	Y	Y
1.6. Are patient payments under the statutory health system, other than obligatory cost-sharing (e.g., gratitude payments, payments to foundations, balance/extra billing), clearly regulated, and clearly communicated to the public?	S	S	S
2. Accountability
2.1. Are there any laws or regulations, and are they enforced in practice, to penalize individual health professionals for demanding or accepting informal patient payments?	Y	S	S
2.2. Are there any laws or regulations, and are they enforced in practice, to penalize health care legal entities (e.g., hospitals, clinics, individual practices) for demanding or accepting informal patient payments or for their employees demanding or accepting informal patient payments?	Y	N	S
2.3. Are there any laws and regulations, and are they enforced in practice, to penalize patients (or individuals acting on their behalf) for giving informal payments?	Y	S	S
2.4. Are there any mechanisms within the health system (e.g., internal whistleblowing, complaint mechanisms) to enable people to report cases of informal patient payments and be protected against reprisal?	Y	Y	S
2.5. Are there any watchdogs (e.g., committees, Ombudsman) at the national, regional, local or individual level, which are responsible specifically for protecting patients’ rights.	Y	Y	Y
2.6. Are there established and effectively implemented mechanisms to hold health care legal entities accountable for providing adequate quality and access to care (e.g., accreditation, monitoring of errors and compliance with quality standards, quality-based payment mechanisms, etc.)?	Y	N	N
2.7. Are there established and effectively implemented mechanisms to ensure adequate financing of the benefit package by public payer/s (e.g., cost-based price setting, population needs assessment, etc.)?	Y	N	S
3. Participation
3.1. Is there a rule and practice of involving relevant stakeholders (including patients) in health care decision making at the local, regional, or national levels?	Y	S	S
3.2. Are there any monitoring and evaluation mechanisms in place that enable citizens to provide feedback on the quality of care?	Y	N	N
3.3. Are there any mechanisms and policy initiatives to foster patient involvement in decisions regarding their health (allowing the choice of providers, promoting shared decision-making, patient empowerment, and person-cantered care)?	Y	S	S
3.4. Has the participatory and consensus-based approach been applied to policy on obligatory patient cost-sharing in the statutory health system?	Y	N	S
4. Integrity
4.1. Are there any specific missions, strategies, codes of conduct to fight/prevent informal patient payments, which authorities and institutions are committed to?	S	S	S
4.2. Are the public sector and private sector well separated, i.e., are health care legal entities allowed to provide both public and private services, and are medical professionals allowed to work in both the public and private sectors?	S	S	S
4.3. Are there any regulations and mechanisms to take into account the performances of health professionals when hiring, promoting, and remunerating them?	N	N	N
5. Capacity
5.1. Are there any specific institutions that provide evidence and support health policymaking, including policy on patient payments (e.g., HTA agency, research institutes)?	Y	Y	Y
5.2. Is there a mechanism and practice of relying on evidence in health policymaking?	S	N	N
5.3. Are reliable data (e.g., from national household surveys) on informal patient payments systematically collected and available for policymakers?	N	N	N

Note: Y – yes, S – somewhat, N – no

In all five domains, gaps in health system governance are the least common in Denmark. Greece and Poland perform much worse, particularly in the accountability and participation domains. Between these two countries, gaps are more frequently observed in Greece. The poorest overall performance, considering all three countries, is found in the integrity and capacity domains.

Transparency

Governance gaps in the transparency domain are less common than in other domains. The three countries clearly specified who is entitled to publicly financed health care, though in Poland, the main basis for the entitlement is insurance status, which can be verified via an electronic system [60], while in Denmark and Greece, the right is granted to all residents [61, 62].

In Greece and Poland, the benefit package is clearly defined, whereas in Denmark, the list of services is only broadly specified [60, 61, 63]. These lists are publicly available (e.g., on governmental websites) and communicated to the public [64–66], though they might not be easy to understand for all. In Denmark, the guaranteed quality and waiting time for care are specified. The maximum waiting time of 30 days is specified giving the right to a patient to use services in the private sector without extra charge. These aspects are also systematically measured, and information on waiting times for various treatments, clinical performance of providers, and patient-reported experiences is publicly available to help patients make an informed choice about their providers [67, 68]. In the other two countries, with some exceptions (e.g. elective surgery waiting times in Greece [69]), the law does not define patient entitlement to quality and timely care. Moreover, consumers do not have access to information on the quality of care by different providers, and information on waiting times is available to patients only in Poland (since 2018) [70].

Obligatory patient payments for publicly financed health care are clearly defined in all three countries, with no obligatory fees for primary care, outpatient specialist care, and hospital care (in Greece, only in public health care facilities) [60, 63, 65, 71]. However, there is less transparency when it comes to non-obligatory payments under the statutory health system. Namely, in all countries, there is no list of goods and their values that can be legally given to health care providers as an expression of gratitude, which makes it difficult to distinguish between bribes and gratitude payments. Voluntary formal payments for upgraded or additional services (balance and extra billing) are allowed and regulated by the state in Greece [72]. In Poland, these payments have been considered by the public payer as illegal, though the regulations are not clear enough to prevent providers from extra billing patients in the past [73].

Accountability

Denmark performs very well in the accountability domain, which contrasts with the gaps observed in the other two countries, particularly noticeable in how accountability mechanisms are used in practice. In all analysed countries, there are criminal law regulations in place to penalize individuals (health care professionals, patients, and people acting on their behalf) involved in informal payment transactions, though only when they are reported and proven to have a bribery nature [74–76]. The severity of the penalty depends on the scale of the crime, with the highest maximum penalty in Greece, i.e., 10 and 8 years of imprisonment for accepting and giving a bribe, respectively. In Greece, disciplinary actions may also be taken independently of criminal proceedings under civil service law, which applies to physicians working full time within the National Health System [77]. Additionally, health care professionals can be held accountable for ethical and professional-conduct violations before disciplinary courts run by medical associations, as in Greece and Poland, with penalties ranging from a warning to a deprivation of the right to practice the profession [78, 79]. In Denmark, this function is carried out by an independent public statutory authority, i.e. the Health Service Disciplinary Board (Sundhedsvæsenets Disciplinærnævn) that investigates complaints about the professional conduct of individual health care professionals [80]. Additionally, in certain cases the Danish Patient Safety Authority, which supervises health care facilities and health professionals, might initiate an investigation [81]. Nevertheless, in the two countries where informal payments are more common – Greece and Poland – these laws and professional regulations are not often enforced in practice [82]. In Denmark and Poland, there are also regulations to penalize health care legal entities if undue payments are revealed in these institutions (e.g., in Poland, it is the fine of a max. 2% of the contracted amount) [83, 84].

Specific mechanisms to report informal patient payments anonymously or confidentially (identity must be kept confidential), and thus be protected against reprisal, are present in Greece and Denmark [85, 86], while in Poland they are not commonly implemented yet. In all countries, there are institutions responsible for protecting patient rights, where incidents of informal patient payments can also be reported [87–89]. These institutions operate at different levels, from national (e.g., the Patient Complaints Agency in Denmark, Styrelsen for Patientklager) to individual (provider) level (the Office for the Protection of Health Service Recipient Rights in public hospitals in Greece [62]).

The difference between Denmark and the other two countries is also evident in how accountability is assigned for aspects of health care that contribute to informal patient payments, i.e., quality of care and financing of the benefit package. Poland and Greece do not yet have mechanisms to effectively hold health care providers accountable for the quality of care. There is no mandatory (internal or external) evaluation of health care providers or reporting of medical errors. Only in recent years have some steps been taken towards quality monitoring and incentivizing health care providers based on their performances in both countries [90, 91]. Similarly, the two countries do not have strong and effective mechanisms to ensure adequate financing of services in the benefit package. In Poland, public health expenditure is largely determined by the available resources from health insurance contributions, and the cost-based tariffs for services began to be set in 2015 but have not yet been developed for all services [60, 92]. In Greece, public health expenditure is covered through social health insurance contributions and government transfers allocated based on the previous year’s budget for health [91]. Also, cost-based service tariffs have not been fully implemented yet. On the other hand, Denmark has implemented various quality-improvement initiatives that increase the accountability of health care providers for their performances [93–95]. Danish hospitals undergo regular mandatory external accreditation, and a national system requires the reporting of adverse events. Patient complaints are handled nationally by a dedicated agency – the Danish Patient Complaints Agency. A clinical data-based quality monitoring system is in place, with mandatory participation from all hospitals. Provider performance data are also publicly disclosed [96]. In terms of financing, the allocation of tax resources to municipalities and regions in Denmark is based on negotiations and objective criteria to account for population needs and performed tasks [97].

Participation

Participation is another area where Poland and Greece fall behind Denmark, especially in the implementation of existing laws. Public consultation of normative acts is mandatory in all three countries [98–100]. However, the influence of patient organizations on the policymaking process remains limited in Poland and Greece. This is due to the still weak professionalization of these organizations and their fragmentation, despite some institutionalization of their role in recent years (e.g., the establishment of the Patient Organization Council at the Ministry of Health in Poland) [91, 101]. In these two countries, consumers are also not yet systematically involved in the evaluation of provider performance, unlike in Denmark, where patient feedback is collected through the annual National Study of Patient Experiences [102].

The involvement of patients at the individual level is facilitated in all countries through free choice of health care providers [103–105]. However, patient participation in treatment decisions and patient empowerment are still limited in Poland and Greece [73, 91], and these two countries are behind Denmark in terms of the promotion of person-centred care and shared decision-making [103].

There is generally weak consensus on formal patient cost-sharing for services in Greece, where the policy on obligatory fees for inpatient and outpatient services has been changing over the years [72]. In Poland, there have also been discussions on the need to extend cost-sharing, mostly spurred by health care providers [106]. However, due to strong public opposition, no government has decided to put patient payments on the policy agenda. On the other hand, in Denmark, there is a common agreement that patient payments should not be a part of the equity-driven Danish health care system [107].

Integrity

We assessed integrity through the existence of mission statements, strategies, and codes of conduct to prevent or eliminate informal patient payments. None of the countries has developed strategies specifically targeted at informal patient payments. In Denmark, this is considered unnecessary, as informal patient payments have never posed a significant problem. However, in all countries, we have identified strategies/plans aimed at fighting corruption in general that might include actions in the health sector as well [108–110]. In Denmark, there are also codes of conduct on gift-giving, issued by the government [111], while in Poland, some health care institutions specify procedures for giving and receiving gifts [112].

Strengthening integrity through the separation of the public and private health sectors is not fully implemented in the countries analysed as the private sector exists alongside the public one, and they both overlap. Health professionals can work in both sectors, and health care institutions can provide public and private services [113–115]. The rules specify that the provision of private services should not reduce quality and access for patients using public care, and that secondary employment may not conflict with the main employment. However, in practice, this separation is very challenging in all three countries.

Across all countries examined, regulatory frameworks and employment policies do not systematically incorporate health professionals’ performance in their employment and remuneration criteria [73, 91, 116]. There are no incentive structures in place to encourage professionals to provide good quality care.

Capacity

The capacity of government to formulate and implement effective policies seems greater in Denmark than in Greece and Poland, though gaps exist in all three countries. Although all countries have institutions to provide evidence for policymaking, such as VIVE in Denmark [117] or the National Institute of Public Health – National Research Institute in Poland [118], the mechanisms and practice of involving evidence in policymaking are weak, particularly in Poland and Greece [82, 119]. Reliable data on informal patient payments to inform policymakers are not systematically collected in any of the analysed countries, apart from scattered evidence provided by researchers or think tanks, most commonly from Greece [82]. In Denmark, this can be attributed to the limited scale of informal patient payments, which are generally not considered a significant issue.

Discussion

This study assesses health system governance in three European countries, i.e., Denmark, Greece, and Poland, using an instrument developed based on the TAPIC framework. It contributes to the literature on informal patient payments and their causes [2, 3, 7, 18, 54] by identifying governance aspects that may foster informal patient payments and thus, indicating measures to tackle them.

The results show that the most prevalent gaps in health system governance are present in Greece, followed by Poland. In these two countries, the shortcomings are observed across all five governance domains, i.e. transparency, accountability, participation, integrity, and capacity. In contrast, Denmark where informal patient payments are rare, shows much better performance, particularly in holding health system actors accountable for their actions and involving them in decision-making processes.

The identified gaps refer to the underlying reasons for informal patient payments and informal patient payments themselves. In line with the previous evidence [82], this suggests the need for both long-term and short-term strategies to eliminate informal patient payments. Specifically, within the five domains of governance, we identified various aspects related to governance for quality of care that are still lacking in Greece and Poland. These include quality and waiting time guarantees, measurement and public reporting of quality and waiting time with patient involvement in providing feedback on those aspects, mechanisms to motivate and hold providers accountable for quality and timely access, incorporating performance evaluation into employment policies of medical professionals, and mechanisms for ensuring adequate financing of the benefit package. These elements reflect a comprehensive approach to quality assurance in health care that addresses three components: (a) setting standards, (b) monitoring, and (c) promoting improvement, while targeting a broad range of stakeholders [120]. Denmark serves as a strong example of a country that has implemented comprehensive strategies for quality improvement in health care across various governance domains [96]. Other European countries with notable initiatives, particularly in transparency (measurement and public reporting) and accountability include the Netherlands, the United Kingdom, and Germany [120].

The long-term strategies can be combined with measures that are more easily implemented to bring more immediate results (short-term strategies), and which directly address informal patient payments [82]. Based on the countries’ analysis, we observed that one of the barriers to holding involved parties accountable for informal payments is the lack of laws and regulations to penalize informal payments that are not bribes, allowing consumers to make gratitude payments. At the same time, the existing legislation does not make a precise distinction between bribes and gratitude payments, leaving a grey area between the two and making it difficult to hold accountable for informal payments, even if they are in fact bribery. The literature indicates that even payments made ex-post and not initiated by providers might not have a true gratitude and voluntary nature, as they may affect the use of subsequent services in the treatment process by the same provider, or they are given because the patient feels the provider expects payment [6, 12]. Moreover, the supposed gratitude payments might be of high value and/or constitute a financial burden for households [121]. Thus, specifying through regulations, guidelines, and codes of conduct how patient gratitude can be expressed seems to be the right step forward.

Our results also show that the main mechanism for penalizing informal payments is situated outside the health system, i.e., within criminal law. Punitive legal procedures often take a long time, and enforcement authorities are not always interested in penalizing informal payments, which might be considered less severe than other crimes [82]. This discourages the reporting of informal payments, and in both countries, Poland and Greece, informal payments are rarely disclosed. Hence, establishing accountability mechanisms within the health care system, independent of medical professional self-government bodies, for both professionals and health legal entities could be a more feasible and effective measure to address informal patient payments. For example, Denmark has an independent authority, the Health Service Disciplinary Board, which handles professional-conduct cases involving individual health care practitioners. In Poland, health care providers can be financially punished by the National Health Fund (the public payer) for undue patient payments. Nevertheless, for such measures to be effective, there must be a reliable mechanism for reporting informal payments, while also ensuring the protection of the reporting person’s identity [122].

The shortcomings observed in the two countries struggling with informal patient payments concern both structural elements – such as the existence of laws, institutions, and mechanisms – and processes, i.e. how these are implemented, enforced, and function in practice. For instance, while all countries have regulations and even institutions intended to incorporate evidence and stakeholder input into policymaking or to hold providers accountable for accepting bribes, these measures are often ineffective in practice. One possible reason lies in limited transparency, as previously noted in the context of the blurred distinction between bribes and gratitude payments. Another explanation may be institutional weakness, including a lack of public trust, path dependency, and informal norms. The mismatch between formal and informal norms has already been highlighted in previous studies on informal payments, pointing to the need to bridge this gap through education and awareness campaigns as well as adjustments to formal regulations to better align them with socially accepted norms – provided these norms do not have negative social effects [123, 124].

Our results also contribute to the growing literature on governance and its importance in achieving health system goals and tackling various health system challenges [125–130]. The added value of our study lies in the application of the TAPIC framework and the developed assessment instrument. Given the relevance of governance and its complexity, various frameworks have been proposed to facilitate its conceptualisation and measurement [43, 131]. The TAPIC framework, which we used, was developed through an inductive approach by identifying governance attributes from other frameworks and classifying them into five domains [37, 132]. Thus, it is considered to present the concept of governance in both a comprehensive and practical manner. The TAPIC framework has already been applied in several studies [129, 130, 133–138]. We extend its use to assess governance in the elimination of informal patient payments, adding to the still-needed evidence of the application of governance frameworks [43]. The proposed assessment instrument can be further developed and validated, e.g. by incorporating a broader range of stakeholders beyond academia, to ensure its comprehensiveness and broader applicability. It may serve as a valuable source for policymakers, and policy advisors in identifying areas for improvement to eliminate informal patient payments.

Study limitations

This study has several limitations that need to be acknowledged. First, when developing the assessment instrument, we relied on an existing review that did not specifically focus on governance. Thus, it is possible that we may have missed some important aspects. Although the external experts provided assurance regarding the comprehensiveness of our questionnaire, their views reflect an academic perspective. Our questionnaire might also not capture all the differences across countries, as the items are rather broad to be able to reflect the diversity of informal payments and the broad nature of the concept of governance. The questionnaire also measures governance in terms of structure (e.g., whether there are mechanisms, norms) and process (how they are implemented, communicated), rather than outcomes, (i.e., whether they achieve their intended impact) [139]. Having structures and processes in place does not ensure the outcomes are achieved, but focusing on necessary structures and processes is more meaningful from policymaking perspective.

When applying the assessment instrument to the three countries, we focused on the legislation in force at the time of the study, with less consideration given to the time of its implementation or any past/future legislation. However, it should be remembered that health systems are often subject to reform, and the situation is rarely static. At the same time, the effects of the implemented changes may not be visible until several years later. The results may be also prone to subjectivity bias as we had to rely on our knowledge of the country when answering some questions and categorizing the countries. We tried to reduce this bias by discussing each response for the three countries among the research team when making the categorization. We also included descriptive answers to each question in Additional file 2. Finally, by focusing on governance, our study overlooks other factors, such as cultural norms or economic conditions that also affect informal patient payments and efforts to eliminate them.

Conclusions

In this study, we assessed health system governance in three European countries and identified gaps that might contribute to informal patient payments. Our results highlight the weaknesses of governance in two countries that struggle with informal patient payments (Greece and Poland), which refer to the underlying reasons for informal patient payments that might require large-scale reforms, as well as aspects directly linked to informal patient payments. Among the former are poor transparency in health coverage (including quality and waiting times guarantees); the lack of a quality monitoring system that produces data available for patients to inform their decisions and is used to hold health care facilities and individual professionals accountable for their performances; and the absence of mechanisms that link resource allocation to population needs and costs of services. The factors directly related to informal patient payments include the absence of a precise distinction between bribes and gratitude payments, with sanctions being applicable only for bribes and primarily situated outside the health care system. We also observed that the gaps include both the structural aspects of governance (such as the existence of laws, institutions, and mechanisms) and the practical functioning of these structures (processes). Addressing the latter may be more challenging, especially when institutions are still weak or when formal rules conflict with cultural norms.

The importance of each governance aspect for the presence of informal patient payments might be context-specific and vary across countries. There is a variety of patient payments that exist between formal payments and under-the-table payments, or that occur at the interface between public and private sectors. These various payments might require a differentiated approach to tackle them, and they all require more policy and research attention. When developing strategies to eliminate informal patient payments other factors beyond governance should also be considered, including cultural norms, institutional maturity, and financial capacity, as they all shape state actions and their outcomes.

Supplementary Information

Below is the link to the electronic supplementary material.

Abbreviations

CVI

Content Validity Index

GDP

Gross Domestic Product

TAPIC

Transparency, Accountability, Participation, Integrity, and Capacity

Author contributions

Conceptualization: MT, SBM, PK; Data curation: MT, SBM, PK, DAB, Formal analysis: MT, SBM, PK, DAB, LEK; Investigation: MT, SBM, PK, DAB, LEK; Methodology: MT, SBM, PK, LEK; Supervision: MT; Writing – original draft: MT; Writing – review & editing: MT, SBM, LEK, PK, DAB.

Funding

The article processing charge was funded by internal funds of the Jagiellonian University Medical College.

Data availability

All data generated or analysed during this study are included in this published article [and its supplementary information files].

Declarations

Ethics approval and consent to participate

This study was performed in accordance with the Helsinki Declaration. Ethics approval and consent to participate were deemed unnecessary according to applicable regulations, i.e. the Act of 10 May 2018 on the protection of personal data, and the Announcement no. 22 of the Proxy of the Rector of the Jagiellonian University for Research and Development at the Medical College of 2 December 2015 regarding the type of research requiring the opinion of the Bioethics Committee of the Jagiellonian University. The collected data solely comprised the opinions of other researchers on the developed assessment tool or consisted of publicly available information on national regulations and health care systems.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.