Background. The dominant view in the literature is that informal payments in healthcare universally are a negative phenomenon. By contrast, we theorize that the motivation healthcare users for making informal payments (IP) can be classified into three categories: (1) a cultural norm, (2) “grease the wheels” payments if users offered to pay to get better services, and (3) “sand the wheels” payments if users were asked to pay by healthcare personnel or felt that payments were expected. We further hypothesize that these three categories of payments are differently associated with a user’s outcomes, namely, satisfaction with healthcare, local and national government, satisfaction with life, and satisfaction with life of children in the future. Methods. We used microdata from the 2016 Life-in-Transition survey. Multivariate regression analysis is used to quantify relationships between these categories of payments and users’ outcomes. Results. Payments that are the result of cultural norms are associated with better outcomes. On the contrary, “sand the wheel” payments are associated with worse outcomes. We find no association between making “grease the wheels” payments and outcomes. Conclusions. This is the first paper which evaluates association between three different categories of informal payments with a wide range of users’ outcomes on a diverse sample of countries. Focusing on informal payments in general, rather than explicitly examining specific motivations, obscures the true outcomes of making IP. It is important to distinguish between three different motivations for informal payment, namely, cultural norms, “grease the wheels,” and “sand the wheels” since they have varying associations with user outcomes. From a policy making standpoint, variation in the links between different motivations for making IP and measures of satisfaction suggest that decision-makers should put their primary focus on situations where IP are explicitly asked for or are implied by the situation and that they should differentiate this from cases of gratitude payments. If such measures are not implemented, then policy makers may unintentionally ban the behaviour that is linked with increased satisfaction with healthcare, government, and life (i.e., paying gratitude).
IP is defined as a direct contribution in cash or gifts that is in addition to any formally required contributions and which are made by users to healthcare personnel or others acting on their behalf [1, 2]. Since such payments are made out of the counter and under the table, they are not part of formal healthcare expenditures and can be made in the form of cash such as small tips and large sums of money, or through various types of gifts such as flowers and sweets, and before or after receiving services . IP is a subsection of a wider category of out-of-pocket payments . Thus, out-of-pocket payments represent the amount of IP and legitimate legal fees paid in the healthcare sector taken together. Legitimate fees may include copayments for compulsory and voluntary health insurance schemes and payments for healthcare services which are not covered by compulsory and voluntary health insurance schemes.
Various estimates show that IP represents the lion’s share of out-of-pocket payments . For instance, the share of IP has reached 96% in Pakistan  and 74% in Azerbaijan . Even in EU and OECD countries, incidents of IP are high, reaching 35% in Poland, 41% in Lithuania, and 17% in the Czech Republic and Slovakia . From the standpoint of health policy and planning, such a large share of IP underlines a shift in healthcare funding from a solidarity approach that is based on budget-financed or insurance-financed schemes, to an individualistic approach where consumers are expected to bear the main responsibility for healthcare costs [8, 9].
Against this background, the literature highlights a lack of studies on association between different motivations for IP and user outcomes and points out that the current literature tends to evaluate overall effect of IP without considering different motivations for making IP [10, 11]. With the above evidence in mind, we theorize that the motivations for making could be grouped into three broad categories, namely, “cultural norm,” “grease the wheels,” and “sand the wheels.” We further theorize that the direction of association between IP and satisfaction is not universal and depends on the specific motivation for making IP. More specifically, we hypothesize that “cultural norm” and the “grease the wheels” conceptualization of IP may be associated with positive user outcomes, while the “sand the wheels” conceptualization will have an opposite association. To test these hypotheses, we separately analyze the effect of each of the above-discussed theoretical motivations of IP on user well-being. This approach allows us to shed light on differences in the association between the various motivations for making IP with a wide range of users’ outcomes. In this way, the study answered to the following three research questions: (1)How do each of these motivations influence satisfaction with public healthcare?(2)How do each of these motivations influence satisfaction with local and national governments?(3)How do each of these motivations influence satisfaction with one’s own life and expected satisfaction with the future life of one’s children?
The unique contribution of this study is threefold. First, as far as we know, this is the first study which tests for plausible variation in the influence of the different conceptualizations of IP on users’ outcomes on a large sample of countries. Second, we test for the influence of IP on a wide range of outcomes including satisfaction with local and national governments and satisfaction with one’s own life and expected satisfaction with the future life of one’s children.
Finally, we focused on postcommunist countries where incidents of IP are high and have a prolonged history. Historically, under the Semashko system, the state in the communist countries assumes the primary responsibility to provide universal healthcare to the citizens free at the point of utilization . However, considerable shortage in the available public funding together with the nonexistence of official and legitimate mechanisms for engaging private healthcare expenditures led to widespread inequalities in access in the 1970s and IP became an important factor in ensuring access to rationed public healthcare since 1970s [13, 14]. The role of IP in providing access to public healthcare further grew through 1980 as postcommunist countries were not able to sufficiently increase public finding for healthcare and IP became widespread in forms of cash and small gifts, for instance, liquors, cigarettes, and perfume [15–17]. Collapse of communist economic system in the 1990s increased the spread of IP since the profound and protracted political and economic crisis associated with transition from communist further reduced public funding for healthcare [18, 19].
To curb IP, postcommunist countries embraced the wide range of healthcare reforms and each postcommunist country has chosen their own way for reforms with at least four main models were utilized: (1) to introduce compulsory health insurance system, (2) to implement guaranteed benefit packages for specific types of healthcare services or for specific population groups (e.g., maternal healthcare and healthcare for internally displaced people), (3) to use some combination of both above-described approaches, and (4) to remain with a traditional model of healthcare financing where healthcare funding is paid from the general budget revenue [20–23]. The fully comparable data about current characteristics of the healthcare systems in postcommunist countries is hard to find, so Table 1 provides the available information from the Global Health Expenditure database by the WHO that is the most reputable source of cross-country comparison for healthcare .
Government schemes and compulsory contributory health care financing schemes
Voluntary health care payment schemes
Household out-of-pocket payment
Bosnia and Herzegovina
Data is from the WHO’s Global Health Expenditure database by WHO at https://apps.who.int/nha/database/Select/Indicators/en. Household out-of-pocket expenditures encompass informal payments (IP) and various legitimate fees, as detailed in Introduction.