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

backgroundInformal 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.

methodsTo 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.

resultsIn 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.

conclusionsWhile 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.