The ASSPRO CEE 2007 project confirmed that informal patient payments remain an important feature of healthcare systems in virtually all Central and Eastern European countries. The findings have led to high-level policy discussions in Bulgaria, Hungary, Poland and Romania, and even led to a review of patient payments legislation in Lithuania and Ukraine.

Identifying informal patient payments

“While official patient charges (user fees) were introduced in most Central and Eastern European countries following the collapse of communism, these have until now never been systematically evaluated,” explain project coordinators Milena Pavlova and Wim Groot from Maastricht University in the Netherlands. “We were concerned at the start of this project that official patient payments impose a double financial burden on consumers because of the persistence of informal payments for healthcare services.”

The project found that informal payments are still routinely paid to both healthcare providers in hospitals and general practitioners in regional polyclinics. “Informal payments can take monetary as well as non-monetary form, and can be classified into three main groups,” say the coordinators.

“The first group includes informal payments that cover the costs of medical supplies and personnel; the second group comprises informal payments resulting from the misuse of market power by the healthcare providers due to monopoly; while the third group covers informal payments for services not covered by public healthcare budgets.”

These informal patient payments are problematic because they distort healthcare financing and put those who cannot afford to pay informally in a disadvantageous position. They also introduce perverse incentives in the patient-doctor relationship, which can result in corruptive behaviour – patients can bribe doctors to receive better services for example. “For a proper evaluation of official patient payments therefore, the persistence of informal payments must be taken into account,” adds Groot.

Assessing the impact of informal payments

The project revealed that taken together, formal and informal patient payments in the Central and Eastern European region do indeed result in a large share of patients being unable to pay for healthcare, obliging them to take loans to use primary or hospital care or to even forego healthcare.  

“In Bulgaria, Hungary, Lithuania and Poland, inability to pay was observed among 20 to 30 % of patients,” says Pavlova. “In Romania and Ukraine, inability to pay was reported by about 50 % of patients. This underlines the significance of the affordability issue in Central and Eastern Europe’s healthcare sectors.”

The project also found that around 60 to 70 % of the general public would be willing to pay extra for better services. “This is especially evident in countries where healthcare quality and access problems are more persistent,” says Pavlova. “Central and Eastern European healthcare reforms must therefore focus on a more efficient allocation of available healthcare resources to tackle these issues at a micro-level, rather than on macro-level reforms with no visible effects for the patients.”

Next generation of healthcare researchers

ASSPRO CEE 2007, which was completed in February 2013, also helped to train up young researchers from Central and Eastern European countries. In total, eight young researchers completed and defended a PhD thesis as a result of this project.

“All eight were offered academic positions across Europe after the project ended. The project also boosted opportunities for three regional SMEs who were closely involved in the project, and opened the door to several new projects under the Erasmus+ and the EU Health Programme (2008-2013) involving Central and Eastern European partners.”