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Healthcare accessibility and equity remain important issues, as corruption in the form of informal payments is still prevalent in many countries across the world. This study employs a panel data analysis over the 2006-2013 period to explore the role of different institutional factors in explaining the prevalence of informal payments. Covering 117 countries, our findings confirm the significant role of both formal and informal institutions. Good governance, a higher trust among individuals, and a higher commitment to tackling corruption are associated with diminishing informal payments. In addition, higher shares of private finance, such as out-of-pocket and domestic private health expenditure, are also correlated with a lower prevalence of informal payments. In policy terms, this displays how correcting institutional imperfections may be among the most efficient ways to tackle informal payments in healthcare.

Although major advances have been made in relation to explaining the supply side of the informal economy, this is not the case for the demand-side of the informal economy. This study analyses for the first time the purchasers of undeclared goods and services in the healthcare sector. To evaluate the purchase of undeclared healthcare goods and services, logistic regression analysis and robustness tests are used on 3048 interviews in Cyprus, Greece, Italy and Malta. The finding is that an important share of the purchasers make this type of purchase unknowingly. However, no difference in terms of socio-economics characteristics of those who knowingly and those who unknowingly made purchases of undeclared healthcare goods and services was identified. Meanwhile a significant influence of trust (in government and in other citizens) has been identified in relation to those who made these purchases knowingly. As such, policy measures aimed at decreasing unknowing purchases and at nurturing trust are discussed in the concluding section.

Confronted with a global pandemic, public healthcare systems are under pressure, making access to healthcare services difficult for patients. This provides fertile ground for using illegal practices such as informal payments to gain access. This paper aims to evaluate the use of informal payments by patients during the COVID-19 pandemic and the institutions that affect the prevalence of this practice. Various measurements of formal and informal institutions are here investigated, namely the acceptability of corruption, the level of trust, transparency, and performance of the healthcare system. To do so, a logistic regression of 10,859 interviews with patients conducted across 11 Central and Eastern Europe countries in October-December 2020 is employed. The finding is that there are large disparities between countries in the prevalence of informal payments, and that the practice is more likely to occur where there are poorer formal and informal institutions, namely higher acceptability of corruption, lower trust in authorities, lower perceived transparency in handling the COVID-19 pandemic, difficult access to, and poor quality of, healthcare services, and higher mortality rates due to the COVID-19 pandemic. These findings suggest that policy measures for tackling informal payments need to address the current state of the institutional environment.