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In the post-communist countries, limited access to treatment, lack of financial protection mechanisms, lack of information and low quality of health care frequently imposes an enormous burden on family’s well-being when cancer is diagnosed. While many studies have explored barriers to cancer treatment, little attention is paid to the question how patients and their caregivers cope with cancer. In this paper, we systematically review the evidence on patients’ coping strategies with cancer in post-communist countries. We performed a literature search in PubMed, JSTOR, Web of Science and EBSCO (CINAHL) to identify papers that describe patients’ coping strategies because of organizational and financial barriers to cancer treatment. Papers published between January 1991 and January 2020 were included if they described individual experiences of patients at any stage of cancer treatment. We applied the Preferred Reporting Items for Systematic Literature Review as a guide for our review. In total, 28 publications from post-communist countries were included in this review. They presented evidence on coping strategies and barriers faced by patients when coping with poor access to cancer treatment, lack of finances, lack of information and low quality of health care services. Most sought coping strategies included using personal finances to pay for medical services, medicines and supplies, charitable contributions to the hospital and informal payments; visiting a private medical doctor; using personal connections and looking for additional information. We conclude that coping strategies are similar across post-communist countries and can be seen as an indicator of the shortcomings in cancer treatment. This evidence can be used to study and/or improve access to cancer treatment and improve health care policies. Research on the prevalence and quantification of coping strategies is needed to provide evidence-informed policies for countries that face gaps in cancer treatment.

This paper analyzes patterns of tips, gifts and bribes paid by patients for health care services. Informal payments are more prevalent in developing and transition countries because the economic and socio-cultural environment is more conducive to “gifts”-exchange as a means to maintain the underfunded health care system. Moreover, most Eastern European countries have experienced wider socio-political reforms, which have also affected health care service provision and have led to a greater reliance on informal patient payments in the access and quality assurance of health care services. This study provides evidence on public attitudes and recent experiences with informal patient payments in post-Soviet and post-communist countries, namely in Lithuania, Ukraine and Poland. The empirical results suggest a lower share of informal patient payments as well as a prevalence of more negative attitudes towards informal patient payments in Poland compared to Lithuania and Ukraine. Informal payments are more common and more expensive for in-patient health care services in contrast to out-patient ones in all countries. Still, in post-Soviet Lithuania and Ukraine informal patient payments co-exist with other types of patient payments such as quasi-formal patient payments. When clear regulation of the basic package and formal patient charges is lacking, patients experience a mixture of payment obligations. About three quarters of the respondents support the statement that informal patient payments should be eradicated. It is proposed therefore that governments of the countries should meet public expectations and implement a strategy to deal with informal patient payments. In all three countries, informal patient payments (both “bribes and fees”) are a symptom of system failure and provide a means for patients to obtain the health care they desire, which the government is not able to guarantee. Suitable regulations coupled with (dis)incentives may decrease the level of informal payments for health care provision.

Background Although the literature offers various theoretical explanations for the existence of informal patient payments, empirical research has mostly focused on socio-demographic features as determinants of these payments. The role of health-care users’ perceptions on informal payments are rarely taken into account especially in multicountry surveys. Objective Our aim is to examine the association between informal payments for health-care services and perceptions of health-care consumers about paying informally as well as socio-demographic characteristics. Design We use data from a multicountry quantitative empirical research conducted in 2010. Setting and participants A national representative sample is drawn in six Central and Eastern European countries – Bulgaria, Hungary, Lithuania, Poland, Romania and Ukraine. In each country, about 1000 respondents are interviewed. Main variables studied Data related to informal payments for health-care services consumed during the preceding 12 months are analysed in addition to data on respondents’ perceptions about paying informally and socio-demographic data. Results Health-care users in Bulgaria and Poland are less inclined to make informal payments, while health-care users in Romania and Ukraine most often report such payments. The informal payment rates for Hungary and Lithuania fall between these two groups. In all six countries, individuals who feel uncomfortable when leaving the physician's office without a gratuity and who feel unable to refuse the request of medical staff to pay informally, more often make informal payments. Conclusions Such consumers’ perceptions can undermine policy efforts to eradicate these payments; therefore, health policy measures should reinforce social resistance to informal payments.

In this study we aim to compare the public perceptions towards informal patient payments in six Central and Eastern European countries (Bulgaria, Hungary, Lithuania, Poland, Romania and Ukraine). Overall, around 35–60% of the general public in each country has ever made informal payments, though informal cash payments are perceived negatively, mostly as corruption. In-kind gifts are often seen as a token of gratitude. However, significant differences among countries are observed. Despite the public support for the eradication of informal payments, there are population groups who favor their existence and this should be taken into account in policy-making.

Maternity care in Ukraine is a government priority. However, it has not undergone substantial changes since the collapse of the Soviet Union. Similar to the entire health care sector in Ukraine, maternity care suffers from inefficient funding, which results in low quality and poor access to services. The objective of this paper is to explore the practice of informal payments for maternity care in Ukraine, specifically in cases of childbirth in Kiev maternity hospitals. The paper provides an ethnographic study on the consumers' and providers' experiences with informal payments. The results suggest that informal payments for childbirth are an established practice in Kiev maternity hospitals. The bargaining process between the pregnant woman (incl. her partner) and the obstetrician is an important part of the predelivery arrangement, including the informal payment. To deal with informal payments in Kiev maternity hospitals, there is a need for the following: (i) regulation of the "quasi-official" patient payments at the health care facility level; and (ii) improvement of professional ethics through staff training. These strategies should be coupled with improved governance of the health care sector in general, and maternity care in particular in order to attain international quality standards and adequate access to facilities.

The lack of systematic research on the assessment of patient payment policies emphasizes the need to evaluate the mechanisms of official patient charges. This paper aims to contribute to this research area by outlining a comprehensive framework for the assessment of patient payment policies, and by validating it on data for six CEE countries (Bulgaria, Hungary, Lithuania, Poland, Romania and Ukraine). Three broad groups of assessment criteria are included in the framework: policy context, policy content and policy effects. Within each of these groups, several sub-groups of criteria are defined. Our application of the assessment framework to the six CEE countries shows its relevance for the comparison of patient payment policy across countries, and for outlining common policy options. At the same time, it also reveals the need of collecting data on other relevant indicators that are not included in this paper, as well as for updating indicators already included. Research on patient payments will be essential for a continuous monitoring of patient payment policies (e.g. those in CEE) and their prompt adjustment.

The healthcare systems of many European post-communist and post-Soviet countries have been considerably affected by informal patient payments (also known as ‘under-the-table’ or ‘envelope’ payments) (Chawla et al., 1998; Gaal et al., 2006; Stepurko et al., 2010). The definition of informal patient payments usually includes a cash or in-kind supplement to the official payment for healthcare services (Belli, 2002; Gaal et al., 2010) as well as payments for commodities, such as pharmaceuticals (Lewis, 2000). Additionally, informal payments take place outside the official payment channels (Lewis, 2007), and payers may not even know that they are making an informal payment if they are not well informed about official fees (Thompson and Witter, 2000). Still, informal patient payments are not always perceived as illegal (Ensor, 2004; Gaal et al., 2006; Lewis, 2000) especially when the legislation and codes of ethics (even the moral codes) in the country fail to prescribe proper conduct and behaviour. As a result, informal patient payments are typically not prosecuted. Besides, the healthcare sector is not unique in such behaviour. Informal payments are also seen in other areas, for example in education, police, court and customs offices (Miller et al., 1998; Polese, 2008). Thus, general moral dispositions in society such as ‘everything that is not forbidden is allowed’ may well predispose to the existence of informal payments in the healthcare sector.

Informal payments for health care services are a well-known phenomenon in many health care systems around the world. Deeply ingrained informal practices accepted by both providers and consumers, and neglected by the government, seem to be a major impediment to ongoing health care reforms. The examination of level, scope and consumer’s perceptions of informal patient payments in Central and Eastern European (CEE) countries is the aim of the thesis. Based on national representative samples, the most empirical data are collected in 2010 in six CEE countries and in 2011 in three CEE countries. The results of the cross-country comparison suggest a relatively higher prevalence of informal patient payments in Romania and Ukraine, then in Hungary and Lithuania and much lower than in Poland and in Bulgaria. In the latter one, patients also meet formal service charges in the public sector. The patterns of informal patient payment confirm more incidents and higher expenditures for hospitalizations than for ambulatory care. Although users resort to informal patient pursuing better quality, quicker access and better attention, public opinions towards informal patient are quire negative and associated with corruption suggesting users’ willingness to elimination of this practice. Hereby, governments should meet public expectations and implement a strategy for dealing with informal patient payments.

Informal payments for health care are a well-known phenomenon in many health care systems around the world. While informal payments could be an important source of health care financing, they have an adverse impact on efficiency and access to care, and are a major impediment to ongoing health care reforms. This paper aims to study the scale and patterns of informal patient payments for out-patient and in-patient services in three former-socialist countries: Bulgaria, Hungary and Ukraine. The data are collected in 2010 and 2011 based on national representative samples and are analysed in pooled models to explain variations in payments. The results of the cross-country comparison suggest a relatively higher prevalence of informal patient payments in Ukraine and Hungary than in Bulgaria, where patients also have to pay formal user charges in the public sector. Nevertheless, informal payments for hospitalization in Bulgaria are quite extensive. We observe some differences in informal payments across the years. Variations in payment size are mainly explained by the nature, type and need for services, fee awareness and, on some occasions, by household income. Interpreted within the context of structural differences (e.g. reform paths, regulations, funding, user fees, anti-corruption policies), the findings of our study have implications on how to address informal payments for health care.