Sharing healthcare costs in Central and Eastern Europe: The quest for fair and sustainable policies

Striking the right balance between providing healthcare services and paying for those services is a challenge for all societies. In Central and Eastern European (CEE) countries, this challenge is complicated by a mix of formal and informal patient payments that have evolved through decades of political change. In order to assess the patient payment policies in the region, the European Union launched a major collaborative research project a few years ago known as ASSPRO CEE 2007. Preliminary results from the project show just how diverse payment policies are in CEE states, and why any effort to change those policies should be approached with considerable caution.

The ASSPRO research project is analysing the efficiency, equity and quality effects of patient payment policies in six countries of the CEE region. Five of these - Bulgaria, Hungary, Lithuania, Poland, and Romania - are EU Member States, and one - Ukraine - is on the European Union’s eastern perimeter. What all of these countries have in common (to greater or lesser degrees) is a tradition of patients paying informally for healthcare. These can be voluntary or involuntary cash payments or payment in kind rendered to both medical staff in hospitals and physicians in policlinics. As the ASSPRO consortium reminds us, the practice is strongly associated with healthcare provision in former socialist countries, although it is sometimes also seen in prosperous parts of Western Europe.

Informal patient payments are highly problematic from a policy perspective. They distort the healthcare system in numerous ways: by jeopardising efficiency, undermining equity and ultimately compromising the quality of healthcare. Indeed, the ASSPRO researchers make it quite clear that informal payments constitute a threat to public health. The most serious risk associated with these kinds of payments is that patients who cannot afford them may postpone or forego medical treatment.

Those who live in a system where informal patient payments are common may concede that the practice is less than ideal. But changing that system and introducing a viable alternative can be extremely difficult. One reason is that the practice tends to be culturally embedded. Beyond that, its persistence is frequently attributed to a chronic lack of resources for healthcare provision. Taking this into account, the researchers decided to survey the attitude of different healthcare stakeholders toward the idea of introducing (or expanding) a system of formal patient fees. The results (see Figure 1) show considerable differences in attitude among healthcare consumers, providers, policy makers and insurers.


Figure 1 – Support for formal patient fees by country (median values)



0 = strongly oppose, 1 = oppose, 2 = neither support/oppose, 3 = support, 4 = strongly support

Source: ASSPRO CEE 2007 European Policy Brief: Patient payments in Central and Eastern Europe: The opinions of health care stakeholders (forthcoming).

In all six countries examined, the research reveals that healthcare consumers are the group who least support formal patient fees. This is especially true of Lithuania and Poland, regarded as economically advanced CEE countries. Healthcare providers, insurers and policy makers, on the other hand, generally favour formal fees, regardless of what country they happen to be in. Interestingly, the researchers note that stakeholders across the board are united in doubting that official fees can reduce or eliminate informal patient payments. This is especially visible in the case of Bulgaria, where official fees for healthcare services were introduced a decade ago but informal payments for such services continue to exist.

While the ASSPRO team acknowledges differences in the specific policy context of each country examined, the consortium has succeeded in formulating a number of insights aimed at providing policy makers with guidance on this vital issue. The following suggestions (stated for inclusion in a forthcoming ASSPRO Policy Brief) are addressed to policy makers at the European level:

  • Encourage countries to improve governance and accountability in their healthcare sectors and urge them to create a transparent system of monitoring and control with regard to both healthcare use and payments for healthcare services.
  • Develop professional codes of conduct related to non-medical activities of physicians and other health professionals at the European level, where the request or acceptance of any informal payment (either in cash or in kind) is banned. This ban should extend to gratitude payments.
  • Establish instruments to increase awareness among European patients, physicians and policy makers about the negative effects of informal patient payments. Promote patients’ rights, particularly the right of access to healthcare services of adequate quality with no informal charges or gratitude payments.
  • Promote research on the measurement of corruption in the healthcare sector in general and on informal patient payments in Europe in particular. This research should combine quantitative and qualitative research methods from a broad range of fields related to socio-economic science and humanities.

ASSPRO CEE 2007 - Assessment of patient payment policies and projection of their efficiency, equity and quality effects. The case of Central and Eastern Europe (duration: 1/3/2008 – 28/2/2013). FP7 Socio-economic Sciences and Humanities, Activity 6 “Socio-economic and scientific indicators", Research area 6.2 "Developing better indicators for policy". Collaborative project (small and medium scale focused research project).


Contact: Milena Pavlova,