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Informal patient payments are deeply rooted in Central and Eastern European countries. Despite the socio-political changes in the health care sectors after 1990s and the subsequent health care reforms, informal payments for health care services continue to serve patients` and physicians` interests. These payments also fill gaps in health care funding in this European region. Nevertheless, unofficial payments are not a desirable payment channel. They lack transparency and distort the efficiency and equity in health care provision. Still, the successful elimination of these payments will depend on the public attitude towards these payments. This study aims to compare public attitudes towards informal patient payments and payment experience in six Central and Eastern European: Bulgaria, Hungary, Lithuania, Poland, Romania, and Ukraine. The data have been collected in 2010 in nation-wide representative surveys using an identical standardized question- naire administrated via face-to-face interviews. We have collected about 1000 questionnaires in each country. The results show that a major group of respondents in each country expresses a negative attitude towards both informal cash payments and in-kind gifts. 208, 187, and 174 respondents paid informally for out-patient service in Ukraine, Romania, and Hungary respectively. We also analyse the relation between public attitudes and respondents` past experience with informal payments, e.g. whether they have paid informally payment for out-patient service used last year. In Bulgaria and Poland, negative attitude is mostly observed among those who have not paid informally. The existence of positive and indifferent attitudes towards informal pay- ments as reported in our study, indicates a challenge for policy makers in Central and Eastern European countries. The acceptance of government initiatives aimed at the elimination of informal payments will largely depend on the governments` ability to create a social resistance towards these payments.

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.