Understanding the causes of informal payments through poor health system governance:Application of the TAPIC framework to policies and strategies in Denmark, Greece and Poland

Informal patient payments are still a significant problem in many health care systems in Europe. Poor health system governance is considered one of the main factors contributing to their presence. The aim of this study was to identify aspects of health system governance that can be linked to informal patient payments for publicly financed health services. Method: We used the TAPIC framework (Transparency, Accountability, Participation, Integrity, Capacity), to develop an assessment instrument that could identify gaps in health system governance and thereby the causes of informal payments. We then applied this instrument to three European countries; Denmark, Greece, and Poland where informal payments differ in scale. Our instrument includes 22 questions in the five TAPIC domains. They highlight the role of governance in eliminating the underlying reasons for informal payments, particularly in ensuring the quality of health care, and in effective penalization of informal payments. Results: Existing mechanisms failed to penalize payments that are not proven to be bribes. In Poland and Greece, where informal payments are more common, the gaps in health system governance were also more prominent than in Denmark. This indicates the importance of health systems governance for eliminating the causes of informal payments. Conclusion: Our instrument can facilitate the development of long and short-term policies and strategies to eliminate informal payments in European countries.