The decline of informal payments for healthcare in Romania: understanding change through patients’ voices

Informal payments have long been embedded in the Romanian healthcare system. However, Eurostat data indicate a sharp decline in reported informal payments, from 28% in 2013 to 9% in 2023, with a ten-percentage-point drop in 2023 alone. This paper examines the factors behind this change from the perspective of healthcare users. Drawing on in-depth interviews with 27 patients from various regions of Romania and using the constructivist grounded theory framework, the study investigates participants’ perceptions of and experiences with informal payments, as well as their views on the causes behind the decline. The reduction in informal payments can be attributed to salary reforms for medical staff, the expansion of private healthcare, migration opportunities for health professionals, anti-corruption efforts, and patients’ greater exposure to foreign healthcare systems. Higher salaries reduced the financial need for informal payments, while private healthcare and migration allowed dissatisfied practitioners to leave the public system. At the same time, reforms and anti-corruption campaigns contributed to denormalizing the practice. The study shows that in order to curb informal payments, it is necessary to concurrently address the structural and cultural determinants of the practice.