Equity in access to health care in Serbia: Exploring the role of informal patient payments in health care in the Western Balkan

Sofie Buch Mejsner

Research output: ThesisPh.D. thesis


Informal patient payments (IPP) are discussed in various literature, showing negative effects on the access to health care, health equity, and population health. They include gifts and bribes given to health care providers to receive (easier) access to health care
services. These payments may widen health inequities in societies, as those who are able to pay or those with favourable networks may receive (easier) access to health care services. Countries in transition often face challenges with the growing complexity of governance of their health systems. Informal patient payments are seen as a symptom of poor health systems governance. Evidence regarding informal patient payments and their effect on inequity in access to health care in the Western Balkan countries and in particular Serbia is scarce. This thesis sought to contribute in filling this knowledge gap.

Aim and research questionsThe overall aim of this thesis was to examine informal patient payments and equity inaccess to health care as parts of health systems governance. The thesis identifies anddescribes the process through which these payments may take place, using Serbia as acase. Evidence from the other Western Balkan countries were included to capture theoverall picture on informal patient payments (including also bought and brought goods)in the region. The specific objectives of the thesis were:

1. To explore existing evidence on informal patient payments in Western Balkan and toanalyse what are public health civil servants’ perceptions on informal patient paymentsand service provision, and how do they perceive governance of the health care systemin Serbia? (Paper I)

2. To explore what is known about informal patient payments and bought and broughtgoods in Western Balkan, to examine their influence on healthcare, and to identify fromthe evidence what actions can be taken to tackle this problem? (Paper II)

3. From a health governance and equity perspective, to specifically investigate what are civilservants’ and asylum-seeking migrants’ perceptions of informal patient payments inSerbian health care and barriers and facilitators to access care? (Paper III and IV)

MethodsQualitative methods were used as means of data collection. The pilot study (Paper I)included both empirical data and a literature review. The empirical part consisted ofsemi-structured interviews of public health civil servants and health care providers(n=4), which was analysed using a phenomenological hermeneutical approach. Theliterature review focused on mapping the existing evidence of informal patient8payments in all Western Balkan countries. The pilot study was followed by a deeperexploration of the existing evidence regarding informal patient payments in the region.In the form of a scoping review (Paper II), the study identified key aspects of informalpatient payments and bought and brought goods in all Western Balkan countriesthrough a systematic analysis of 24 published and unpublished studies. The finalempirical part of the study (Paper III and Paper IV) focused specifically on Serbia. Thefocus was to examine civil servants’ (N=8) and asylum-seeking migrants’ (N=6)perceptions of informal patient payments and barriers and facilitators in accessinghealth care services in Serbia. The data was collected through qualitative interviews andanalysed using Grounded Theory Approach.

ResultsThe Pilot study (Paper I) indicated that informal patient payments and quasi-formalpayments mostly took place in inpatient care and were done due to perceived lowsalaries of doctors, poor health care resources, a desire to receive better or fasterservice, fear of being denied treatment, and willingness to express gratitude throughgifts. The Scoping Review (Paper II) revealed that incidents of informal patientpayments took place on a wide scale. Evidence regarding bought and brought goodsremained limited, indicating that such practices may be even more problematic thaninformal patient payments. The qualitative study (Paper III) findings suggest that themain triggering elements to pay informally was the high value put into doctors and thelacking resources of the health care system. Migrants further navigated the health caresystem differently than other locals in Serbia which resulted in different outcomes ofpaying informal patient payments. The final part of the qualitative study (Paper IV)showed that the intercultural mediators had a pivotal role in shaping better and quickeraccess to health care services for asylum-seeking migrants in Serbia. Overall, the fourstudies showed that culture and the lacking resources of the Serbian health care systemseemed to rationalize paying informally for health care. From all Western Balkancountries, evidence was lacking on bought and brought goods and quasi-formalpayments.  

ConclusionThis thesis provides new insights on the perceptions and experiences with payinginformally and the equitable access to health of asylum-seeking migrants in Serbia.Together the four papers addressed the complexity around informal patient paymentsand bought and brought goods in the Western Balkan countries. The thesis finds thatproviding gifts to providers was somewhat accepted, while others believed it to becorrupt and unacceptable. Though, a commonness in paying informally was found inSerbia, especially due to the high value put into doctors and the lacking resources of thehealth care system. The asylum-seeking migrants seemed to be exempted from suchpayments. Reducing these informal patient payments for health care is highly importantto facilitate equity in access to health care.
Translated title of the contributionLigelighed i adgang til sundhed i Serbien: En undersøgelse af den rolle, som uformelle patientbetalinger spiller i sundhedsvæsenet på det vestlige Balkan
Original languageEnglish
Awarding Institution
  • University of Southern Denmark
  • Karlsson, Leena Eklund, Principal supervisor
  • Kristiansen, Maria, Supervisor, External person
Date of defence7. Mar 2022
Publication statusPublished - 3. Feb 2022

Note re. dissertation

Print copy of the thesis is restricted to reference use in the Library.


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