Informal Payments in Greece’s Public Healthcare System: Determinants and Challenges to Sustainable Health Governance

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Abstract
The study examined the extent of bribery within the public healthcare system in Greece and the influence of its determinants at the macro-, meso-, and micro-levels, highlighting institutional and cultural influences, systemic weaknesses, inequalities, and high-risk groups. Structured questionnaires were administered to a representative sample of adult users of healthcare services in public hospitals located in urban areas. The analysis included descriptive statistics to examine variable distributions and trends, bivariate non-parametric tests to assess associations between informal payments and selected demographic and socioeconomic characteristics, as well as binary logistic regression modelling to estimate the probability of exposure to informal payments based on specific individual characteristics. The study sample comprised 2072 adults, of whom 59.5% were female and 40.5% male, with the largest age group being 36–55 years. A proportion of 23.2% resided outside the metropolitan areas of Athens and Thessaloniki, while nearly 50% reported a monthly household income of up to €1500, indicating a substantial representation of socio-economically disadvantaged groups. The large size of the sample, the fact that the residence place of the responders is spread all over the country, the stratified procedure for the hospitals selected and the fact that sampling method used is a typical one in the case of sample frame lack, ensure the greatest achievable representation of the Greek population. The analysis revealed the existence of a significant problem of informal payments within the Greek public healthcare system and identified specific institutional, cultural, and organizational determinants, as well as demographic and socioeconomic groups that are particularly vulnerable to such practices. The phenomenon disproportionately affects economically, educationally, and geographically disadvantaged populations. Addressing informal payments in healthcare is essential to preventing the erosion of the social fabric of the country and requires comprehensive transparency-oriented policies, the strengthening of equitable access to services, and targeted interventions for high-risk groups, in order to ensure the sustainability of the public healthcare system and the promotion of equitable and healthy living conditions for the population.

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