Informal Payments in Czech Healthcare: The Blurry Line Between Greed and Need

Our contribution aims to explore various forms of corruption, specifically informal payments, within the Czech healthcare system, through both qualitative and quantitative data. Corruption and out-of-system payments erode public trust, compromise patient satisfaction, exacerbate healthcare inequalities, and drive up costs (Habibov et al., 2017; Schaaf & Topp, 2019). Building on the theoretical frameworks by Parvanova, Habibov and others, we examine the dual nature of healthcare corruption, driven by “need” and “greed” (Bauhr, 2017; Habibov et al., 2021; Parvanova, 2024; Vian, 2006). "Need corruption" involves coerced payments by patients to access basic healthcare services they are legally entitled to but can’t receive due to systemic failures, while "greed corruption" occurs when patients willingly pay to gain preferential treatment beyond standard entitlements, often motivated by the desire to bypass formal system constraints. This tension is not merely about detecting and penalising corruption; it is about understanding the socio-economic conditions that foster these practices. By identifying these conditions, our research has the potential to inform policy, contributing to the development of a more resilient and ethically sound healthcare system. Furthermore, this study helps identify the necessary data and methodologies for effective public policy formulation. Our study investigates two central questions: What delineates “need”-driven from “greed”-driven payments in Czech healthcare, and do these payments stem from a post-communist legacy or represent an ingrained behaviour likely to persist over time? The research employs a mixed-method approach, ideal for capturing complex social phenomena both qualitatively and quantitatively. We began with in-depth interviews with sector experts, selected to capture a range of perspectives across healthcare. Experts were recruited using purposive sampling (Patton, 1990) and a snowball technique to identify information-rich cases. Following this, a survey was conducted to capture a broader insider perspective, with opportunities for respondents to share their own views and experiences, thus enriching the study’s qualitative dimensions. The final stage involved workshops to discuss and refine our findings in collaboration with stakeholders. We found a significant discrepancy in how “need” and “greed” are perceived: behaviours typically classified as “greedy” by policy standards were often viewed as “necessary” by respondents. The primary issue, according to respondents, lies in a flawed system that does not allow for legitimate payments for enhanced services, resulting in a culture of tolerance around informal payments. They suggest that clearer regulations on permissible payments could improve system transparency and fairness. This insight is crucial for policymakers aiming to enhance integrity in healthcare and build a foundation for gradual, systemic improvement.