The European Journal of Health Economics

, Volume 17, Issue 2, pp 159–170 | Cite as

Informal payments in the Greek health sector amid the financial crisis: old habits die last...

  • Kyriakos SouliotisEmail author
  • Christina Golna
  • Yannis Tountas
  • Olga Siskou
  • Daphne Kaitelidou
  • Lycourgos Liaropoulos
Original Paper



Under-the-table informal payments are commonplace as reimbursements for health care services in Greece. As the country faces a severe financial crisis, the need to investigate the extent of such payments, their incidence and their impact on household income is pressing.


A survey of 2,741 persons from across the country was conducted between December 2011 and February 2012. The sample was defined via a multistage selection process using a quota for municipality of residence, sex and age. The maximum error margin was 2.41 % with a confidence interval of 95 %.


The survey reports under-the-table payments for approximately 32.4 % of public hospital admissions. Private clinics, which display the bulk of out-of-pocket payments, naturally display the lowest under-the-table payments. The highest percentage of under-the-table payments in the private sector appears at visits to private practitioners and dentists (36 %). Informal payments are most frequently made upon request, prior to service provision, to facilitate access to care and to reduce waiting times, and at a much lower percentage, to post-service provision, and out of gratitude.


This survey reveals that, due to severe financial pressure, there is a growing unwillingness of citizens to pay informally and an increasing demand for these payments as a prerequisite for access to services or to redeem services provided. This “hidden” financial burden of at least 27 % impacts negatively on the living conditions of households and is not reported as purchasing ability or cost of living.


Health expenditure Health policy Hidden economy Tax evasion Informal health payment Greek health care system 

JEL Classification

I12 (Health Behavior) I13 (Health Insurance, Public and Private) I14 (Health and Inequality) I18 (Government Policy, Regulation and Public Health) 



The authors would like to express their gratitude to KAPPA RESEARCH for selection of the sample and the collection of data.

Conflict of interest

There are no any kind of conflict of interest.

Supplementary material

10198_2015_666_MOESM1_ESM.doc (46 kb)
Supplementary material 1 (DOC 46 kb)


  1. 1.
    European Commission. Study on corruption in the healthcare sector. October (2013)Google Scholar
  2. 2.
    Newhouse, J.P.: Medical care costs: how much welfare loss? J. Econ. Perspect. 6, 3–21 (1992)CrossRefPubMedGoogle Scholar
  3. 3.
    Souliotis, K.: Health policy in times of global economic crisis (in Greek). In: Siousiouras, P., Hazakis, K. (eds.) Globalization, European Union and Greece, pp. 761–781. Poiotita, Athens (2009)Google Scholar
  4. 4.
    Pavlopoulos, P.: The hidden economy in Greece. A first quantitative demarcation (in Greek). Institute for Economic and Industrial Research, Athens (1987)Google Scholar
  5. 5.
    Negreponte-Delivani, M.: Economics of the hidden economy in Greece (in Greek). Papazisis, Athens (1991)Google Scholar
  6. 6.
    Vavouras, I., Koutris, A.: The hidden economy. The extent of the phenomenon in Greece and abroad (in Greek). pp. 74–75. Papazisis, Athens (1991)Google Scholar
  7. 7.
    Tatsos, N.: The hidden economy and tax evasion in Greece (in Greek). Institute for Economic and Industrial Research, Athens (2001)Google Scholar
  8. 8.
    Siskou, O., Kaitelidou, D., Papakonstantinou, V., Liaropoulos, L.: Private health expenditure in the Greek health care system: where truth ends and the myth begins. Health Policy 88, 282–293 (2008)CrossRefPubMedGoogle Scholar
  9. 9.
    Economou, C.: Greece: Health System Review. Health Systems in Transition, vol. 12, no. 7. WHO Regional Office for Europe on behalf of the European Observatory on Health Systems and Policies, Copenhagen (2010)Google Scholar
  10. 10.
    Economou, C., Kaitelidou, D., Kentikelenis, A., Maresso, A.: The impact of financial crisis on health and the health system in Greece. WHO Regional Office for Europe. European Observatory on Health Systems and Policies, Copenhagen (2013)Google Scholar
  11. 11.
    Polyzos, N., Karanikas, H., Thireos, E., Kastanioti, C., Kontodimopoulos, N.: Reforming reimbursement of public hospitals in Greece during the economic crisis: implementation of a DRG system. Health Policy 109, 14–22 (2013)CrossRefPubMedGoogle Scholar
  12. 12.
    Liaropoulos, L.: Greek economic crisis not a tragedy for health. BMJ 345, e7988 (2012)CrossRefPubMedGoogle Scholar
  13. 13.
    OECD, Health data (2014)Google Scholar
  14. 14.
    Greek System of Health Accounts: Center for Health Services Management and Evaluation. National and Kapodistrian Univeristy of Athens, Athens (2014)Google Scholar
  15. 15.
    Souliotis, K.: Analysis of health expenditures in Greece 1989–2000, methodological clarifications and discoveries concerning the health system (in Greek). In: Kyriopoulos, J., Souliotis, K. (eds.) Health expenditures in Greece: methodological problems in measurement and their consequences for health policy, pp. 65–77. Papazisis, Athens (1992)Google Scholar
  16. 16.
    Niakas, D., Mylonakis, J.: Choice of physician, private payment and patient satisfaction. Is there any relationship? Int. J. Healthc. Technol. Manag. 6, 288–295 (2005)CrossRefGoogle Scholar
  17. 17.
    Souliotis, K., Dolgeras, A., Kontos, D., Economou, H.: Patient satisfaction from hospital care in Greece: results from a Household survey in the greater Athens region (in Greek). Prim. Health Care 14, 114–118 (2002)Google Scholar
  18. 18.
    Souliotis, K.: The role of the private sector in the Greek health system (in Greek). Papazisis, Athens (2000)Google Scholar
  19. 19.
    Tountas, Y., Karnaki, P., Pavi, E., Souliotis, K.: The unexpected growth of the private health sector in Greece. Health Policy 74, 167–180 (2005)CrossRefPubMedGoogle Scholar
  20. 20.
    Liaropoulos, L., Siskou, O., Kaitelidou, D., Theodorou, M., Katostaras, Th: Informal payments in public hospitals in Greece. Health Policy 87, 72–81 (2008)CrossRefPubMedGoogle Scholar
  21. 21.
    Kaitelidou, D., Tsirona, C., Galanis, P., Siskou, O., Mladovsky, P., Kouli, E., Prezerakos, P., Theodorou, M., Sourtzi, P., Liaropoulos, L.: Informal payments for maternity health services in public hospitals in Greece. Health Policy 109(1), 23–30 (2013)CrossRefPubMedGoogle Scholar
  22. 22.
    Souliotis, K.: Economic inequalities and health policy (in Greek). Papazisis, Athens (2007)Google Scholar
  23. 23.
    Souliotis, K.: Social and regional health inequities in Greece (in Greek). Topos 17, 49–72 (2001)Google Scholar
  24. 24.
    Mossialos, E., Allin, S., Davaki, K.: Analysing the Greek health system: a tale of fragmentation and inertia. Health Econ. 14, 151–168 (2005)CrossRefGoogle Scholar
  25. 25.
    Transparency International. Gloabal Corruption Report. Executive summary, p. xvi (2006)Google Scholar
  26. 26.
    Balabanova, D., McKee, M.: Understanding informal payments for health care: the example of Bulgaria. Health Policy 62, 243–273 (2002)CrossRefPubMedGoogle Scholar
  27. 27.
    Ensor, T.: Informal payments for health care in transition economies’. Soc. Sci. Med. 58(2), 237–246 (2004)CrossRefPubMedGoogle Scholar
  28. 28.
    Cohen, N.: Informal payments for health care—the phenomenon and its context. Health Econ. Policy Law. 7(3), 285–308 (2012)CrossRefPubMedGoogle Scholar
  29. 29.
    Souliotis, K., Kyriopoulos, J.: The hidden economy and health expenditures in Greece: measurement problems and policy issues. Appl. Health Econ. Health Policy 2, 129–134 (2003)PubMedGoogle Scholar
  30. 30.
    Gaal, P., McKee, M.: Informal payment for health care and the theory of ‘INXIT’. Int. J. Health Plan. Manage. 19(2), 163–178 (2004)CrossRefGoogle Scholar
  31. 31.
    Gaal, P., Belli, P.C., McKee, M., Szócska, M.: Informal payments for health care: definitions, distinctions, and dilemmas. J. Health Polit. Policy Law 31, 251–293 (2006)CrossRefPubMedGoogle Scholar
  32. 32.
    Thompson, R., Witter, S.: Informal payments in transitional economies: implications for health sector reform. Int. J. Health Plan. Manag. 15, 169–187 (2000)CrossRefGoogle Scholar
  33. 33.
    Miller, W.L., Grødeland, A.B., Koshechkina, T.Y.: If you pay, we’ll operate immediately. J. Med. Ethics 26, 305–311 (2000)PubMedCentralCrossRefPubMedGoogle Scholar
  34. 34.
    Gaal, P., Evetovits, T., McKee, M.: Informal payment for health care: evidence from Hungary. Health Policy 77, 86–102 (2006)CrossRefPubMedGoogle Scholar
  35. 35.
    Schneider, F.: The Influence of the economic crisis on the underground economy in Germany and the other OECD-countries in 2010: a (further) increase. ShadEcOECD2010.doc Revised Version (2010)Google Scholar
  36. 36.
    Schneider, A., Buehn, F.: Shadow economies and corruption all over the world: revised estimates for 120 countries. Economics: The Open-Access, Open-Assessment E-Journal, 1. Version 2, 2007–2009
  37. 37.
    Yfantopoulos, J.: Health Economics (in Greek). Theory and policy. Dardanos, Athens (2003)Google Scholar
  38. 38.
    Hirschman, A.O.: Exit, voice, loyalty: responses to decline in firms, organizations and States. Harvard University Press, Cambridge (1970)Google Scholar
  39. 39.
    Kentikelenis, A., Karanikolos, M., Papanicolas, I., Basu, S., McKee, M., Stuckler, D.: Health effects of financial crisis: omens of a Greek crisis. The Lancet, 378, 1457–1458 (2011)Google Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2015

Authors and Affiliations

  • Kyriakos Souliotis
    • 1
    • 2
    Email author
  • Christina Golna
    • 2
  • Yannis Tountas
    • 2
  • Olga Siskou
    • 3
  • Daphne Kaitelidou
    • 3
  • Lycourgos Liaropoulos
    • 3
  1. 1.Faculty of Social and Political SciencesUniversity of PeloponneseCorinthGreece
  2. 2.Centre for Health Services Research, Medical SchoolNational and Kapodistrian University of AthensAthensGreece
  3. 3.Centre for Health Services Management and EvaluationNational and Kapodistrian University of AthensAthensGreece

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