Informal payments are quite common in many countries, especially developing countries, to facilitate access to public services and ensure quality of services. Health care is one sector where informal payments are often used. Patients give doctors, nurses, and hospital staff gifts or money or offer services in exchange for health services. This article combines vignettes with in-depth interviews to explore how Romanians assess the practice of informal payments. The vignettes served as a starting point, an opening for the interviews that facilitated a deeper investigation of people's attitudes.Interactions between health professionals and patients are surrounded by a great deal of uncertainty regarding the demand for services and the information asymmetry between health professionals and patients (Savedoff 2006). Professionals act as gate-keepers to health facilities, treatments, and nonmedical care such as food or clean sheets. Offering gifts and paying bribes are therefore quite common in many health care systems, and the distinction between the two is often quite narrow (Werner 2002). The same actions and behaviors may be seen as corruption by some observers and as expressions of gratitude by others (Emerson 2005). Across professions, gifts are increasingly seen as "morally undesirable practices" (Schultz 2010). Research in the health sector often uses the concept of "informal payments" to label the exchange of money, gifts, or services between patients or their families and health-care personnel (Gaal, Evetovits, and McKee 2006;Lewis 2007).This article investigates how people assess the exchange of informal payments by concentrating on the process and content of such exchanges. Respondents who had been hospitalized recently, or who had cared for family members in the hospital, were shown six short vignettes and then asked to explain their attitude toward informal payments. Fieldwork was done in a city in Romania, a country where empirical evidence suggests that the use of informal payments is widespread (see, e.g., Cherecheş, Ungureanu, Rus, and Baba 2011; Fărcăşanu 2010). As noted below,
• public integrity fAll 2013Andrada Moldovan and Steven Van de Walle "Informal payments serve several purposes. They can be merely a contribution to the cost of care; they can result from abuse of market position by health professionals; or they can be used to procure additional services. Very often informal payments are no more than thank-you gifts."the Romanian health-care system suffers from a range of difficulties, including extensive centralization, management deficiencies, inadequate or insufficient medical equipment, and limited or no access to medical care in rural areas.
