The Informal Payments and their Managerial Implications in the Medical System. An Analysis from the Perspective of the Values and of the “Gift Culture” in the Romanian People

Abstract

The informal payments in the Romanian medical system have generated several ethical dilemmas, as they are regarded either negatively, as an act of corruption, either positively, as gratifications or “small attentions” from the part of the patient. According to a study of 2013 of the European Commission, the percentage of the Romanian patients claiming that they offered attentions to the physicians is of 28%, whereas the European average is of 5%. Our study starts from the assumption that the practice of informal payments in the Romanian medical system is not based only on the low remuneration level, but mostly on deep “socio-cultural roots”. A first aspect approached referred to values specific to the Romanian people, based on the survey of several works and research whose results are thoroughly presented in the specialty literature, but also the analysis of statistics or debates in the media. The gift practice in Romanians is a national-cultural feature intensely debated by several authors. Our assumption is that this cultural specificity in conjunction with other factors (for instance, specific values, such as safety, sacrifice, hospitality, kindness, tolerance, but also the hierarchical submission or the importance of the group opinion, the attitude towards the risk) can be factors which explain the practice and the magnitude of the informal payments phenomenon in the autochthonous medical system. The results of our study can be useful in adopting certain substantiated political and managerial strategies and adapted to the socio-cultural context, which take into account the deep cause of the situation.

Keywords: Informal payments in the medical systemvalues and cultural dimensions in the Romanian peoplegift practice in Romanians

1. Introduction

The informal payments practice in the medical system generate numerous debates and ethical

dilemmas to which no social consensus has been found yet. The large number of publications on this

topic proves that this phenomenon is present in several countries and is approached from multiple

views: the type of payment, the factors generating it, manners of offer and reception, impact on the

employees and on the performance of the system, negative consequences on the patients, social

pressures.

The informal payments have various forms (monetary and non-monetary - services, gifts), as well as

the offer time (before receiving the treatment, after receiving the treatment), motivation (influence for a

better treatment, a more qualitative service; a gesture of thanks/in gratitude for the provided services;

need – covering certain breaches in the proper functioning of the system, such as the lack of medicines

and materials/medical services), magnitude (consistent or symbolic value), perception

(custom/tradition, bribe/corruption).

Various research works reveal that these payments exist in the medical system. Certain of them are

suggested by the medical staff, others are voluntarily offered by the patients/ex patients. In certain

systems, the informal payments coexist with the formal payments.

According to the Eurobarometer 397 of 2013 on corruption (European Commission, 2014), one in 6

Europeans considers that it is acceptable to give money so as to receive something in exchange from

the public administration services or from the public services (p. 11). One in 20 Europeans (5%) stated

that when he visited the practitioners or institutions in the public health sector, he gave an additional

payment, a valuable gift or he made a donation to the hospital (p. 12). 2% of the Europeans state that

they were asked or expected to pay a bribe for the services provided in the medical system (p. 12). 49%

of the Europeans believe that the situation worsened in the health care sector (p. 20).

The results of the study carried out by Tambor et al (2014) prove that in the post-communist

countries such as Bulgaria, Romania and Ukraine, the payments for the medical services are

significantly more widespread, as compared to Hungary and Poland, where they are lower as compared

to Lithuania. The patients are looking for coping strategies and borrow money or sell their assets in

order to cover these expenditures, their percentage being higher among those with a poorer health

condition, those with chronic diseases and with a lower income. These strategies are applied even by

young people with academic studies. These payments are noticed to the largest extent in Romania (and

to a smaller extent in Bulgaria and Hungary, as compared to Lithuania). The informal payments have a

high percentage especially in Ukraine, Romania and Lithuania, but also in Hungary. The research

carried out on 647 persons by Ungureanu et al. (2013, p. 217) highlights that the Romanian patients

considerably support with money these informal payments offered to the health care professionals, but

also for the provision of the services which should be supported by the system. 18.1% are as gifts

and/or services; 29.8% as medicines and 22.4% as food. The money was given both individually

(95.92%) and collectively (2.04%). The amounts vary between 2 and 3,000 Euros, but what is worrying

is that 58.8% of the patients cover these payments from their monthly income (Ungureanu, 2013, p.

216).

The results of the cross-national study carried out in 2010 by Stepurko et al. (2015, p. 2) highlight in

Romania, as in other countries (Bulgaria, Hungary, Lithuania, Poland and Ukraine) the manifestation

of a negative attitude of the representatives of the households with regard to the informal payments in

money (connotation of corruption, socially undesirable). However, gifts in kind are positively seen, as

a gesture of gratitude. As a matter of fact, according to the respective research, the positive perception

towards the informal payments prevails among those who offered gifts in kind, as compared to those

who offered money.

A starting point in understanding the informal payments in the Romanian medical system is the

understanding of the mechanisms of the deep action of the cultural factors. The definition of the term

of “informal payments” itself at European level becomes a challenge, it also depends on the cultural

factors, together with other elements, as this phenomenon “includes social, cultural and moral aspects,

which must be pointed for each country taken separately” (Pitea, 2015, p. 74). Certain authors

(Stepurko et al;, 2015) highlight that in the undertaking of policy analysis and research, there must be a

clear differentiation between what informal payments made as a sign of gratitude truly mean (which do

not have a real impact on the manner in which the care service is provided) and other types (associated

with bribe) which affect the proper operation of the medical system. The attitude study is necessary and

revealing for this purpose.

In order to deeply capture the informality phenomenon, Morris and Polese (2013) refer to the

ethnographic method, which, for the situations of breaking the law or the rules, allows the best the

perception of the “moments of informality in the life of the citizens in the post-communist countries

from the interior to the exterior”, ..”and to capture slices, glances, specimens” [....] Indeed, the

informality from the socialist and post-socialist ex Soviet countries and from Eastern Europe is

different. It can be regarded in the light of the “household dependence on the subsistence and

redistribution production, the lending of the informal relationships and mutual benefit..” (p. 3).

However, what deserves attention is the specification that it would be wrong to consider informality as

a mere “transition phenomenon”, as a deficiency of the institutionalized system, ... “it’s never a mere

corollary of the insufficient income obtained in the formal system, [...] it’s a tactic [...] rather rooted in

the social life [...], it’s about poaching opportunities and using the rules, the existing gaps within the

formal one” (Morris & Polese, 2013, p. 8).

2.Methods

The research question which concerns us in this article is to which extent the informal payments

phenomenon can be explained in light of the cultural factors specific to the Romanian environment.

For this purpose, we approached a deductive undertaking and the presented argumentation is based

(as background method) on the authority of the source (Șandor, 2011). We have studied opinions

belonging to sociologists, historians, psychologists, economists, found in the articles and studies

appeared over time in the specialty literature on the topic of the Romanian cultural specificity, but also

analyses of the official statistics or debates and positions expressed in the printed media. In order to

obtain a solid confirmation on this aspect, in the first phase of our approach we have conducted an

extensive scientific review of research of other authors on the importance of cultural factors in

sustaining the practice of informal payments in the health system of other countries.

2.1.Importance of the Cultural Factors in the Practice of the Informal Payments in the Medical System

Based on the specialty literature, Gaal and Mckee (2005, pp. 1445-1457) group the factors

underlying the informal payments into 3 categories: socio-cultural ([gesture of] gratitude, tip practice,

retardation in the development of human attitudes); legal-ethical (low moral standards in the medical

profession –individualistic/small bourgeois approach); the voluntarism of the 1950’s – the collectivistic

approach; the lack of control and responsibility); economic , both from the perspective of the demand

and of the offer (demand without limits or excess demand; restriction of consumer’s sovereignty –

reduction of the purchasing power, lack [of the possibility] of supplier’s free choice, lack of

confidence, fear and anxiety; an unexpected increase in the demand for health care services;

macroeconomic policies which do not favor the health care sector, inappropriate payment methods of

the suppliers of medical services, low wages of the physicians (employees in the healthcare sector).

The social-cultural factors are explained from the perspective of what happens in the medical

system in Hungary: the informal payments in health are related to the birth of the socialist state model

at the end of the years 1940, when they were legitimated by means of the tip practice and of the

imminent gestures of expressing the gratitude – the health care services are all the more valuable as

they cannot be paid, that is why the patients can express their satisfaction in this way (in contrast to the

corruption practices, considered as illegal). They must be accepted as a part of the national culture,

“deeply rooted in the old traditions and offering tributes”.

However, the abovementioned authors delineate two hypotheses: the “donation” one (culturally

dependant practice) and the “payment for service” one (specific to the health care system in the

socialist system).

Stepurko et al. (2015, p. 47) explains at length this practice of the informal payments in the post-

communist countries, which can be noticed to the largest extent starting with the years 1970’s (even

though it existed long before and it was present in the Western Europe countries). The socio-political

system in that period, with the acute under-funding of the sanitary system and the inequality in the

access to the medical services has determined the occurrence of a “diversity of informal strategies” in

the sanitary system and in other non-productive sectors. Therefore, the ride (the procurement or the

access to the public assets was carried out based on the personal relationships) has become “a

governing approach in the social relationships and life”. The lack of products on the market (even

though there was money) determined that these attentions (perfumes, alcohol) be assessed as gifts in

the informal payments in the medical system. Therefore, the patients supported the lack of the adequate

funding of the medical staff and succeeded to receive a better attention from the latter. The fall of

Communism has perpetuated even more deeply the under-funding, the informal payments (mostly as

money) continuing to contribute to the support of the system and of the staff, these payments being

deemed as more important than in the preceding era.

From this perspective, we can consider plausible the fact that, because of the historical experience,

the informal payments are “absolved” of the non-ethical nature.

Cohen (2011, p. 286) offers another picture regarding this aspect, by interlacing the political factor

with the cultural one: the informal payments are “alternative policies” (the political culture), namely

“specific strategies adopted by individuals or groups as a response to their dissatisfaction” before

government incapacity to ensure appropriate medical services. As a consequence, they are disposed to

“adopt strategies in breach of the law or illegal” so as to improve them, or, in certain cases, to obtain

faster more qualitative services or a better receptivity from the part of the governmental authorities.

These alternative policies manifest in a certain culture (Cohen, 2011, p. 300). We can consider that the

reaction manner of a citizen before a situation, the position towards the law, risk taking are elements

which cannot be dissociated by the socio-cultural components. Therefore, they become involuntary co-

producers in system support.

Other studies also bring to our attention the cultural component in explaining the practices of the

informal payments. The research carried out by Vianet al. (2015) highlights that in the Republic of

Moldova (a post-communist country) a lot of respondents motivate the informal payments (even

though their percentage is decreasing) to the providers of medical services by gratitude and tradition. In

the analysis of the motivation for these informal payments in Turkey, Özgen et al. (2010, p. 391)

identified that gratefulness was reported by 67% of those who made payments as gifts and as being the

only motivation for 33% who mentioned gifts of an event type. These motivations are complemented

by others, including the one that “it is common”. The authors sum up that the payments as gifts in

Turkey are “beyond the cultural traditions and represent a valid type of informal payment”, even

though it represents a small percentage.

In the countries in Central Asia, offering money or gifts to the physician on the part of a patient is a

tradition, as a gesture of respect and appreciation, all the more as in the soviet period it was common to

go to the personal physician with chocolate or flowers (Baschieri & Falkingham, 2006, p. 446).

However, over time this voluntary tradition has been “complemented or even replaced by the payment

demand on the part of the health care provider, as a precondition for ensuring the treatment” (Baschieri

& Falkingham, 2006, p. 442).

The study carried out by the European Commission in 2013 on the corruption in the health care

sector (European Commission, 2013) highlights that in the countries in the S-E Europe and those

belonging to the European Community, the informal payments are deeply rooted in the cultural factor,

on the belief that the physician must receive “something extra” (as in the communist period and in the

transition one). The informal payments are not seen as acts of corruption, but as a normal practice,

which makes difficult the enforcement of the laws adopted so as to stop them. Therefore, for instance

in Portugal, it is perceived that the physician is doing a favour to the patient when he gives him the

treatment, and therefore it is common to offer gifts to the physician in exchange (“ cunhas ”). The

witness of an ex medical student (intern) in Romania comes to consolidate this argument for what

happens in a similar manner in our country too, this one “experiencing another face of bribe”: the older

patients, mainly those in the rural area used to bring gifts; knowing that in the hospital the physician

does not receive money, a patient from the countryside brought him a chicken and two liters of wine,

but being refused, he insisted that “I must give you something”. Those from the countryside used to

bring vegetables, something cultivated by them.

For 18% of the respondents of a study on this question carried out in Greece (Liaropoulos et al.,

2008, p. 61), the additional payments that they make to the physician are justified by the rooting in the

Greek culture (even though the overall results show that these payments are not due to a cultural

characteristic, but it represents a forced social behavior for the access to a quality treatment). Those

who offered them motivated that “everyone does this”. In other countries, where physicians’ wages are

high, such as Cyprus, the informal payments are rare, but in certain cases, as in the case of the women

who want to deliver in a public maternity hospital assisted by a physician chosen by them, it is

common to offer gifts.

However, the cultural explanations in justifying the informal payments in the sanitary system do not

have many supporters: Cohen (2012, p. 294) assesses that they “do not seem to apply beyond the health

care area and do not suggest that a behavior with similar characteristics exists in other fields of policies

or contexts within the same society”. But, many research works are based on questionnaires which give

the patient (or the ex patient) the opportunity to express his opinion, without a more complex

exploration of his attitude and behavior and of his roots.

For this reason, we consider that the cultural factor deserves a particular attention and we feel the

need to deeply investigate the manner in which it intervenes in the attitude, behavior of the patients

(but also of the medical staff) towards the informal payments, regardless of their form.

The risk factors and the indicators related to the corruption by informal payments are connected to

the cultural factor, together with the economic, personal and governmental ones (European Comission,

2013, p. 59). This factor can explain why these payments are tolerated (allowed) at societal level

(whether they are seen or not as part of the corruption, such as the acceptance of a higher level of the

latter), in certain countries offering gifts is considered as a “normal” practice, “as a part of their

culture” (even though the economic factors have indeed a stronger prevalence in the ex socialist

countries, where the health system is under-funded, staff wages are low and the system of the good

governance is absent). In the ex communist countries, we can notice people tolerance as regards the

informal payments in the medical system.

Many authors recognize that within the research on this topic it is difficult to clearly differentiate

between a payment as a gesture of gratitude and one meant to influence the quality of the medical

service (imposed or not).

2.2. “The Collective Mental Program” – an Important Cultural Benchmark

The attitudes and behaviours of the individuals in a society are influenced by the cultural variables.

The studies on culture carried out by the famous Dutch sociologist Geert Hofstede and by his team,

help us to better understand the national cultural specificity of each country and the influence on the

social practices. Each person has her own template of thinking, sensibility and potential action that he

has learned during the life (Hofstede, Hofstede and Minkovp, 2010, p. 4). By analogy with the

computer world, it is called a “mental program” or “software of the mind” (Hofstede, Hofstede and

Minkovp, 2010, p. 5). This template or program is influenced by the social environment where the

person grew up and collected the social experiences. What we must keep in mind is that this “mental

program” predetermines only to a certain extent the behaviour of the person; therefore, the individual

has the ability to act in a different manner before a new, reactive, destructive or unexpected situation.

However, once this manner specific to each person of thinking, feeling and acting is established in her

mind, so as to learn something new, different, she must unlearn it, and the unlearning manner is more

difficult than the initial learning one (Hofstede,Hofstede and Minkovp, 2010, pp. 4-5). A usual term of

this mental program is the “culture” one, and Hofstede et al. use it as a large concept which includes all

other “usual activities in life: the manner in which gratitude is expressed, the manner of eating, the

manifestation or not of the feelings, the keeping of a certain social distance, the manner of loving …”

(Hofstede, Hofstede and Minkovp, 2010, p. 5). In the proposed meaning, “culture is always a collective

phenomenon”, as it is learned and shared at least partially with those who “live or have lived in the

same social environment”. “It’s a collective mental program which makes the difference between the

members of a group and those of another group” (Hofstede, Hofstede and Minkovp, 2010, p. 6).

Culture is a construction integrated from several human behavior templates and includes “language,

thinking manners, communication styles, actions, habits, beliefs, values, institutions of the racial,

entity, religious or social groups” (Borkowski, 2009, p. 21). The national cultural model consists in six

cultural dimensions (“independent preferences for a particular state of facts to another…..”, cf. The

Hofstede Centre, https://geert-hofstede.com/national-culture.html), whose scores differentiate the

countries.

We assume that this could be a starting point necessary for understanding the action of the cultural

factor in supporting the informal payments practice.

3.Some theoretical research results. Informal Payments in Romania – a Possible Explanation

from the Perspective of the Cultural Factors

According to a poll carried out by the European Commission in 2013, in Romania 28% of the

respondents state that they made informal payments to the physicians (the European average is of 5%),

the patients in the countries of the Eastern and Central Europe offering gifts to the physicians and the

physicians with low wages accept them (The Economist, 2014).

A study of 2015, carried out by the Ministry of Health and the Association for Implementing

Democracy shows that more than 50% of the Romanian people give money and “attentions” to the staff

in the medical system (from the physicians, nurses, to stretcher bearers and security guards), but at the

same time one supports the idea that the maintenance of corruption in this system is determined

precisely by the patients by the voluntary offer of these payments and who are “reconciled to the

situation”. The representatives of the National Association for Patients Protection (ANPP) state that

they receive hundreds of complains a day for different dysfunctions met in the medical system

(malpractice, lack of medicines..), but however no patient claimed corruption problems to this body

(even though certain local public health directorates rule out this detail and state that they received claims from the patients that the physicians asked for money (acc. to Kolbay,http://www.viata-libera.ro, 2012). Moreover, the Romanian press frequently presents cases of physicians caught receiving a bribe; after the patients themselves filed a criminal complaint in this regard.

In addition, the refusal of a physician to receive money or gifts from a sick patient, had a “perverse effect”, the latter fell into depression and made his will, interpreting from the gesture of refusal of the

physician that he has a serious disease and that he will die (even though he was not in this situation,

acc. Oprea, http://www.evz.ro, 2015). The occurrence of this effect is also supported by other sources:

“there are also cases where the patients, usually the old ones, want to offer an attention to the

physician and are scared when the latter refuses them. They think that their condition is serious and that the physician can’t do anything” (acc. Kolbay,http://www.viata-libera.ro, 2012).

The research of Moldovan and Van de Walle (2013, p. 21) highlights that the behavior of the Romanian patients in offering informal payments (gifts, other services) to the medical staff also confirms the conclusions of other studies: they make them from fear of what could happen if they do not pay them, “as they hope to receive a better or a faster treatment”, because of the unfavorable situation of the system (low wages of the medical staff, lack of funds), this being the only manner of “receiving the services they need”. They consider that it’s a “bad mentality”, but they believe that even though they pay insurance and medical services (being therefore free), if they did not offer a bribe or gifts to the medical staff they would not receive the appropriate treatment. Certain patients state that these payments (mostly those made as gifts) are made as a sign of gratitude, politeness and respect.

According to the research carried out by the Aspen Institute, 62% of the Romanian people admit that they made informal payments and they offered gifts to the medical staff, so as to receive more attention during the treatment, 83% of these payments being made in the public medical institutions (Posirca, 2013). The study of Pitea (2015, p. 75) on 13 Romanian patients with chronic diseases of Iași highlights that for them it’s a positive aspect when they voluntarily give money to the physician (the latter did not ask for it), as a sign of gratitude. They make informal payments in cash (being called in this case “bribe, incentive, attention, thanks, sale-purchase act or blackmail”) or gifts (calling them “attentions, gift, thanks, gratitude or protocol”).

However, the informal payment is seen as bribe only when the physician asks for the money. The Romanian law is ambiguous in this respect, the physician who is caught receiving gifts can be held criminally liable (develops the activity in carrying out a public interest service, is a civil servant, acc. to Art. 289 of the New Criminal Code, Law 187/2012 – for the implementation of Law no. 286/2009 regarding the Criminal Code of October 24th, 2012, the Official Gazette 757/2012), but however art. 34of the Law on patient’s rights determines that “the patient can offer to the employees or to the unit where he was treated additional payments or donations, by observing the law ”, as long as there is no pressure on him in this regard (Danileţ, 2015).

3.1. Values, Orientations and Cultural Dimensions

The informal payments are carried out by individuals’ reference to a certain social system of values

developed at the level of the community where they live, the binding agent of the cohesion and the one

which allows the cohabitation within it. Our research assumption – the values and the cultural

specificity (cultural factor) can explain to a certain extent the phenomenon of the informal payments in

the medical system in our country, is based on the definition given to values by Voicu&Voicu (2007, p.

10): “Values are hidden realities in the inner side of the individuals, but they have a strong social

determinative”…”they serve to the individual in ordering priorities”. Values show what is desirable,

draw the border between what is good and what is wrong, what is allowed or not, have a moral

component (”involve moral considerations”, Voicu&Voicu, 2002, p. 4).

Values orient individual’s attitudes and behavior in the community, direct his choices. At the same

time, they model the structuring and functioning of the society and of its institutions and the manner in

which appear and develop the social relationships among its members and the connections with the

exterior.And “any social relationship has a determination and an intrinsic moral significance, …there

are no social relationships ... without the presence or the active intervention of the relationships and of

the consciousness accompanying them … impregnating all the spheres and areas of the social life”

(Stroe, 1997, p. 154).

The anthropologists Florence Kluckhohn, Clyde Kluckhohn and Frederick Strodtbeck (Gallagher,

2001) aimed in 1940 at confirming that there is a certain limited number of common human problems,

to which societies struggle to find a solution and “the manner in which a group is inclined to

understand them, to find a meaning and solve them is the external manifestation of its most intimate

values, its window towards the world: namely its value orientation”. Researchers identified five

specific cultural orientations and one of them is the “orientation towards the relationships” (the manner

of interacting with the others in the group). This result has raised numerous directions in enforcing the

method of the value orientation in explaining the phenomena in several fields, including in

management and in the clinical medical system.

3.2.The Chart of Values, Cultural Dimensions and the Care for Health in the Romanian People

The chart of values places Romania among the countries with mostly traditional values (among

others, people value religion, the respect towards the authority, the traditional values of the family) and

survival values (the accent falls on the economic and physical safety; the levels of confidence and

tolerance are low) (WVSS, 2008). The wide study recently carried out by David (2015, p. 164)

illustrates that survival values have high scores, together with, among others, conformism, religiosity,

avoidance of incertitude/ defensive style. In a somehow unexpected manner, the study confirms the

values of the Romanian people (young generation) identified by Bogdan and MădălinaVoicu in the

research of 2005 (2007, p. 260), the specifically conservatory ones - tradition, conformity, safety. It

shows the strong “rooting” of values in the existence of the Romanian people, and how slow changes

produce, even though Romania entered in the meantime in the EU and implemented several economic-

social and political reforms.

The care for health is in itself a survival value and the research works show that patients consider

that if they give informal payments they will receive a more qualitative service on the part of the most

skilled physicians. What is interesting is that Romanians are concerned with the existence of the

infectious diseases in the world (David, 2015, pp. 156-157).

The assessments made by Geert Hofstede and by his team (http://geert-hofstede.com/romania.html),

show that with regard to the cultural dimensions, Romania has a high index of the distance towards the

power (the extent to which individuals expect and accept with no resentment that the power be

unequally distributed in society(score 90).

Theoretically speaking, in the countries with a long distance towards the power, the largest number

of chances belongs to the paternalist (priestlike, parental) model in the physician-patient relationship,

where the physician probably expects the patient to follow his recommendations (Oetzel, 2014, p. 736),

he makes decisions in the interest of the patient, the latter having a higher degree of passiveness. Aycan

(quoted by Zhou, 2006, p. 83) states that the paternalist model (in general) is positive and advisable in

countries with a high degree of collectivism and long distance towards the power). This combination

creates a humanistic, friendly, tolerant and earnest, empathic, protective and supporting environment,

but at the same time it is authoritarian, based on control and discipline (Akiș, 2004, p. 434).

It’s a relationship of voluntary dependence towards the one holding the power. The paternalist status

of the superior is acquired by the legitimate position in the hierarchic system, experience, age, know-

how/knowledge, but even sympathy (reference power) (Aycan,2006). As a matter of fact, Aycan

identified in his research that the distance towards the power between physician-patient manifested in

terms of the level/status differences is due to the differences between the knowledge/experience levels

(Aycan, 2006, p. 458).

The patients are in an authority relationship, where the physician, by his know-how, is

metaphorically the “ruler” who offers them what is the most important for them – life and health.

Within the society, he is the one who has an explicit contribution in maintaining the health and life of

its members. The physician is “the agent by means of which the scientific understanding is expressed”

and “Medicine refers to the experiences, feelings and interpretations of the human beings in often

extraordinary moments of fear, anxiety and doubt” (PubMed.gov, 2005). The physician does the

reasoning in situations of incertitude and he also takes responsibility for the manner in which he does

it. Physician’s professionalism is based on a “set of values, behaviors and relationships supporting the

public confidence” in physicians and in the medical system, but physicians assess that it is not

supported, but vice versa, by the current political and cultural environment in health (PubMed.gov,

2005, http://www.ncbi.nlm.nih.gov/).

As long ago as 1521, Neagoe Basarab (voivode of Wallachia) taught his son, a future ruler, how to

behave with his vassals (his “servants”) and how much he will count in their lives, highlighting certain

psychological features of the Romanian people, which can metaphorically explain the current

physician-patient relationship (Basarab, ed. 2001.): “[…] and his heart groans in him as a wood that

you put on fire and which has a wormhole … this is what happens with the heart of your servant when

you do not spare him. As it is only from you that he hopes to have mercy and he expects to have mercy

and a good word, to sweeten at the sight of your face. And those that you will spare and to whom you

will give good words, will never forget your mercy and your words” (Basarab, ed. 2001, p. 215). […]

and your servant will always thank you, as he has no other mercy from anyone, except for you” … for

the mercy that you show to him, he will not only thank you in this world, he and his sons, but he will

give his head for you, he and his sons. Until his people and his seed will disappear and they all will

say: “God forgive such master, as he saved us” (Basarab, ed. 2001, p. 216). “As they serve you and

give their head and blood for you for the love and mercy with which you want to save them” (Basarab,

ed. 2001, p. 216).

This high index of the distance towards the power also reflects the manner in which individuals

accept the differences among classes and the privileges of those who have more power. Offering a gift

to the one who holds power (legitimate, expertise, reference, reward, etc.) would not seem something

unusual. “And the servant acknowledges his condition by submitting a gift meant to ensure an

equitable balance of the relationships between the parties. [….] As the gift is a social technique by

means of which the strong one is forced to divide his power …. and to invest it as services” (Barbu,

2001, pag. 64). The Romanian people accept authority and traditions, they have a low autonomy

(David, 2015, p. 212).

Also, in the Romanian people, there is a high index of prevention of the incertitude (“the extent to

which individuals feel threatened by ambiguous or unknown situations, and they created beliefs and

institutions in order to avoid them”) (score 90). The high care for health, the fear of not being rejected

and of not receiving a better treatment and the sacrifice made by the informal payments for this are

enclosed in the essence of this index.

The study carried out by Voicu (2013) shows that in the Romanian people the level of social

confidence (generalized confidence) is very low (the level of confidence in people, assessed in the

analyzed group is of 8%, for the period 2010-2012). This index is also related to the level of social

confidence. The level of social confidence [involves “the generalized norm of reciprocity”], shows the

degree of confidence in others and their intents, in the fact that you can rely on them, as they take into

account your interests, observe the rules of the society, will observe your “freedom and personal

safety” (Voicu, 2013, p. 1).“Confidence is the belief, depending on a context, that an agent shall act in

a manner which corresponds to the present expectations of the one who decides to have confidence or

not” (Voicu&Voicu, 2007, p. 125). The Romanian people trust the most their families (81%), a little

the people they know personally (11%) or/and practically not at all the persons they see for the first

time (1%). The level of confidence in our country is lower than in the rest of Europe and is due both to

the unfavorable economic conditions and to “certain historical features” which find their roots

hundreds of years ago (Voicu, 2013, p. 1). David (2015, p. 300) consolidates the existence of this

reality: “the landed mistrust of the Romanians in people”. The gift (as an informal payment in the

medical system) can be however the “Trojan horse” so as to supplement this low level of confidence,

so as to win the guarantee that we can rely on each other … that it will ensure us this personal safety

(in terms of healthcare). The high score for this index also suggests that the resistance to change is

high.

The perception of the lack of efficiency at institution level transmits the feeling of uncertainty and

this perception is also associated to the employees of the system. The informal payment has in this case

the role of reducing the feeling of uncertainty. Specialists say that when we offer gifts, “our intent is

not totally disinterested”, we expect them to be mutual, namely we wish to receive another gift in

exchange (Jasinski, 2011, p. 34). “The informal offering of gifts acts as a cement for the social

relationships, as it involves the “offer and take” principle or a reciprocity norm”, in other words, “it

contributes to solidarity” (Komter, 2005, p. 123). Gifts reflect and bring into light the identity of the

one who offers (personality, personal tastes, cultural values, financial resources), but also of the one

who receives (how one perceives and assesses his tastes, preferences, needs) (Jasinski, 2011, pp. 35;

43). The studies show that there is a strong connection between receiving and offering gifts (“doing

well has its reward”, Jasinski, 2011, p. 41). In our argumentation, we give credit to the psychological

function of gifts: the moral connection that it creates, as “it makes people feel morally related to each

other, because of the expectances and mutual obligations which appear of giving back a gift” (Jasinski,

2011, p. 43).

However, even though there is the belief that offering gifts “is a confirmation of the reciprocity and

creates a sense of community in a monitored environment” (the ward), that it is a symbolic gesture

(“sweets, chocolate and stockings”) it generates an imbalance of power. Malcolm Johnson (quoted)

highlighted as long ago as 1975 that “old persons are frequently powerless... being systematically

excluded from the possibility to [prove] reciprocity… [….] being poor and socially isolated” (Cooke

&Philpin, 2008, p. 113)”.

The existence of the informal payments is also related to the manner of observing the law, which is

essentially a cultural behavior related to the incertitude prevention index. The study on the integrity in

the Romanian people carried out by Dorin Bodea (2011) shows that “only 66.8% of the participants

consider that they observe the rules to a significant extent”, which “confirms person’s tendency

towards breaking certain rules”. The same study shows that “50.4% of the Romanian people are seen as

breaking the rules to a considerable extent” (“a culture of violation of the rules in the Romanian

people” (Bodea, 2011, p. 148), “a lot of participants consider that rules are made to be broken” (idem,

p. 149). Even though we have laws (which ensure the constraint of violation of the rules), “the

sanctions are not quite enforced”, that is why Romanian people’s reference to rules remains at their

belief. The attitude towards the honesty or lack of honesty of the informal payments (both the payer

and the beneficiary) is that of “moral anesthesia” (“a sort of disinterest for what is good or bad, just or

unjust”). This behavior of passivity, of lack of involvement and accountability is a tribute given by the

Romanian people in their attempts to adapt to “an unstructured, unsafe environment, without clear

directions of evolution” (Bodea, 2011, p. 114). The emotional need for rules is an attribute of a high

index of incertitude. Even though it seems to be a contradiction between a high index of incertitude and

the violation of rules, the system of informal payments is an institution in itself (even though informal,

and supposes in its turn some rules) which contributes, “in a vicious circle” to the reduction of patient’s

degree of insecurity. David’s comparative study (2015, p. 306) negatively shows that the Romanian

people are oriented towards indiscipline (breaking certain social rules, antisocial actions). Moreover,

“they have a defensive psychological profile” (“denial of the negative aspects”), which leads to the use

of certain coping mechanisms, but not always with a positive effect (amorality, antisocial attitudes ...

etc.) (David, 2015, p. 299-300).

The ( in-group) collectivismindex is high in the Romanian people (the interdependence degree that a

society maintains among its members), the norms of the group are important and observed. David

(2015, p. 165) highlights that most probably, we talk about a collectivism which “favors a survival

cooperation”, based not on collectivity, but on specific safety (tradition, conformism) needs, justified

by the historical conditions. Moreover, the tendency to imitate has an important place in Romanian

people’s perceptions and unfortunately it has been the basis of the “corruption and fraud model

promoted … in the last twenty years”, the public institutions adapting to “this imitative pattern”

(Bodea, 2011, p.101). The high degree of collectivism supposes close relationships among people, the

power of the group. The Romanian people are “warm in the interpersonal relationships”( (David,

2015, p. 212; p. 299). A large number of studies show that patients offer gifts to the physicians

because of the personal relationships, wishing to maintain them (Belli, Gotsadze and Shahriari, 2004,

p. 6).

Gregariousness (considered as a feature of the Romanian people – “have a gregarious spirit”; “we

are collectivist and gregarious”, acc. to David, 2015, p. 312; 315) has a role in the formatting of a

certain behavior: “ vox populi ”, “village voice”, what others say, is an important social aspect in the

Romanian people, “has a great deal in our country”, a lot of their beliefs are based on the “public

rumor”.. “The temperamental individual, in the Romanian people, is not the one who is self-consistent,

but the one who danced attendance on the group, namely the one who has always followed the bell of

the herd” (Constantin Rădulescu Motru, in 1937; ed. 1998, p. 35). If all others give something to the

physician, then everyone will follow the behavior “pattern”, irrespective of whether it is a gift in

gratitude or a payment in cash.

Certain articles on this topic in the Romanian media highlight the unequivocal presence of this

generalized informal practice, with a “collective participation”, but which revolts (“cancer”) and is

asked to be removed: “Let’s not use shifts! …. Some people see it as a sign of thanks, others as an

obligation. But everyone pays it, almost of one’s own free will …. In general, people know even the

“rates”, according to the seriousness of the surgery, the position or the fame of the physician and the

possibilities….. a system which has been functioning for decades and to which everyone obeys”

(Doagă, http://www.obiectivbr.ro, 2015) ”.

The great danger in the Romanian people is however the generalization, “the dumping into global,

the refusal of discrimination as a strategy of stopping to feel guilty … a strategy where you adopt and

propose the non-difference so as to save you”. This contributes to the “induction of a complex of

culpability which “negatively” feeds the collective identity and produces a lot of “social confusion”.

The specific verbal patterns, easy to recognize in this case are “we are all guilty”, “we all do this”. This

“tendency of globalism, the overgeneralization must be reformed by reflection and prudence”

(Liiceanu, 1998, page 213-214).

In the research carried out by Heinz (2005, page 81), on labor ethics in the Romanian people, his

interlocutors “were revolted when they were left with no money” by an officer, “but they had a speech

of self-justification when they offered bribes”, and this justification was made not based on certain

“social actions, but on the perception of these actions, which was often deformed by assumptions and

prejudices regarding the socialist inheritance, corruption omnipresence”. As a matter of fact, what Boia

noticed in 1997 (page 292), seems to be equally actual in 2016, “the Romanian people let themselves

enslaved by history or rather by the mythologies built on history…. The great decisions that the

Romanian society must take at present represent a rupture from the past, from any past… the dominant

feature of the Romanian imaginary still remains autochthonous and authoritarian”, but the European

world to which we belong is now focused on strong democratic values.

3.3.Hospitality, Kindness and Gift Culture in the Romanian People

In the picture of Romanian people’s values we also meet values which are in their essence related to

offering gifts (a form of the informal payments): kindness, well-doing, hospitality and generosity, the

forgiving spirit. In this regard, Sorin Mitu (1997) gathers more notes of the Transylvanian writers: “ The

hospitality and generosity of the Romanian nation are recognized not only by the compatriots, but also

by the impartial foreigners ” (Mitu, 1997, p. 296); “The kindness of the Romanian people can manifest

by their forgivingspirit (Mitu, 1997, p. 292-293); “This kindness [..........] being applied to those who do

not deserve to benefit from it. On the edge, it could also suggest that it would be more appropriate to

give up such an attitude, which did not bring us only good things”; [.....] “The Romanian people and

foster in their chests feel such a great humanness ”, that they do not even answer to the foreign

calumnies. The kindness and gentleness of the Romanian people, rewarded by foreigners with the

keenest and the more unjust treatment, raise the compassion of Papiu-Ilarian: “For God’s sake, have

pity on these good, obedient, kind and very poor people” (Mitu, 1997, p. 293). Hospitality, as a cultural

feature specific to the Romanian people, as a form of trust and openness towards the others, is not

validated by all the recent autochthonous research, being considered rather as an auto-stereotype (see

David, 2015, p. 316-317).

Gift culture in the Romanian people is often mentioned by other authors in the undertaking of

explaining the social relationships and the economic evolution of the society. Therefore, we also meet

references in the volume “Firea românilor”, coordinated by Daniel Barbu (2001): “ In certain types of

societies, the Romanian one apparently being among them, the gift creates mutual social obligations,

by the symbolic anticipation of a profit ”. All over the time, it was only in XVIII-th century that bribe

incrimination itself in the Criminal Code was truly carried out, for the judges “who give unjust

solutions … or based on bribery”, but however “the legislator does not decide with regard to the gift

offered so as to precipitate a just resolution or given as a sign of gratitude for such a resolution”

(Barbu, 2001, p. 148).

According to Romanian sociologist Dimitrie Drăghicescu (1907, p. 374), gift practice in the

Romanian people is a habit whose origins are rooted in the Orient, closely related to the tributes

brought to the saints in the orthodox church: “this Romanian rite perfectly reflects the image of social

life. In their affairs between them and in which they are related to the government too, the Romanian

people have never entered the door of their superiors empty-handed. At the judge, at the ruler, at the

sub prefect and even at the mayor and notary of the village, they knew that prayer is dead without a

gift . The countrymen could only tame the superiors in the State hierarchy with tributes and gifts”.

“Both for the earthy needs and for those of the future life, the Romanian people have only addressed

to God by tributes brought to saints…” (p. 374).

Sorin Mitu (1997, p. 297) also reveals the hidden, innocent at all side of gift practice: “Actually, the

gift replaces the exchange relationships practiced in the “more evolved” societies (and practically

represents the origin of these relationships), the disinterested offering of gifts being only an

appearance, as it always supposes a reciprocity, with role of social redistribution of the subsistence

means”.

Gift practice in the Romanian people is however treated as a pamphlet by Ştefan Zeletin in his book

of 1916, where he associates the gift with giving and receiving a tip: “Indeed, without tipping nothing

can be done [in the country ....]. Therefore, it has come to be known by foreigners under the nickname

of tip country. [….] everyone receives a tip” (ed. 1998, p. 47).

Another angle of view could be the one of understanding the tolerance of the informal payments

practice in the medical system by means of the religious factor. Religion is “one of the numerous

institutions involved in the socialization of the citizen at the basic norms of the community in which he lives” (Johnstone, 2015, p. 17). Religion is “a vital part of the culture of a society” (Hall, 2013, p. 101) and can be used so as to understand the relationships and the dependences of the individual with the society, but also in order to clarify the responsibilities of the moral agents” (Hall, 2013, p. 46), being therefore a starting point when someone wants changes of situations at consciousness level too.

The orthodox worship prevails among the Romanian people (81.04%, acc. to NIS, http://www.recensamantromania.ro/rezultate-2/), religiosity is higher (David, 2015, pp. 118; 160, 164), “Romanians are ones of the most believer Europeans” (Onea, p. 172, 2011) and its religious percepts support the lack of care for the material richness – “ Do not store up for yourselves treasures on earth, where moths and vermin destroy, and where thieves break in and steal… (Matthew 6, 19-20); “ How hard it is for the rich to enter the kingdom of God! Indeed, it is easier for a camel to go through the eye of a needle than for someone who is rich to enter the kingdom of God ' (Luke 18, 24-25) (http://patriarhia.ro/patima-lacomiei-de-avere-7532.html).

At least the generation of the eldest, with a strong religious feeling, gives from the little that they have, without necessarily having the feeling of frustration or doubt. Orthodoxy has forgiveness in the core of its belief (“ But if you do not forgive others their sins, your Father will not forgive your sins .” (Matthew 6, 15).; “ And forgive us our trespasses as we forgive those who trespass against us (The Lord’s prayer); “ The forgiveness of our neighbor, even the enemies, is one of the most delicate aspects of the Christian teaching ”; “ Forgivenessis the greatest effort of the belief in God and of the love for humans and which needs a self-control and an incommensurable moral victory ” (http://www.crestinortodox.ro/morala/iertarea-lumina-invaturii-crestine-70853.html); and even in the case of injustice (based on the belief of receiving in exchange justice “on the other world” and redemption): “ Receive injustice as a great blessing, as it gives you the heavenly blessing. But do not aim at receiving the injustice, as this hides a polite malice ” (Saint Paisios of Mount Athos, http://citateortodoxe.ro/citate-nedreptate); “ The one who believes in the reward of God, to the extent of his belief, happily tolerates all the injustice ” (Saint Marcus the Ascetic). The sacrifice accepted without dissatisfaction by the Romanian people is another value which deserves to be analyzed. Abrudan (1999, p. 24) reminds of “Mioriţa”, one of the most representative Romanian ballads, in which we see that the Romanian (the shepherd in the ballad) resignedly embraces his destiny – which means in essence the renunciation of his sheep, namely of the material richness (in the orthodox religion, the material richness is less important for the believer, as compared to the desire to get closer to God and the desire for redemption), without fight and without questions. For the Romanian (symbolized in the ballad by the Moldavian shepherd), the renunciation of richness is serene, as it represents the path to the transcendental. But this suggests at the same time his passivity. The fact that this system of the informal payments has existed for many years proves that by its nature, the Romanian people has a

vocation of passivity in respect of the change, obedience, permissiveness.

As a matter of fact, the cultural studies show that the indulgence index (the extent to which

individuals try to control their desires or impulses) is low (score 20).

As the Romanian philosopher Emil Cioran stated in 1936 (1990, p. 31), ”A total transformation

volition never existed from us, the dissatisfaction with our destiny and with our condition has not

determined us to transced the approximate shape of a skeptical attitude. ....... Our superficiality

originates from our impossibility of coming out of this first form, of being established as comfortable

spectators of our inertia, tasting with irony our own agony. The Romanian people procreate their own

condition and consume themselves in an easy and sterile self irony. .......”. If this is stil a Romanian true

reality, this could be a very unfavorable cultural risk against the socio-economic change.

4.Conclusions

Obviously, the analysis of motivations from a cultural point of view in the practice of the informal

payments in the medical system cannot be carried out without taking into account the other factors. It

would be a myopic and unrealistic approach.

Reflection is however useful so as to identify those factors on which one must act with realism, so

as to be able to make a prediction with regard to the procurement of certain positive results in a certain

period of time. The enforcement of certain measures and policies at system level, which had positive

effects in other countries, will not have the same consequences if they are not adapted to the cultural

specificity. The research carried out by the European Commission (European Commission, 2013 a), p.

150) show that “the policies and practices which function in a country do not necessarily function in

another country”. At regional level, there may be differences.

The message which must be retained is that we need the moral education of the citizens, of the

consumers of medical services and of the medical staff, clear and strongly punishing laws in case of the

breaches appeared as a consequence of the violation of the laws and of the ethical standards, regardless

of the person in charge of it. A mentality is difficult to change, the mental software will not reset from

one day to the next , that is why we need public-private partnerships, the active involvement of the

authorities, of the education institutions, of the media, of patients’ associations, of the NGOs. There is

the need for the study of the good practices in other systems, for understanding and time. Generations

coexist and the focus must be on the formation of the young generation, “the value change at the level

of a society appears when the young cohorts start to replace the old ones in the population” (Inglehart

quoted by Voicu&Voicu, 2002, p.5). David (2015, p. 170) states that Romania, because of the

increasingly “decisive” economic development and of the European integration, will unavoidably be

involved in the process of transformation of the collectivist psycho cultural imprint into the

individualism one, the young generation being more oriented towards individualism

(autonomy/independence). In these conditions, the question arises whether values, norms, mentalities

and behaviors will align between generations. The civic education, the awareness are the essential

pillars of an economically and morally developed society. As Constantin RădulescuMotru (Romanian

philosopher, psychologist and sociologist) said early in 1937: “ A good political law only increases the

possibility of good deeds, but does not give the motivation of these deeds; motivation comes from the

individual soul ” (Constantin RădulescuMotru, ed. 1998, p. 39).

Regardless of the form (money or gifts), reason (gratitude or desire to receive a qualitative medical

service), the informal payments frame into the black area of the economy, legality and morality.

The analysis of their practice from a cultural point of view does not aim at legitimating or excusing,

but at deeply identifying their cause, the objective starting point in the removal of their existence and in

the adoption of some integrated, adequate mechanisms, adapted to each country and context. While the

tradition exists, accompanied by the emotion and desire of giving (and receiving) the gift or the

informal payment, the constraint by heavy laws will only incite to looking for bypass strategies and

mechanisms in order to fulfill them.

Time, small, strategically controlled and consistent steps are needed.

Sociologists Voicu&Voicu (2007, p. 10) warn that the change of values will not occur immediately,

from a day to the next. It happens in time, by the interaction between groups/generations with different

values and views and occurs gradually: first at the level of certain smaller communities and then

expanding to the level of the entire society. Also, as the above mentioned sociologists state, a sudden or

total removal of the “old” values will never happen (namely there will always be groups promoting

them), but there will be a gradual transformation of the first or a hybrid co-operation between them and

the “new” ones, which try to find their place. Definitely, this change of values must be accompanied by

“the change of the economic conditions and by the technological progress, by the change of

generations”.

In its turn, the change of values can contribute in time to the favorable influence of the economic

conditions. But, certainly, to a greater or to a smaller extent, “consumer’s culture plays an important

role” in accepting or not the informal payments, “the degree of solidarity, or conversely, of

individualism” influencing in this regard. In other words, “the members of the richer, more

Occidentalized groups are more individualistic from a cultural point of view, as they moved away from

their socialist past” (Thompson & Witter, 2000, p. 186).

In Western Europe, this phenomenon is reduced or almost inexistent, because of a set of systemic

and systematic measures: restrictive legislative measures, strongly punishing both for the one who

offers and for the one who receives the informal payment, regardless of the reasons, but also the

assurance of funds and of an adequate infrastructure in the medical system. All these involve “ensuring

the social dignity” of the physician, of the patient and of society in general. Last but not least, an

important role in society is that of the early civic education (as early as at nursery school), the civic

education of the adults, the education the professional ethics of the physicians and of the other actors in

the healthcare system, of the legislators and of those in the legal system, including of the patient (who

must be aware of his rights, have a strong civil attitude and who may dispose of functional control

mechanisms and institutions which can support him in this regard).

Without adequate measures, “people will continue to bribe and receive bribes, without too many

feelings of guilt, even if they see bribe in a negative way, as long as this exchange appears as the best

solution” (Heintz, 2005, p. 81).

On the other hand, we can suppose that a total change will never happen, as long as certain informal

payments are seen through the “lens” of customs, frames into a tradition, but mostly in the field of the

complex relationships among people and they are specific and mirror the existence and identity specific

to a nation.

Acknowledgements

Scientific research financed by the University of Medicine and Pharmacy “Grigore T.Popa” Iaşi according to the contract 30888/30.12.2014.

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