Researchers: Nissim Cohen¹, Dani Filc²

Background: Informal payments in healthcare—commonly referred to in Israel as “black medicine”—represent a persistent phenomenon with significant implications for health equity and public trust. Although informal payments are often framed as a form of gratitude or compensation for underpaid providers, they may also constitute corruption and reflect structural failures in healthcare delivery. Existing international and Israeli literature highlights their impact on inequality and efficiency, yet empirical data on their scope and characteristics in Israel have been limited in recent years.

Objectives: This study aims to evaluate, characterize, and explain the phenomenon of informal payments in the Israeli healthcare system. Specifically, it explores how patients’ experiences with medical care processes and outcomes influence their engagement in or justification of informal practices. The study also seeks to offer policy recommendations to mitigate such practices.

Method: We conducted a nationwide survey (N=1,504) using a structured questionnaire comprising both closed- and open-ended items. The sample included adults aged 30 and above who themselves, or a close family member, had been hospitalized or undergone a medical procedure within the past five years. Quantitative data analysis was complemented by qualitative thematic coding of open responses. Ethical approval was granted by the University of Haifa's Institutional Review Board (IRB #360/22).

Findings: Approximately 17.5% of respondents reported engaging in at least one informal payment behavior in the last five years, such as paying discreetly for preferential care or giving gifts before treatment. In addition, 35.9% reported using personal connections (protekzia) to obtain better services. Key predictors of informal payment use included low levels of trust in the healthcare system, dissatisfaction with care, and feelings of discrimination. Respondents with higher perceived procedural justice and equality in care provision were less likely to justify or engage in such behaviors. While attitudes toward black medicine were generally negative, a substantial minority justified such practices under certain conditions.

Conclusions: Informal payments remain a prevalent and partially normalized practice within the Israeli healthcare system. Although the scope may have decreased compared to past decades, their existence signals persistent perceptions of inequality and inefficiency. Informal practices are sometimes initiated by patients themselves, but in other cases, medical staff implicitly or explicitly encourage them.

Recommendations: To curb the reliance on informal payments, policymakers should enhance procedural fairness, transparency, and public trust in the healthcare system. This includes strengthening regulation, improving waiting times, reducing disparities in access, and reinforcing ethical guidelines among providers. Public awareness campaigns may help delegitimize black medicine and empower patients to demand equitable care through formal channels.

Research end date: 07/2025