It is no secret that rule of law in places like Slovakia is weak. Corruption, pay-offs, bribes and twisted use of power often pass for “rule of law.” However, this problem has infected health care as well, which means those who are able to bribe the doctor or health care worker is the one who will get the care.

The Economist describes Communist-era corruption as a holdover infesting much of central and eastern Europe, and not just in health care. However, it’s one thing to bribe an official to get a building permit; it’s quite another to have to do it for live-saving surgery.

In Latvia Valdis Zatlers, an orthopaedic surgeon who served as the country’s president from 2007 to 2011, accepted what he called “gratitude payments” from patients without declaring them to the tax authorities. He was fined just 250 lats ($466). A European Commission survey in 2013 found 28% of respondents in Romania and 21% in Lithuania had made informal payments to pared to an EU average of 5%.

In Poland 15% of respondents admitted to paying a bribe in the past year; in nine out of ten cases it was for health care. SomePolish hospitals allow women to deliver by Caesarean section on demand, for an off-the-books fee of up to 1,000 zlotys ($266). One survey found that Poles consider health care the second-most corrupt area of public life after politics. Even in Estonia, where thee-health system is widely praised as a model of transparency, a hospital director lost his job in 2011 for demanding 4,000 kroons ($362) and a bottle of cognac from an elderly patient to remain in hospital.

Some say that “gifts of gratitude” are a cultural phenomenon, and should not be viewed as bribery. Many patients see payments and gifts to the doctors as simply part of getting the health care they need.

However, such a “system” clearly skews health care to those who can pay the bribes, and may leave those who need care and cannot pay “gifts” out of “luck” in a corrupt system. One Slovakian doctor says gifts are necessary for his clinic:

Peter Liptak, a prominent Slovakian general practitioner, began speaking to the media about his own acceptance of “gifts” in an effort to bring attention to the system’s failures. Dr Liptak, who runs his own clinic, says he receives the equivalent of €2 per patient per month under Slovakia’s payment scheme, which grants fees based on the number of registeredpatients, whether they are treated or not. He says he needs €3 per patient just to break even, and bridges this gap by demanding additional payments of €5-10 from the patients he does treat. “If a Slovak doctor wants to deliver quality care, it is detrimental to their wages,” Dr Liptak says. The gifts he receives, he says, are “part of the operating budget.”

Read “Patients bearing gifts” at The Economist.