Defining IPHC

One can assert that IPHC are paid to various suppliers of healthcare services in order for those services to be accessible or to obtain services of a higher quality (for instance, earlier appointments, the ability to choose a doctor and more). Such payments are made by bypassing the existing formal rules. This definition includes the insight that those payments are clearly a kind of bribery. Furthermore, they often indicate the defects in the regulation of the provision of medical services to large groups in the population. Nevertheless, this definition is not perfect because it excludes a major part of the phenomenon and does not encompass the various configurations that exist worldwide. The literature reveals that some of the IPHC are received as ‘gifts’ or ‘presents of gratitude’ to doctors only after the patient has been treated properly in every sense of the term, including quality and speed of care. In those cases, it is impossible to contend that there is a relationship between the IPHC and the patient's desire to have priority over other patients. Moreover, the literature maintains that ‘bribery’ cannot be a successful definition for IPHC. Even though this phenomenon is illegal, there are various places and times when it is lawful (Lewis, Reference Lewis2000: 1). Indeed, although we cannot exclude bribery from the description of the phenomenon, it does not appear to be the characteristic that distinguishes informal payments from other phenomena (Gaal et al., Reference Gaal, Belli, McKee and Szocska2006: 270).

In her important work, Lewis (Reference Lewis2000: 1) defines IPHC as payments to individuals and institutional providers, in kind or in cash, that are made outside official payment channels and purchases that are meant to be covered by the healthcare system. However, Lewis’ definition is incomplete because it does not entirely explain the normative significance of the payments and the social implications of the phenomenon in all cases. Is the purpose of those payments to receive top priority over other patients? Are the payments offered as gratitude or as bribery? Are they always part of ‘corruption’?

Lewis (Reference Lewis2000: 1–2) asserts that in some countries IPHC are indeed illegal, whereas in other countries their legal position is controversial. Furthermore, there is a problem in describing the phenomenon of IPHC as ‘informal’. Some of those payments are entirely formal because they are reported and submitted by the authorities. Hence, in Hungary, for instance, those who report IPHC to the tax authorities can receive refunds, making the phenomenon formal (Gaal et al., Reference Gaal, Belli, McKee and Szocska2006: 268). This situation also exists in Poland (Shahriari et al., Reference Shahriari, Belli and Lewis2001). In addition, the use of IPHC is not confined to public healthcare services, as this phenomenon exists even when healthcare products and services are privately supplied. Thus, a patient in a private hospital may informally pay the private services supplier IPHC, as gratitude and out of a desire to be given priority over other patients who pay ‘regularly’.

Ensor (Reference Ensor2004) also attempted to delimit the phenomenon. He divided IPHC into three categories: contributions (including equipment or salaries), abuse of position and supplementary payments. However, given the variations in IPHC, these categories probably do not include all the aspects of the phenomenon. Some IPHC are received as cash, some as contributions and some as gifts or presents of gratitude to healthcare providers.

Gaal et al. emphasized the difficulty in doing comparative, cross-national research on the subject, citing the lack of a definition that is acceptable to researchers in other countries (Gaal et al., Reference Gaal, Belli, McKee and Szocska2006: 262–266). Some researchers emphasize the illegality of the phenomenon, some researchers focus on its informality, and others see it as indicative of corruption in the system. Hence, Gaal et al. offer a definition based on ‘entitlement for services’ and the additional nature of informal payment-type contributions. In other words, IPHC are everything that exceeds basic entitlement for services (Gaal et al., Reference Gaal, Belli, McKee and Szocska2006: 260). However, this definition does not encompass cases in which the basic eligibility for services is not so clear to everyone or is vague.

In addition, it is very difficult to gauge this phenomenon. Usually there is no documentation of this activity, which is normally done secretly. Only small parts of it emerge for public discussion every so often. Some countries forbid this phenomenon by law, making documentation difficult to acquire. Nevertheless, even if IPHC are not unlawful, they are usually offered in private by the person who is paying the supplier of the service without many witnesses, making the collection of data about monetary amounts difficult (Lewis, Reference Lewis2000: 11; Gaal et al., Reference Gaal, Belli, McKee and Szocska2006: 259). Since the early 90s, attempts to gather such data have been made by introducing questions in surveys, even recurrent and comprehensive surveys, and through interviews and surveys which focus exclusively on IPHC. Another approach to gathering data is through focus groups (Lewis, Reference Lewis2006: 22). Of all those research methods, surveys of households are the most common way of measuring the phenomenon throughout the world. Surveys of the World Bank Group may provide a relatively good comparative basis because they use a constant standard questionnaire throughout the world, a random sample and various applications of healthcare models.

IPHC: typology

IPHC exists in tens of countries throughout the world in various configurations. IPHC are mainly paid in the former USSR, in Eastern and central Europe, in Northern and Central Asia, in South America and in Africa – as well as in other places. Lewis (Reference Lewis2000) claimed that with the possible exceptions of the Czech Republic and Slovenia, the phenomenon has been reported in all countries of the Eastern Europe and Central Asia Region. Gaal et al. (Reference Gaal, Belli, McKee and Szocska2006: 253) pointed out this phenomenon in at least 22 countries throughout Europe, Africa and Asia. A broad review indicates the prevalence of this phenomenon in many other countries, such as Albania (Vian et al., Reference Vian, Gryboski, Sinoimeri and Hall2006), Armenia (World Bank, 2000), Bolivia (Chakraborty et al., Reference Chakraborty, Gatti, Klugman and Gray-Molina2002), Bulgaria (Delcheva et al., Reference Delcheva, Balabanova and McKee1997; Balabanova, Reference Balabanova1999; Balabanova and McKee, Reference Balabanova and McKee2002), Costa Rica (Lewis, Reference Lewis2006: 29), Georgia (Belli et al., Reference Belli, Shahriari and Gotzadze2004), Hungary (Gaal and McKee, Reference Gaal and McKee2005; Szende and Culyer, Reference Szende and Culyer2006), India (Gopakumar, Reference Gopakumar1998), Kazakhstan (Ensor and Savelyeva, Reference Ensor and Savelyeva1998; Sari et al., Reference Sari, Langenbrunner and Lewis2000: 37), Poland (Chawla et al., Reference Chawla, Berman and Kawiorska1998; Shahriari et al., Reference Shahriari, Belli and Lewis2001; McMenamin and Timonen, Reference McMenamin and Timonen2002), Russia (Feeley et al., Reference Feeley, Sheiman and Shiskin1999) and Tajikistan (Falkingham, Reference Falkingham2004).

Studies have also pointed out the phenomenon in various countries in Northern and Central Asia and in the southern and eastern parts of the continent, in such countries as Bangladesh (Killingsworth et al., Reference Killingsworth, Hossain, Hedrick-Wong, Thomas, Rahman and Begum1999), Vietnam (World Bank, 1992), the Philippines (Killingsworth, Reference Killingsworth2003), South America (Giedion et al., Reference Giedion, Morales and Acosta2001; Gatti et al., Reference Gatti, Gray-Molina and Klugman2003; Barber et al., Reference Barber, Bonnet and Bekedam2004), Africa (McPake et al., Reference McPake, Asiimwe, Mwesigye, Ofumbi, Ortenblad and Streefland1999; Lindelow et al., Reference Lindelow, Ward and Zorzi2004) and even in more prosperous countries such as Turkey (Adaman Reference Adaman2003; Tatar et al., Reference Tatar, Ozgen, Sahin, Belli and Berman2007), and in members of the OECD, such as Greece and Mexico (Liaropoulos and Tragakes Reference Liaropoulos and Tragakes1998; Mossialos et al., Reference Mossialos, Allin, Karras and Davaki2005; Hofbauer, Reference Hofbauer2006: 43–45).

A comparative study conducted in Bangladesh, India, Nepal, Pakistan and Sri Lanka affirmed that in all those countries citizens had to pay informally in order to get a hospital bed, and receive subsidized medicines and healthcare services from the hospital. With the exception of Sri Lanka, IPHC were a precondition for the receipt of healthcare services from the suppliers of healthcare services (Thampi, Reference Thampi2002). A more disturbing phenomenon was revealed in India where mothers were forced to pay nurses IPHC in order to see their new born babies (Gopakumar, Reference Gopakumar1998). A recent study of three hospitals in Greece discovered that in addition to considerations of timing and the convenience of the date of the surgery, there were financial bonuses that encouraged the doctors there to do more cesarean sections. Those bonuses were paid as payments for private medical services in hospitals but also by IPHC (Mossialos et al., Reference Mossialos, Allin, Karras and Davaki2005). The prevalence of the phenomenon throughout the world is considered one of the main reasons for studying it and bringing it to the attention of decision makers (Gaal et al., Reference Gaal, Belli, McKee and Szocska2006: 253).

On the basis of a systematic review of cross-national evidence for IPHC, this article suggests a typology of the phenomena. This typology is based on two variables: legality and improvement, as shown in Table 1.

Table 1

Typology of informal payments for health care

Legality refers to the question: ‘Is the payment legal or not?’. Hence, IPHC can be considered as an illegal activity, or can be considered as a legal or vague activity. Vague activity refers to laws or organizational rules that do not strongly forbid the activity. Although such activity can raise ethical questions, in these cases, the payer does not break the law or the formal institutional rules. Improvement refers to the outcome created as a result of the payment: ‘Did the payment actually change the payer's situation for better or not?’. Theoretically, IPHC could also worsen the payer’ situation in some cases, but it is reasonable to assume that in most cases, it will better the situation and in other cases it might not make any change. Thus, this typology distinguishes between four types of IPHC: ‘Black’ payments, ‘Grey’ payments, ‘Gratitude’ payments and ‘Lost’ payments. As will be shown, the first two types can be considered AP.

Black payments are probably the most discussed and critiqued type of IPHC. In these cases, the payment is given illegally and the payer receives better treatment. In essence, these payments are part of corruption. Perhaps due to the fact that many discussions in the literature about this subject emerge or develop from a broader discussion about the issue of corruption (Gaal and McKee, Reference Gaal and McKee2004: 164; Spector, Reference Spector2005; Lewis, Reference Lewis2006), research has paid more attention to this issue in developing countries with minimal income levels (Ensor, Reference Ensor2004; Gaal et al., Reference Gaal, Belli, McKee and Szocska2006; Lewis, Reference Lewis2007). Clearly, however, such a focus does not imply that the phenomenon exists only there. Indeed, we may infer that while the phenomenon occurs in developing countries more often than other places, it is also present in wealthier countries.

Black payments are also related to discussions about ‘black’ medicine, which is part of the ‘Shadow Economy’. The term ‘black medicine’ refers to a variety of illegal actions that individuals take in order to obtain healthcare services for themselves. Such actions include direct payments to the doctor in order to improve one's position on the waiting list (especially for surgeries); payment to the doctor so he or she will treat the patient personally; giving gifts and bonuses to the doctor before or after treatment; donations to research funds of the hospital department where the patient is treated in order to receive a better treatment; donations of instruments and medical equipment or money for the purchase of medical equipment for the department; payment for treatment which is supposed to be given free of charge in the framework of the regular healthcare insurance in the hopes of improved care; and doctors’ use of instruments and public buildings without permission in order to treat their private patients.

Shadow economies exist worldwide. They are considered a negative socio-economic influence and are related to corruption (Schneider, Reference Schneider2007: 3). In the literature, there is no consensus about the definition of the activities in what is known as the shadow economy. Neither are there indications about the methods of evaluating it nor using the results of the evaluation in an economic analysis of public policy. However, there are indications which point to a definite increase in these activities in various places in the world (Schneider, Reference Schneider2007: 3; Schneider and Buehn, Reference Schneider and Buehn2007: 1). Schneider and Buehn (Reference Schneider and Buehn2007: 2, 3–5) include all market-based legal production of goods and services that are deliberately concealed from public authorities in their definition of the shadow economy and provide various reasons for its appearance.

Interestingly enough, in many countries in which the literature discussed IPHC as a kind of black medicine, two researchers found that the shadow economy accounted for a relatively large portion of the country's income. In 2006, in Greece and Mexico, the shadow economy accounted for 25.3% and 31.5% (respectively) of the gross domestic product, and the average for the other 25 countries of the OECD whose citizens earn a good income was 15.8% (Schneider and Buehn, Reference Schneider and Buehn2007: 26). In developing countries, IPHC were defined as a kind of black medicine. A large percentage of the gross domestic income was derived from activities in the shadow economy (Schneider and Buehn, Reference Schneider and Buehn2007: 15–22).

This finding reinforces the claim that in a society that has extensive activity in a shadow economy in a certain area of policy (e.g. health care), there will be similar phenomena in other areas of policy. As will be demonstrated, the acceptance of a shadow economy in one area becomes part of the local political culture and is then diffused to the rest of the actors and areas of policy in the society.

Grey payments have also emerged in the literature as a dominant configuration of IPHC. In these cases, there is no obvious rule forbidding informal payments, hence the payment is given legally and the payer eventually receives better treatment. For example, in Hungary and in Poland IPHC is legal, and those who report IPHC to the tax authorities can also receive refunds (Shahriari et al., Reference Shahriari, Belli and Lewis2001; Gaal et al., Reference Gaal, Belli, McKee and Szocska2006: 268).

However, IPHC may also be paid in indirect and circuitous ways, further complicating the identification of the phenomenon. The supplier of public healthcare services may not be paid directly or immediately. He may be paid for his services in the future, or for another area of services. This issue emerges as part of the dialogue about political culture in Arab countries. In their classic research, Cunningham and Sarayrah (Reference Cunningham and Sarayrah1993) identified the concept of wasta that they define as a ‘hidden force behind the Mediterranean society’ and an explanatory variable of decision-making in Mediterranean societies. Literally, the meaning of the word is ‘middle’ or in declension, to push two sides of a dispute to a middle point or compromise between them (meaning, the compromiser and the act). Nevertheless, in recent decades the word has come to mean to ‘receive dividends from the government’ (through connections) or a method of overcoming societal obstacles through connections. Wasta is based on familial or clan loyalty, which Arabs leverage to obtain positions or promote their causes in government offices and sometimes academic institutions (Cunningham and Sarayrah, Reference Cunningham and Sarayrah1993: 192). If one is close with the group in power, he or she will receive preferable services, including healthcare services. The supplier of healthcare services and his or her relatives will then be well treated in other policy areas such as education or higher education.

Hence, the cross-national evidence of black and grey payments appears to be related to other concepts and areas, as suggested in discussions describing AP. Therefore, the notion of AP, referred to by other names in other countries (e.g. Wasta) is not confined to the Israeli experience.

Gratitude payments emerged in the literature as a dominant configuration of IPHC especially in Eastern Europe. In these cases, the payment is given legally and the payer does not receive better treatment. The literature reveals that some of the IPHC are received as ‘gifts’ or ‘presents of gratitude’ to doctors only after the patient has been treated properly in every sense of the term, including quality and speed of care. Hence, it is impossible to contend that there is a relationship between this IPHC and the patient's desire to have priority over other patients. Thus, Gaal and McKee (Reference Gaal and McKee2004: 164) claim that the origins of IPHC are in the ‘Semashko’ method of giving gifts of gratitude that was customary in Hungary in the communist era. The notion that one should be grateful for health care and reward its providers with gifts is deeply entrenched in Hungary and effectively impossible to eradicate.

Lost payments are the last configuration of IPHC in our typology. In these cases, the payment is given illegally, but eventually the payer receives equal or even worse treatment than others. This configuration proved to be mainly theoretical, as the literature did not provide empirical data for this type of payment. However, it is reasonable to assume that in a variety of cases and conditions we may observe lost payments, and future research should delve in to this theoretical option.

IPHC: explanations

The literature supplies a variety of explanations for the phenomena of IPHC. However, as will be shown, there is no systematic framework that integrates these variables into one model. Owing to the complexity of the phenomenon and its various configurations, it is unlikely that one will be developed. Above all, there is a lack of literature about the diffusion processes that the phenomenon goes through (or may go through). As described earlier, AP can help by suggesting a wider and much more systematic theoretical framework for the phenomena, and by stressing how, under certain conditions, such mode of behavior is diffused to all sectors and levels of society through a process of collective learning. However, the explanations of IPHC suggested by the literature establish that the motion of AP, even by another name, is not a phenomena exclusive to Israel or to the Israeli healthcare system.

IPHC: consequences

Generally, IPHC prove to threaten the efficiency of healthcare systems, as well as their equity. However, given certain conditions, the phenomenon also has some advantages. Cases in which IPHC are an expression of the patient's gratitude to the supplier of healthcare services, those payments might be more desirable than private healthcare services. Thus, one might argue that the payments provide further resources to the healthcare system without introducing the problem of inequality into the equation, which additional fees would. IPHC may also strengthen healthcare systems’ responsiveness to the demands of the public (Gaal et al., Reference Gaal, Belli, McKee and Szocska2006: 256). IPHC are also perceived to create continuous relationships between patients and providers, improve workers’ motivation and allow patients to show both gratitude and respect to health providers (Chawla et al., Reference Chawla, Berman and Kawiorska1998; Balabanova and McKee, Reference Balabanova and McKee2002).

Nevertheless, in most cases, IPHC proves to cause significant problems related both to efficiency and equity. The phenomena can cause patients to forgo or delay care, sell assets to seek care, or lose faith in the health system (Lewis, Reference Lewis2000; Thompson and Witter, Reference Thompson and Witter2000; Akashi et al., Reference Akashi, Yamada, Huot, Kanal and Sugimoto2004; Falkingham, Reference Falkingham2004; Vian et al., Reference Vian, Gryboski, Sinoimeri and Hall2006). It may also reduce the efficiency of the healthcare system because suppliers of healthcare services will pay the greatest attention to those who pay them extra. These suppliers may also try to reduce transparency and limit consumers’ information about the nature and the price of services (Gaal et al., Reference Gaal, Belli, McKee and Szocska2006: 256). Thus, the prevalence of IPHC highlights the inefficiencies of the healthcare system and undermines the goals and applications of universal health care (Gaal et al., Reference Gaal, Belli, McKee and Szocska2006: 254).

IPHC can also detrimentally affect the quality of clinical care and the treatment received. For example, it can motivate family members to resort to performing some clinical services themselves, in an effort to defray healthcare costs. It can also result in doctors recommending procedures in order to increase their income rather than for therapeutic benefit (Di Tella and Savedoff, Reference Di Tella and Savedoff2001; Falkingham, Reference Falkingham2004). IPHC in public facilities can also create distortions in health financing systems, draining revenue needed to support public sector goals and activities (Ensor, Reference Ensor2004).

Worse yet, IPHC may impede the efficiency of various regulatory mechanisms. Medical insurance answers certain market failures by supplying healthcare services and products. The efficiency of that system may be undermined when IPHC are paid regardless of payments the healthcare provider receives through the insurance company. Hence, both providers and recipients of services come to expect that there are both formal and informal rules that govern the delivery of health care. This understanding overshadows both the quality of the medical insurance they have and the formal insurance rules. Moreover, the existence and embeddedness of the phenomenon may undermine the public's trust in healthcare suppliers (Mizrahi et al., Reference Mizrahi, Vigoda-Gadot and Cohen2009) and challenge the latter through mechanisms such as the law, organizational rules and medical ethics.

IPHC have been proven to be a potential barrier against access to health services, particularly for the poorest groups in society (McPake et al., Reference McPake, Asiimwe, Mwesigye, Ofumbi, Ortenblad and Streefland1999). Several studies demonstrated the relationship between IPHC and restrictive social policies (Ensor, Reference Ensor2004: 241; Gaal et al., Reference Gaal, Belli, McKee and Szocska2006: 255). Furthermore, the literature emphasizes that IPHC may increase social inequality because poor people cannot use this strategy (Lewis, Reference Lewis2000: 23). On the normative level, IPHC may have negative social consequences for those who cannot provide the expected gift after having received treatment. Thus, poor people will be deprived of quality services and the gaps between the upper classes and the lower classes will increase. The principles of justice, equality and mutual assistance are violated when healthcare services are given only to the well-to-do who can violate the law. Thus, acceptance of such a system is one of the worst configurations for supplying health care as a private product, because it puts undue pressure for payment on patients and creates obstacles for poor people, underscoring and increasing social inequality (Balabanova et al., Reference Balabanova, McKee, Pomerleau, Haerpfer and Haerpfer2004). The poor are likely to pay a higher share of their income as IPHC than the rich (Balabanova and McKee, Reference Balabanova and McKee2002; Falkingham, Reference Falkingham2004; Szende and Culyer, Reference Szende and Culyer2006; Tatar et al., Reference Tatar, Ozgen, Sahin, Belli and Berman2007). Further, the amount of IPHC made may remain the same or increase with higher income (Falkingham, Reference Falkingham2004; Szende and Culyer, Reference Szende and Culyer2006).

IPHC may hurt not only the lower class, but the middle class as well. Given the embeddedness of the phenomenon in the healthcare system, even those who do not currently have financial difficulties will be under greater pressure to pay IPHC when they are in trouble.

To conclude, the literature points out both efficiency and equity problems derived from the phenomenon of IPHC. However, this article suggests that understanding IPHC in the broader context of AP may provide insights that in the long term, the consequences of this phenomenon will not be limited only to efficiency and equity. Thus, in time, such mode of behavior, based on illegal activities, is diffused to all sectors and levels of society. These activities and patterns of behaviors may become, in time, an integral part of the political process. Hence, IPHC threaten not only the public health values of efficiency and equity, but in the long term, it could also threaten democratic and participation values. As will be demonstrated in the next section, the Israeli experience provides an interesting case study in the attempt to infer the structural conditions that may lead a democratic society to apply this kind mechanism.

IPHC and the notion of AP – the Israeli experience

Summary and discussion

IPHC is a worldwide practice that has been the subject of numerous studies. Its varied configurations and characteristics make it difficult to define. Its equation with corruption is inaccurate, because while the phenomenon is often considered illegal or extra-legal, in some periods and places IPHC are legally permitted. Furthermore, in various places IPHC are entirely formalized, as they are reported and registered by the legal authorities.

The assessment of the phenomenon is very difficult to make as well. Even if the phenomenon is not legally prohibited, it is usually done secretly between the person who pays and the one who supplies services. Hence, it is also very difficult to collect data about payments. Initial efforts were begun in the early 90s to collect data through questionnaires, a practice that has been continued in reiterative and comprehensive surveys, in interviews and surveys that concentrate exclusively on this phenomenon as well as through focus groups.

The article discussed IPHC’ advantages and problems. I demonstrated that IPHC also has some advantages. In most cases, however, these payments proved to cause significant problems related both to efficiency and equity. These payments can cause patients to forgo or delay care, sell assets to seek care, or lose faith in the health system. It also might reduce the efficiency of the healthcare system because suppliers of healthcare services will pay the greatest attention to those who pay them extra and undermine the goals and applications of universal health care. IPHC can also detrimentally affect the quality of clinical care and the treatment received. The existence of the phenomena in public facilities can also create distortions in health financing systems, draining revenue needed to support public sector goals and activities. IPHC also impede the efficiency of various regulatory mechanisms such as medical insurance. The existence of the phenomenon may undermine the public's trust in healthcare suppliers.

IPHC also proved to be a potential barrier against access to health services, particularly for the poorest groups in society. Thus, poor people will be deprived of quality services and the gaps between the upper classes and the lower classes will increase. The principles of justice, equality and mutual assistance are violated when healthcare services are given only to the well-to-do who can violate the law. IPHC may hurt not only the lower class, but the middle class as well.

However, this article claimed that IPHC not only can threaten values of efficiency and equity, it also can challenge democratic and participation values. The article suggested considering IPHC within a broader conceptual framework built upon studies in public policy. Specifically, it suggested viewing IPHC as an integral part of the patterns of political behavior of a given society. This behavior bypasses formal institutions in favor of illegal or semi-legal means of acquiring desired public goods and services. Such behavior is engaged by citizens who are dissatisfied with the quality and/or quality of public goods and services and believe that the political structure is so paralyzed that they are powerless to effectively change the situation. This behavior, which is described as AP, has been identified through an examination of the political and cultural structure in Israel. AP slowly and silently pervades all of the actors, sectors and areas of public policy in Israel.

Although there are certain difficulties with using AP as an explanation for all IPHC worldwide, this explanation does provide us with a much broader perspective on the phenomenon and indicates the diffusion of multi-cultural behavior patterns to other areas of public policy as well. Moreover, it also improves our understanding regarding the structural conditions that may lead societies in both developed and developing countries to apply this kind of mechanism. Wherever the existing political culture sanctions the supply of public goods and services through the black and gray market, one should expect the phenomenon of IPHC as black and grey payments. Furthermore, it is reasonable to assume that in societies that lack strong institutions that enforce legal behavior and a participatory political culture based on transparency, integrity, liability, responsiveness, accountability and credibility, IPHC and similar phenomena will appear in other areas of policy, such as education, social security, housing and more. Additional research will focus on the existence of AP in other countries and will help us determine the interplay between AP and other aspects of healthcare policies.

It is reasonable to assume that IPHC would exist in Israel even if they did not have their special brand of AP. Indeed, as the article reviews, the first documented incidence of ‘black’ IPHC dates back to 1919, long before the establishment of the State of Israel. However, the diffusing processes of AP to most players, sectors and areas of public policy in Israel is what makes the difference between ‘isolated’ phenomenon of IPHC and AP. Thus, weak formal institutions are slowly surrendering to dominant informal institutions (i.e. the given political culture). Thus, as suggested elsewhere (Cohen and Mizrahi, Reference Cohen and Mizrahi2010) it seems that Israeli decision-makers often find it very difficult to fight such phenomena, especially in systems which are in continuous crisis. Under such circumstances, Israeli politicians often attempt to control the system by institutionalizing some of the illegal activities. In other cases, when the phenomenon seems as a direct threat on the state monopoly, it fights it. This is evident in the Israel's opposition to informal channels of supplying public services by the radical Islam among Israeli Arabs.

What other countries can learn from this experience? Does the current world financial crisis create conditions in Western countries that would be conducive to more AP in general, and in particular, to phenomena like IPHC? Tentatively, it seems that the answer will be no. However, AP is strongly correlated with the strength of given formal institutions in those countries and the levels of their governability. Countries with strong institutions enforcing effective regulations against such phenomena, will probably suffer from it less than others.

Some may argue that normatively, AP is not necessarily negative; it may strengthen political participation, increase citizen's involvement in public policy and the ‘civil society’ and serve as a ‘safety valve’ in a complex world. However, as the article explains, AP is not an additional pattern of political participation in a democratic system, but a threat to stability and to the democratic system and values. Thus, citizens internalize illegal and extra-legal behaviors or attitudes that in essence bypass the existing mechanisms of social participation and social norms. In the long term, this may have destructive economic and political outcomes for any society.