Informal gifts to medical staff constitute an important part of out-of-pocket payments in health care imposing a heavy burden on patient’s expenditure. This paper looks at the causes ofinformal gifts in health care in Albania by exploring three main models; social-cultural, economic (lack of resources), and poor governance. We use pooled data from Albania LSMS 2002, 2005, 2008 and employ a tobit model to identify the main individual determinants and propensity score matching to investigate how individual characteristics of people paying informally have changed over years. Most of the evidence found suggests that even though scarcity of resources seems to be related to such phenomenon, governance failures in health care are the main reason behind such payments. Recent measures and reforms have had little effect in reducing such phenomena, and the poorest people are still vulnerable and prone to the adverse effects of such payments.