Earning opportunities and informal payment as influencing factors in medical students’ speciality choice

Background The Hungarian primary care system faces a severe shortage of family physicians. Medical students’ perceptions of family medicine need to be known and medical students need to be given appropriate and comprehensible information about this speciality. The expected future salary is an important factor in career choice. Most of the family doctors are self-employed and the practices have a corrected capitation-type financing. Although the majority of health care services are covered by social health insurance and are provided for the insured patients free of charge, informal payment is an existing phenomenon with different motivations and consequences. This study aimed to investigate medical students’ knowledge about their future earning opportunities and their attitudes towards informal payment. Methods A cross sectional survey with a self-administered questionnaire was conducted. Each of the four Hungarian medical universities were represented by their medical students who attended family medicine lectures in person from December 2019 to April 2020. The students were asked about their career plans, about their estimations of current and ideal expected salaries and about the effect of expected income for the choice of specialisation. Their attitudes towards informal payment were assessed. Results Response rate was 67.3% (N = 465/691). Almost two-thirds of the participants were women. Only 5% of the respondents (N = 23/462) plan to work as a family doctor in the future. The vast majority (91.9%) of the students had already thought about their future income. On a 10-point Likert scale (1 = ‘no influence’, 10 = ‘very big influence’) 76% answered that the expected future income exerts a considerable (≥5 Likert points) influence on their career choice in general. The mean of the ideal expected monthly income of the residents, GPs and other specialists was €1154 ± 648, €1696 ± 904 and €2174 ± 1594, respectively. The mean of the monthly income for a GP, as estimated by the studenst, was €1140 in rural and €1122 in urban settings. More than four-fifths of the students (N = 375/453) rejected the practice of informal payment. Conclusions Expected salaray is one important aspect in the career choice of medical students, students wish to have more information on this topic. The reported ideal incomes are higher than those expected. This points to a relevant gap. However, most of the students do not accept informal payment as a possibility to close this gap. The expected and the ideal income differ from the real incomes of Hungarian GPs – this indicates the need of bringing objectoive information to the students to enhance attractivity of GP as a carer choice.

A hálapénzzel kapcsolatos szokások a magyar egészségügyi szakdolgozók körében

Összefoglaló. Bevezetés: Magyarországon 2021. január 1-jétől a hálapénz minden formájának adása és elfogadása bűncselekmény, kivéve a legföljebb a minimálbér 5%-át (8370 forintot) elérő ajándékot. Míg a tilalmat az orvosok esetében jelentős béremelés kompenzálja, addig a szakdolgozók korábban is kevéssé vizsgált hálapénzjuttatásának helyzetére és megváltozására vonatkozóan alig vannak adatok. Célkitűzés: A szakdolgozói hálapénz 2020 végi kiinduló helyzetének feltárása és az új jogszabályi előírások becsülhető hatásainak vizsgálata a szakdolgozók által nyújtott információ alapján. Módszer: 2020 őszén 167 egészségügyi szakdolgozó kérdőíves felmérése történt meg a Szegedi Tudományegyetem Szent-Györgyi Albert Klinikai Központjában a hálapénzadás motivációinak, formáinak és körülményeinek, valamint összegének megismerése érdekében. Az eredményeket elsősorban leíró statisztikai formában elemeztük, különös tekintettel a műtéti, a belgyógyászati és a gyermekgyógyászati szakterületek között mutatkozó különbségekre; és összevetettük az új törvény hatására várható változásokkal. Eredmények: A 167 válaszadóból 93-an műtéti/operatív területen, 54-en belgyógyászati jellegű területen, 18-an pedig a gyermek/ifjúsági ellátásban dolgoznak. Mindegyik szakterületen megjelent a hála mellett a korrupciós célú juttatás, de ezzel és a hálapénzjelenséggel legkevésbé a gyermekgyógyászati terület volt érintett. A nagyobb értékű ajándék ritka, de a kisebb értékű rendszeresen alkalmazott juttatás. Egy hét benntartózkodás esetén a válaszadók átlagosan 10 851 forintot (36 USD) kaptak hálapénzként, míg egy-egy alkalommal 5326 forintot (18 USD). Az összegek – hasonlóan az orvosi hálapénzhez – jelentős eltérést mutattak az egyes területek között, a műtéti szakmákban pedig meghaladták az új törvényi korlátot. A magánellátásban kapott hálapénz kisebb arányú, a munkahelyen kívül átadott juttatás pedig kifejezetten ritka. Következtetés: A korrupciós célú hálapénz az egészségügyi szakdolgozói szférában ugyan jelen van, de nem jellemző. A szakdolgozóknak juttatott hálapénz büntetőjogi szankcionálását nem kompenzálja az orvosokéhoz hasonló béremelés. A pénzbeli juttatás ajándéktárgy formájában történő juttatása minden területen jelent veszteséget, a műtéti területen az értékben kifejezett veszteség is jelentősebb lehet. A büntetőeljárási fenyegetettség nem elegendő a magyarországi hálapénzrendszer megszüntetéséhez, további társadalompolitikai intézkedések szükségesek az egészségügyi dolgozók és a betegek attitűdjének megváltoztatásához. Orv Hetil. 2021; 162(41): 1658–1668. Summary. Introduction: In Hungary, since January 1st, 2021, the giving and acceptance of all forms of informal payments constitute a crime, except for gifts of a value of no more than 5% of the minimal monthly salary. While in the case of physicians, a pay rise compensates the loss of revenue, we hardly have data on the nurses’ attitude in relation to the acceptance of informal payments. Objective: We intend to uncover the situation of informal payments at the end of 2020 and to examine the effects of the new legal regulation, based on information from nurses. Method: In the fall of 2020, we questioned 167 nurses in the Albert Szent-Györgyi Health Center of the University of Szeged, Hungary, in order to highlight the motivations, forms, circumstances, and sums of informal payments. We analyzed the results by means of descriptive statistical methods, with special regard to the differences among surgical, internal medical and pediatric fields. We analyzed the results with a view to the new legal regulations. Results: Out of 167 respondents, 93 work in operative field, 54 in internal medical care, and 18 in pediatric care. Besides gratitude, corruption appeared in all the three fields, however, pediatric care was the least touched by corruption. Gifts of a higher value are rare, however, small gifts are common. The respondents received 10 851 HUF (i.e., 36 USD) as informal payment from in-patients after one week, while, occasionally, 5326 HUF (i.e., 18 USD). The sums – similarly to informal payments to physicians – vary from field to field in healthcare. In the surgical field, the sums surpassed the new legal limit. Informal payments are given in private healthcare more rarely than in public healthcare. Informal payments given outside the workplace hardly ever occur. Conclusion: The informal payment with the goal of corruption is present in the sphere of nurses, however, it is not typical. The criminal sanctioning of informal payments to nurses is not compensated by a pay rise similar to that of physicians. The fact that informal payments are substituted by gifts results in loss of revenue in all fields of healthcare, however, this loss is the most salient in the surgical field. The criminal sanctioning is not sufficient to eliminate informal payments in Hungary; further socio-political measures are to be taken with the goal to change the attitude of healthcare workers and patients. Orv Hetil. 2021; 162(41): 1658–1668.

Exploring contextual factors influencing the implementation of evidence-based care for hypertension in Rwanda: a cross-sectional study using the COACH questionnaire

ImportanceHypertension is the largest contributor to the Global Burden of Disease. In Rwanda, as in most low-income and middle-income countries, an increasing prevalence of hypertension and its associated morbidity and mortality is causing major healthcare and economic impact. Understanding healthcare systems context in hypertension care is necessary.ObjectiveTo study the hypertension healthcare context as perceived by healthcare providers using the Context Assessment for Community Health (COACH) tool.DesignA cross-sectional cohort responded to the COACH questionnaire and a survey about hypertension training.SettingThree tertiary care hospitals in Rwanda.ParticipantsHealthcare professionals (n=223).Primary outcome(s) and measure(s)The COACH tool consists of 49 items with eight subscales: resources, community engagement, commitment to work, informal payment, leadership, work culture, monitoring services for action (5-point Likert Scale) and sources of knowledge (on a 0–1 scale). Four questions surveyed training on hypertension.ResultsResponders (n=223, 75% women; 56% aged 20–35 years) included nurses (n=142, 64%, midwives (n=42, 19%), primary care physicians (n=28, 13%) and physician specialists (n=11, 5%)). The subscales commitment to work, leadership, work culture and informal payment scored between 4.7 and 4.1 and the community engagement, monitoring services for action and organizational resources scored between 3.1 and 3.5. Sources of knowledge had a mean score of 0.6±0.3. While 73% reported having attended a didactic hypertension seminar in the past year, only 28% had received long-term training and 51% had <3-year experience working with hypertension care delivery. The majority (99%) indicated a need for additional training in hypertension care.ConclusionsThere is a need for increased and continuous training in Rwanda. Healthcare responders stated a commitment to work and reported supportive leadership, while acknowledging limited resources and no monitoring systems. The COACH tool provides contextual guidance to develop training strategies prior to the implementation of a sustainable hypertension care programme.

How Different Motivations for Making Informal Out-Of-Pocket Payments Vary in Their Influence on Users’ Satisfaction with Healthcare, Local and National Government, and Satisfaction with Life?

Background. The dominant view in the literature is that informal payments in healthcare universally are a negative phenomenon. By contrast, we theorize that the motivation healthcare users for making informal payments (IP) can be classified into three categories: (1) a cultural norm, (2) “grease the wheels” payments if users offered to pay to get better services, and (3) “sand the wheels” payments if users were asked to pay by healthcare personnel or felt that payments were expected. We further hypothesize that these three categories of payments are differently associated with a user’s outcomes, namely, satisfaction with healthcare, local and national government, satisfaction with life, and satisfaction with life of children in the future. Methods. We used microdata from the 2016 Life-in-Transition survey. Multivariate regression analysis is used to quantify relationships between these categories of payments and users’ outcomes. Results. Payments that are the result of cultural norms are associated with better outcomes. On the contrary, “sand the wheel” payments are associated with worse outcomes. We find no association between making “grease the wheels” payments and outcomes. Conclusions. This is the first paper which evaluates association between three different categories of informal payments with a wide range of users’ outcomes on a diverse sample of countries. Focusing on informal payments in general, rather than explicitly examining specific motivations, obscures the true outcomes of making IP. It is important to distinguish between three different motivations for informal payment, namely, cultural norms, “grease the wheels,” and “sand the wheels” since they have varying associations with user outcomes. From a policy making standpoint, variation in the links between different motivations for making IP and measures of satisfaction suggest that decision-makers should put their primary focus on situations where IP are explicitly asked for or are implied by the situation and that they should differentiate this from cases of gratitude payments. If such measures are not implemented, then policy makers may unintentionally ban the behaviour that is linked with increased satisfaction with healthcare, government, and life (i.e., paying gratitude).

Analysis of Tax Compliance in Sub-Saharan Africa: Evidence from Firm-Level Study

This study analyses tax compliance among firms in Sub-Saharan Africa (SSA) within an extended Slippery Slope Framework (eSSF). It applies instrumental variables and generalized estimating equations models on a constructed World Bank’s Enterprise Survey longitudinal dataset. The results indicate that the perceived power of the tax authorities does not influence firms’ tax compliance, which could be linked to corruption in the form of informal payment. The results also show that corruption encourages the culture of tax non-compliance among firms in SSA because the defaulting firms bribe tax authorities in order to avoid paying taxes and being punished for that. In addition, the results demonstrate that the perceived trust of tax authorities (state representatives) is vitally important in encouraging tax compliance among firms in SSA. In terms of political decisions, it may be implied that gaining trust of taxpayers should be pursued.

Informal payments in Romanian health care system. A sample selection correction

This paper draws on economic theory, sociology and political science approaches to explain informal payments in the Romanian health care system. It estimates the likelihood of paying a bribe (informal payment) using a reduced health care demand equation in a probit model with sample selection correction. Social capital, as having a relationship with doctors, and the perception of the health care system, as corrupt, are found to influence the probability of making an informal payment. The likelihood of making an informal payment in the Romanian health care system is modelled using a maximum-likelihood probit estimation with sample selection correction. In the selection equation, reduced health care demand, self-perceived health status and being afraid of diseases are used as exclusion restrictions for identifying the parameters of the econometric model.

Understanding public health providers’ preferences for interventions against informal payment in Tanzania: a discrete choice experiment

Background Informal payments are regressive. They can limit the access to quality healthcare, particularly of the most vulnerable, and are potentially catastrophic. Little is known in terms of providers' preferences for interventions. Methods We conducted a cross-sectional discrete choice experiment (DCE) among 432 health providers from 42 public health facilities (hospitals and health centres) in seven districts from Pwani region and five districts from Dar es Salaam region. The DCE attributes were derived from a scoping literature review, qualitative interview from 27 key informants from three districts, and through workshop with health providers, managers and policy makers. The final DCE survey tool included 12 unlabeled choice sets, each describing two hypothetical jobs that varied across six attributes: mode of payment, supervision at facility, opportunity for private practice, awareness and monitoring, measures against informal payment, and incentive payment for lack informal payment in the past 6 months. Multinomial logit and mixed multinomial logit methods were used to estimate preferences for the attributes. Results All attribute-levels, apart from supervision at the facility level, were significantly influencing health providers' choice decisions for job type (p &lt; 0.001). The most preferred attributes were measures for awareness creation and monitoring -i.e. preferences were significantly higher for facility with noticeboard (coefficient 0.39, 95% CI 0.29 -0.48 ), followed by provision of receipts (0.34, 0.24 -0.44) and presence of hotline number for reporting corrupt practices (0.26, 0.17 -0.35). Opportunity for private practice was significantly preferred (0.38, 0.31-045) and job preference increases as salary top-up increases (0.06, 0.05-0.7). The less preferred attributes were cash payment for healthcare (-0.27, -0.35- -0.19) and disciplinary measures at the district (-0.15, -0.23 - -0.07) or facility level (-0.10, -0.17- -0.03).

The impact of informal payment on Caesarean delivery rates in obstetric care in Hungary

Background Our objective is to investigate factors increasing the likelihood of Caesarean sections in Hungary, in particular whether planned Caesarean deliveries might be a consequence of the widespread informal payment practice in obstetric care. Methods We use data from the “Cohort '18 - Growing Up in Hungary” birth cohort study. In the 1st wave a nationwide representative sample (N = 8,287) of pregnant women was surveyed in 2018/2019. The 2nd wave was conducted 6 months after childbirth. Data was analyzed by a multinomial logistic regression model. The output variable was the type of childbirth: natural (ref.)/Caesarean/planned Caesarean. The explanatory variables were informal payment at birth, private/public prenatal care, maternal health, SES. Results Based on the explanatory model (Pseudo-R2=0.278) the increased likelihood of planned Caesarean section is associated with out of pocket payment at birth (Exp(B)=3.749). This health system related factor absorbs the effect of social background for the possibility of planned Caesarean section, since its inclusion in the model reduces the independent influence of SES. However, the likelihood of planned Caesarean delivery compared to natural births is also determined by the mother' age and physical condition. Conclusions The high Caesarean delivery rates (over 40%) in Hungary are largely due to features of health system finance, particularly for planned Caesarean deliveries (22% of births). Although deliveries basically take place in public hospitals, the presence of an out of pocket paid private doctor at birth is a frequent and socially selective factor. Whereas planned Caesarean sections are strongly determined by SES, at the system level it is channeled into the various private or informal forms of financing. Key messages Informal payment within the general public care system strengthens the social selection in prenatal and delivery care in Hungary. This effect is reflected in the proportion of planned Caesarean sections.

Informal Payments for Maternal and Neonatal Health Services in Public Hospitals in Central India

Background: Informal payments are unauthorised ‘unregistered’ out-of-pocket payments, outside the official payment system, for purchase or service meant to be covered/provided by the healthcare system. This study attempts to measure and report the extent and magnitude of informal payments based on the entitlements in Janani-Shishu Suraksha Karyakram (JSSK) in the Indian context. Methods: A cross-sectional study using convenience sampling and a semi-structured interview schedule was conducted among 281 participants in 2016 in 26 JSSK-notifying health facilities from all five divisions of Chhattisgarh. Pregnant women and women who delivered in the previous year, and provided informed consent, were included. After reviewing various definitions, informal payment was operationally defined in the context of JSSK for India as ‘payments made in cash or kind, unregistered or non-reimbursed, made by/on behalf of the beneficiary or someone related thereof, for free and cashless entitlements in a JSSK-listed health facility, to an individual or institutional healthcare provider/staff who provides/arranges for provision of the service’. Results: Of 281 participants, 91.8 per cent reported informal payments across all JSSK entitlements categories. A relative majority of these payments was made at the district hospital (37%), ranging from ₹2 to ₹6,500 (US$0.03–101). Investigations incurred the greatest median amount of informal payments, at, ₹455 (US$7). Informal payments ranged between three and seven times higher than the JSSK price cap in Chhattisgarh. No significant association was found between participant characteristics and informal payments. Conclusion: Further research is required to understand the magnitude and motivation of informal payments made in programmes like JSSK.