Institutional Determinants of Informal Payments for Health Services: An Exploratory Analysis across 117 Countries

Healthcare accessibility and equity remain important issues, as corruption in the form of informal payments is still prevalent in many countries across the world. This study employs a panel data analysis over the 2006–2013 period to explore the role of different institutional factors in explaining the prevalence of informal payments. Covering 117 countries, our findings confirm the significant role of both formal and informal institutions. Good governance, a higher trust among individuals, and a higher commitment to tackling corruption are associated with diminishing informal payments. In addition, higher shares of private finance, such as out-of-pocket and domestic private health expenditure, are also correlated with a lower prevalence of informal payments. In policy terms, this displays how correcting institutional imperfections may be among the most efficient ways to tackle informal payments in healthcare.

Informal payments in public hospitals in Malawi: the case of Kamuzu Central Hospital

Background Informal payments in public health facilities act as a barrier to accessing quality health services, especially for poor people. This research aimed to investigate informal payments for health care services at Kamuzu Central Hospital (KCH), a public referral hospital in Malawi. Results of this study provide evidence on the prevalence and influencing factors of informal payments for health care so that relevant policies and strategies may be developed to address this problem. Methods This study employed a mixed methods research design. The quantitative study had a sample size of 295 patients and guardians. The qualitative study had 7 key informant interviews (with health workers, health managers and policy makers) and 3 focus group discussions (FGDs) with guardians. Each FGD included 10 participants. Thus, in total, the qualitative sample comprised 52 participants. Quantitative data was analyzed using Excel and STATA. Qualitative data was analyzed using a thematic content analysis approach. Results 80% of patients and guardians had knowledge of informal payments. Approximately 47% of respondents admitted making informal payments to access health services, and 87% of informal payments were made at the request of a health worker. Lack of knowledge, fear and desperation among patients and guardians, low salaries of health workers, and lack of effective disciplinary measures, were reported as key factors influencing informal payments. Regression analysis results showed that occupation and gender were the main determinants of informal payments. Conclusions Informal payments exacerbate inequality in access to free public health services. Particularly, poor people have limited access to health services when informal payments are demanded. This practice is unethical and infringes on people’s rights to universal access to health care. There is a need to strengthen the public health care system by formulating deliberate policies that will deter informal payments in Malawi.

Trends in Informal Payments by Patients in Europe: A Public Health Policy Approach

Background: A new institutional approach toward informal payments in healthcare views informal payments as arising when there is a misalignment between values/norms (informal institutions) and the formal rules (formal institutions) of patients. However, less knowledge is available on the effectiveness of this approach in tackling informal payments in healthcare. This study aimed to fill this gap by evaluating the trends in the effect of institutional misalignment on informal payments made by patients.Methods: A quantitative study design with data extracted from the last three waves of special Eurobarometer surveys on corruption was used to model the propensity of European patients in 27 European Union countries and the United Kingdom to make informal payments. Multilevel logistic regression analysis was employed in order to test the relationship between the formal–informal institution misalignment and the likelihood to make informal payments. Sensitivity analyses were also performed to test the robustness of the findings.Results: The finding is that there is a strong association between the formal–informal institution misalignment and the likelihood to make informal payments for public healthcare services. Similarly, social norms play a pivotal role. When patients perceive that informal practices are widespread in the public healthcare sector they are more likely to make informal payments themselves.Conclusion: The outcome is a call for complementing deterrence measures toward informal payments in healthcare with measures aiming to reduce the formal–informal institution misalignment and to change the social norms. This can be achieved by improving the structural conditions at country level and by changing values/norms and beliefs of patients.

The hidden financial burden of healthcare: a systematic literature review of informal payments in Sub-Saharan Africa

Background: Informal payments limit equitable access to healthcare. Despite being a common phenomenon, there is a need for an in-depth analysis of informal charging practices in the Sub-Saharan Africa (SSA) context. We conducted a systematic literature review to synthesize existing evidence on the prevalence, characteristics, associated factors, and impact of informal payments in SSA. Methods: We searched for literature on PubMed, African Index Medicus, Directory of Open Access Journals, and Google Scholar databases and relevant organizational websites. We included empirical studies on informal payments conducted in SSA regardless of the study design and year of publication and excluded reviews, editorials, and conference presentations. Framework analysis was conducted, and the review findings were synthesized. Results: A total of 1700 articles were retrieved, of which 23 were included in the review. Several studies ranging from large-scale nationally representative surveys to in-depth qualitative studies have shown that informal payments are prevalent in SSA regardless of the health service, facility level, and sector. Informal payments were initiated mostly by health workers compared to patients and they were largely made in cash rather than in kind. Patients made informal payments to access services, skip queues, receive higher quality of care, and express gratitude. The poor and people who were unaware of service charges, were more likely to pay informally. Supply-side factors associated with informal payments included low and irregular health worker salaries, weak accountability mechanisms, and perceptions of widespread corruption in the public sector. Informal payments limited access especially among the poor and the inability to pay was associated with delayed or forgone care and provision of lower-quality care. Conclusions: Addressing informal payments in SSA requires a multifaceted approach. Potential strategies include enhancing patient awareness of service fees, revisiting health worker incentives, strengthening accountability mechanisms, and increasing government spending on health.

The Reasons for Informal Payments from the Perspective of Health Care Providers and Recipients: A Qualitative Study in Iran

Background: Informal payments are one of the major obstacles to health system reform in many developing countries, and its elimination is on the agenda of health system policymakers in many countries, including Iran. This study was conducted to identify the causes of informal payments in the Iranian health system.Methods: This was a qualitative and exploratory study. The study population included health care providers and health care recipients. Data were collected using open-ended questions and semi-structured interviews. Convenience and snowball sampling methods were used to select the providers. Content analysis method was used to analyze the data.Results: In the present study, 6 participants were physicians, 4 were hospital managers or CEOs, 4 were treatment or technical managers, 2 were nurses and 12 were patients or their companions. Reasons for informal payments divided in 4 themes include Economic factors, Socio-cultural factors, Service delivery challenges and Legal-political factors.Conclusions: In the Iranian health system, there is a great effort in order to reduce and eliminate the informal payments phenomenon, especially with the implementation of the health system transformation plan. Knowing the causes of this phenomenon can help reduce or eliminate it.

Informal Payments by Patients in Central and Eastern Europe during the COVID-19 Pandemic: An Institutional Perspective

Confronted with a global pandemic, public healthcare systems are under pressure, making access to healthcare services difficult for patients. This provides fertile ground for using illegal practices such as informal payments to gain access. This paper aims to evaluate the use of informal payments by patients during the COVID-19 pandemic and the institutions that affect the prevalence of this practice. Various measurements of formal and informal institutions are here investigated, namely the acceptability of corruption, the level of trust, transparency, and performance of the healthcare system. To do so, a logistic regression of 10,859 interviews with patients conducted across 11 Central and Eastern Europe countries in October–December 2020 is employed. The finding is that there are large disparities between countries in the prevalence of informal payments, and that the practice is more likely to occur where there are poorer formal and informal institutions, namely higher acceptability of corruption, lower trust in authorities, lower perceived transparency in handling the COVID-19 pandemic, difficult access to, and poor quality of, healthcare services, and higher mortality rates due to the COVID-19 pandemic. These findings suggest that policy measures for tackling informal payments need to address the current state of the institutional environment.

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.

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).

Health extension workers’ perceived health system context and health post preparedness to provide services: a cross-sectional study in four Ethiopian regions

ObjectiveThe health system context influences the implementation of evidence-based practices and quality of healthcare services. Ethiopia aims at reaching universal health coverage but faces low primary care utilisation and substandard quality of care. We assessed the health extension workers’ perceived context and the preparedness of health posts to provide services.SettingThis study was part of evaluating a complex intervention in 52 districts of four regions of Ethiopia. This paper used the endline data collected from December 2018 to February 2019.ParticipantsA total of 152 health posts and health extension workers serving selected enumeration areas were included.Outcome measuresWe used the Context Assessment for Community Health (COACH) tool and the Service Availability and Readiness Assessment tool.ResultsInternal reliability of COACH was satisfactory. The dimensions community engagement, work culture, commitment to work and leadership all scored high (mean 3.75–4.01 on a 1–5 scale), while organisational resources, sources of knowledge and informal payments scored low (1.78–2.71). The general service readiness index was 59%. On average, 67% of the health posts had basic amenities to provide services, 81% had basic equipment, 42% had standard precautions for infection prevention, 47% had test capacity for malaria and 58% had essential medicines.ConclusionThe health extension workers had a good relationship with the local community, used data for planning, were highly committed to their work with positive perceptions of their work culture, a relatively positive attitude regarding their leaders, and reported no corruption or informal payments. In contrast, they had insufficient sources of information and a severe lack of resources. The health post preparedness confirmed the low level of resources and preparedness for services. These findings suggest a significant potential contribution by health extension workers to Ethiopia’s primary healthcare, provided that they receive improved support, including new information and essential resources.