Informal payments for health care: definitions, distinctions, and dilemmas

Barriers to universal health coverage in Republic of Moldova: a policy analysis of formal and informal out-of-pocket payments

BACKGROUND

Universal Health Coverage seeks to assure that everyone can obtain the health services they need without financial hardship. Countries which rely heavily on out-of-pocket (OOP) payments, including informal payments (IP), to finance total health expenditures are not likely to achieve universal coverage. The Republic of Moldova is committed to promoting universal coverage, reducing inequities, and expanding financial protection. To achieve these goals, the country must reduce the proportion of total health expenditures paid by households. This study documents the extent of OOP payments and IP in Moldova, analyses trends over time, and identifies factors which may be driving these payments.

METHODS

The study includes analysis of household budget survey data and previous research and policy documents. The team also conducted a review of administrative law intended to control OOP payments and IPs. Focus groups, interviews, and a policy dialogue with key stakeholders were held to validate and discuss findings.

RESULTS

OOP payments account for 45% of total health expenditures. Sixteen percent of outpatients and 30% of inpatients reporting that they made OOP payments when seeking care at a health facility in 2012, more than two-thirds of whom also reported paying for medicines at a pharmacy. Among those who paid anything, 36% of outpatients and 82% of inpatients reported paying informally, with the proportion increasing over time for inpatient care. Although many patients consider these payments to be gifts, around one-third of IPs appear to be forced, posing a threat to health care access. Patients perceive that payments are driven by the limited list of reimbursable medicines, a desire to receive better treatment, and fear or extortion. Providers suggested irrational prescribing and ordering of tests as drivers. Providers may believe that IPs are gifts and do not cause harm for patients and the health system in general.

CONCLUSIONS

Efforts to expand financial protection should focus on reducing household spending on medicines and hospital-based IPs. Reforms should consider ways to reduce medicine prices and promote rational use, strengthen administrative controls, and increase incentives for quality health care provision.

The link between past informal payments and willingness of the Hungarian population to pay formal fees for health care services: results from a contingent valuation study

We examine the willingness of health care consumers to pay formal fees for health care use and how this willingness to pay is associated with past informal payments. We use data from a survey carried out in Hungary in 2010 among a representative sample of 1,037 respondents. The contingent valuation method is used to elicit the willingness to pay official charges for health care services covered by the social health insurance if certain quality attributes (regarding the health care facility, access to the services and health care personnel) are guaranteed. A bivariate probit model is applied to examine the relationship between willingness to pay and past informal payments. We find that 66% of the respondents are willing to pay formal fees for specialist examinations and 56% are willing to pay for planned hospitalizations if these services are provided with certain quality and access attributes. The act of making past informal payments for health care services is positively associated with the willingness to pay formal charges. The probability that a respondent is willing to pay official charges for health care services is 22% points higher for specialist examinations and 45% points higher for hospitalization if the respondent paid informally during the last 12 months. The introduction of formal fees should be accompanied by adequate service provision to assure acceptance of the fees. Furthermore, our results suggest that the problem of informal patient payments may remain even after the implementation of user fees.

Blurring the boundaries between public and private health care services as an alternative explanation for the emergence of black medicine: the Israeli case

Black medicine represents the most problematic configuration of informal payments for health care. According to the accepted economic explanations, we would not expect to find black medicine in a system with a developed private service. Using Israel as a case study, we suggest an alternative yet a complimentary explanation for the emergence of black medicine in public health care systems – even though citizens do have the formal option to use private channels. We claim that when regulation is weak and political culture is based on ‘do it yourself’ strategies, which meant to solve immediate problems, blurring the boundaries between public and private health care services may only reduce public trust and in turn, contribute to the emergence of black medicine. We used a combined quantitative and qualitative methodology to support our claim. Statistical analysis of the results suggested that the only variable significantly associated with the use of black medicine was trust in the health care system. The higher the respondents’ level of trust in the health care system, the lower the rate of the use of black medicine. Qualitatively, interviewee emphasized the relation between the blurred boundaries between public and private health care and the use of black medicine.

How do supply-side factors influence informal payments for healthcare? The case of HIV patients in Cameroon

Direct out-of-pocket payments for healthcare continue to be a major source of health financing in low-income and middle-income countries. Some of these direct payments take the form of informal charges paid by patients to access the needed healthcare services. Remarkably, however, little is known about the extent to which these payments are exercised and their determinants in the context of Sub-Saharan Africa. This study attempts therefore to shed light on the role of supply-side factors in the occurrence of informal payments while accounting for the demand-side factors. The study relies on data taken from a nationally representative survey conducted among people living with HIV/AIDS in Cameroon. A multilevel mixed-effect logistic model is employed to identify the factors associated with the incidence of informal payments. Results reveal that circa 3.05% of the surveyed patients incurred informal payments for the consultations made on the day of the survey. The amount paid informally represents up to four times the official tariff. Factors related to the following: (i) human resource management of the health facilities (e.g., task shifting); (ii) health professionals' perceptions vis-à-vis the remunerations of HIV care provision; and (iii) reception of patients (e.g., waiting time) significantly influence the probability of incurring informal payments. Also of note, the type of healthcare facilities is found to play a role: informal payments appear to be significantly lower in private non-profit facilities compared with those belonging to public sector. Our findings allude to some policy recommendations that can help reduce the incidence of informal payments.

Informal patient payments in publicly financed healthcare facilities in Lithuania

Background: Since the late 1990s Lithuania has had a mixed, solidary based healthcare system, predominantly funded from the National Health Insurance Fund through a compulsory health insurance scheme. The cultural tradition of informal payments in healthcare in Lithuania was inherited from the Soviet past and is still alive. Aim: This study reveals the extent and nature of informal patient payments, and identifies the motivation behind those payments occurring in publicly financed healthcare facilities in Lithuania. Methods: The quantitative household survey design was chosen for this study. The randomly selected sample was comprised of inhabitants aged 18 years and older, representing the entire population of Lithuania by county, place of residence (urban and rural), age and sex. The study sample consisted of 1067 participants interviewed in 2009 and 2010, and 1068 in 2011 (response rate ranged from 66.6% to 68.2%). Results: Users of healthcare services usually made informal payments for the visit to, and consultation with, a general practitioner or physician specialist and for diagnostic services. Females and older citizens, the disabled, public/private sector employees, retirees, those with higher education and those in the highest household monthly income group were more prone to pay informally for health services. The majority of respondents were against formalization of informal patient payment. Conclusions: National health insurance payments for healthcare services from the formal public fund for healthcare are further augmented by informal payments from service consumers, used routinely for better access to and higher quality of healthcare service.

Informal payments for health services: the experience of Bulgaria after 10 years of formal co-payments

BACKGROUND

Informal payments were reported in Bulgaria before and after the introduction of formal co-payments for services included in the basic benefits package in 2000. The aim of our study was to establish the current scale and type of informal payments, as well as public attitudes towards these payments.

METHODS

A nationally representative survey of 1003 individuals was conducted in Bulgaria in July 2010 using face-to-face interviews based on a standardized questionnaire. Respondents were selected through a multi-stage random probability method. The questionnaire included questions on total informal payments (in cash and in kind) for health services used by the respondent during the preceding 12 months.

RESULTS

About 13% of users reported informal payments for outpatient visits and 33% of users reported to have paid informally for hospitalizations. The average amount paid informally for inpatient services was nearly twice higher than that for outpatient services. More than 50% of the sample had negative attitudes towards informal payments in both cash and kind, but about 27% of respondents had a positive attitude towards giving gifts in kind. Regression analysis showed that respondents with higher levels of education had more negative attitudes towards informal cash payments. Positive attitudes towards gifts in kind were more often stated by citizens of larger cities.

CONCLUSION

Informal payments continue to exist in Bulgaria irrespective of the formal co-payments introduced in 2000. Although the problem has been recognized in Bulgaria, policies should aim to eliminate the underlying structural reasons for such payments.

Informal payments in healthcare: a case study of kerman province in iran

BACKGROUND

Informal payments for health care, which are common in many countries, can have negative effects on health care access, equity and health status as they lead people to forgo or delay seeking care, or to sell assets to pay for care. Many countries are putting reforms in place with the aim of reducing informal payments. In order to be successful, such policies should be informed by the underlying causes of such payments. This study attempts to explore why, how, and in what ways informal payments occur.

METHODS

We conducted face-to-face interviews with a purposeful sample of 45 participants, including patients, healthcare providers and officials, in Kerman province in Iran, in 2010. The research participants were asked about the nature of informal payments, the reasons behind both asking and making those payments. We analysed the data using content analysis.

RESULTS

We found that people make informal payments for several reasons, namely cultural, quality-related and legal. Providers ask for informal payments because of tariffs, structural and moral reasons, and to demonstrate their competence. Informal payments were found to be more prevalent for complex procedures and are usually asked for directly.

CONCLUSION

Informal payments are present in Iran's health system as in other countries. What makes Iran's condition slightly different from other countries is the peculiarity of reasons behind asking informal payments and the disadvantages associated with these kinds of payments. Iran could overcome this dilemma by precise investigation of the reasons to inform appropriate policy formulation. Some policies such as raising salaries, justifying the tariffs and cost-sharing, defining a benefits package of services, and improving accountability and transparency in the health system could be taken by the government to alleviate the problem.

Is it acceptable for a physician to request informal payments for treatment? Lay people's and health professionals' views in Togo

The people's views regarding informal payments for healthcare is essential if we are able to develop publicly supported interventions to address this phenomenon. We recruited a convenience sample of 300 lay people and health practitioners in Togo, a developing country experiencing this practice, and asked them how acceptable it would be for a physician to request informal payments for treatment in 36 scenarios. The scenarios were all combinations of three levels of the physician's income (relatively well-paid, average, or underpaid); two levels of the patient's wealth (wealthy vs. poor); two levels of the frequency of the practice in the area (common vs. rare); and three levels of the amount of payment requested ($50, $30, or $10). Two contrasting positions were found. A substantial minority of participants rejected the practice of informal payments, irrespective of circumstances. In contrast, a majority of them were of the opinion that when patients were wealthy and physicians were underpaid, this practice was acceptable. Health practitioners more frequently adhered to the ethical position than lay people. Implications for health policy are discussed.

Informal payments for health care services in Russia: old issue in new realities

Informal payments can be found across Europe, Africa, Asia and South America. Despite its hidden nature, they pose an important policy issue. Reported as being widespread, the true scale and scope of informal payment are unknown, and estimations differ among studies. We look at the Russian health care sector where the existence of informal payments has persisted for decades. We present the scale and scope of informal payments, as well as patterns of informal payments and their determinants. We discuss the reasons for discrepancies in estimations and implications for the ongoing reforms.

Exploring consumers' attitudes towards informal patient payments using the combined method of cluster and multinomial regression analysis--the case of Hungary

BACKGROUND

Previous studies on informal patient payments have mostly focused on the magnitude and determinants of these payments while the attitudes of health care actors towards these payments are less well known. This study aims to reveal the attitudes of Hungarian health care consumers towards informal payments to provide a better understanding of this phenomenon.

METHODS

For the analysis, we use data from a survey carried out in 2010 in Hungary involving a representative sample of 1037 respondents. We use cluster analysis to identify the main attitude groups related to informal payments based on the respondents' perception of and behavior related to informal payments. Multinomial logistic regression is applied to examine the differences between these groups in terms of socio-demographic characteristics, as well as past utilization and informal payments paid for health care services.

RESULTS

We identified three main different attitudes towards informal payments: accepting informal payments, doubting about informal payments and opposing informal payments. Those who accept informal payments (mostly young or elderly people, living in the capital) consider these payments as an expression of gratitude and perceive them as inevitable due to the low funding of the health care system. Those who doubt about informal payments (mostly respondents outside the capital, with higher education and higher household income) are not certain whether these payments are inevitable, perceive them as similar to corruption rather than gratitude, and would rather use private services to avoid these payments. We find that the opposition to informal payments (mostly among men from small households and low income households) can be explained by their lower ability and willingness to pay.

CONCLUSIONS

A large share of Hungarian health care consumers has a rather positive attitude towards informal payments, perceiving them as "inevitable due to the low funding of the health care system". From a policy point-of-view, the change of this consumer attitude will be essential to deal with these payments in addition to other policy strategies.

Defining informal payments in healthcare: a systematic review

OBJECTIVES

To explore the literature for the definitions of informal payments in healthcare and critically analyze the proposed definitions. This will serve in the process of getting to a coherent definition of informal payments, which will further support acknowledging and addressing them globally.

METHODS

A search strategy was developed to identify papers addressing informal payments on PubMed, ScienceDirect, Econlit, EconPapers and Google Scholar.

RESULTS

2225 papers were identified after a first search. 61 papers were included in the systematic review. Out of all definitions provided, we selected three definitions as being original. All other definitions either cite these definitions or do not provide new insight into the topic of informal payments. Although informal payments have been nominated by various terms over the years, there is a tendency in recent years towards an agreement to use this singular term. Definitions differ in terms of the relation of informal payments with other informal activities, their legality and the motivation behind them.

CONCLUSIONS

The variety of forms which informal payments may take makes it difficult to define them in a comprehensive manner. However, we identified a definition that could serve as a beginning in this process. More effort is needed to build on it and get to a commonly accepted and shared definition of informal payments.

Causes and determinants of inequity in maternal and child health in Vietnam

BACKGROUND

Inequities in health are a major challenge for health care planners and policymakers globally. In Vietnam, rapid societal development presents a considerable risk for disadvantaged populations to be left behind. The aim of this review is to map the known causes and determinants of inequity in maternal and child health in Vietnam in order to promote policy action.

METHODS

A review was performed through systematic searches of Pubmed and Proquest and manual searches of "grey literature." A thematic content analysis guided by the conceptual framework suggested by the Commission on Social Determinants of Health was performed.

RESULTS

More than thirty different causes and determinants of inequity in maternal and child health were identified. Some determinants worth highlighting were the influence of informal fees and the many testimonies of discrimination and negative attitudes from health staff towards women in general and ethnic minorities in particular. Research gaps were identified, such as a lack of studies investigating the influence of education on health care utilization, informal costs of care, and how psychosocial factors mediate inequity.

CONCLUSIONS

The evidence of corruption and discrimination as mediators of health inequity in Vietnam calls for attention and indicates a need for more structural interventions such as better governance and anti-discriminatory laws. More research is needed in order to fully understand the pathways of inequities in health in Vietnam and suggest areas for intervention for policy action to reach disadvantaged populations.

Use of social audits to examine unofficial payments in government health services: experience in South Asia, Africa, and Europe

Background

Unofficial payments in health services around the world are widespread and as varied as the health systems in which they occur. We reviewed the main lessons from social audits of petty corruption in health services in South Asia (Bangladesh, Pakistan), Africa (Uganda and South Africa) and Europe (Baltic States).

Methods

The social audits varied in purpose and scope. All covered representative sample communities and involved household interviews, focus group discussions, institutional reviews of health facilities, interviews with service providers and discussions with health authorities. Most audits questioned households about views on health services, perceived corruption in the services, and use of government and other health services. Questions to service users asked about making official and unofficial payments, amounts paid, service delivery indicators, and satisfaction with the service.

Results

Contextual differences between the countries affected the forms of petty corruption and factors related to it. Most households in all countries held negative views about government health services and many perceived these services as corrupt. There was little evidence that better off service users were more likely to make an unofficial payment, or that making such a payment was associated with better or quicker service; those who paid unofficially to health care workers were not more satisfied with the service. In South Asia, where we conducted repeated social audits, only a minority of households chose to use government health services and their use declined over time in favour of other providers. Focus groups indicated that reasons for avoiding government health services included the need to pay for supposedly free services and the non-availability of medicines in facilities, often perceived as due to diversion of the supplied medicines.

Conclusions

Unofficial expenses for medical care represent a disproportionate cost for vulnerable families; the very people who need to make use of supposedly free government services, and are a barrier to the use of these services. Patient dissatisfaction due to petty corruption may contribute to abandonment of government health services. The social audits informed plans for tackling corruption in health services.

Informal payments for health care--the phenomenon and its context

This paper reviews current research and literature on the issue of informal payments for health care and its context and suggests a new perspective for a better understanding of this phenomenon. This perspective, based on political culture and behavior and on wider social processes, is already used to explain various phenomena from different fields of public policy. The paper explains the impact of a specific type of political culture, called 'alternative politics' (AP) in the Israeli literature, on healthcare policy and institutional healthcare settings. AP is based on a 'do-it-yourself' approach adopted by citizens to address their dissatisfaction with governmental services. When such a mode of political culture is diffused to all sectors and levels of society, all players, including bureaucrats and politicians, are guided by short-term considerations and apply unilateral strategies that bypass formal rules either through illegal activity or by marginalizing formal rules. Explaining informal payments by analyzing social processes and political culture and behavior has some disadvantages, but it provides us with a better understanding of the phenomenon while covering most of its characteristics and configurations.

Health insurance coverage and health care access in Moldova

BACKGROUND

In 2004, the Moldovan government introduced mandatory (social) health insurance (MHI) with the goals of sustainable health financing and improved access to services for poorer sections of the population. The government pays contributions for non-employed groups but the self-employed, which in Moldova include many agricultural workers, must purchase their own cover. This paper describes the extent to which the Moldovan MHI scheme has managed to achieve coverage of its population and the characteristics of those who remain without cover.

METHODS

The 2008 July-October enhanced health module of the Moldovan Household Budget Survey was used. The survey uses multi-stage random sampling, identifying individuals within households within 150 primary sampling units. Numbers and characteristics of those without insurance were tabulated and the determinants of lack of cover were assessed using multivariate regression.

RESULTS

3760 respondents were interviewed. Seventy-eight per cent were covered by MHI. Factors associated with being uninsured include being self-employed (particularly in agriculture), unemployed, younger age and low income. Respondents who were self-employed in agriculture were over 27 times more likely to be uninsured than those who were employed. Agricultural workers in Moldova are responsible for purchasing their own cover; most respondents cited cost as the main reason for not doing so.

CONCLUSION

While being uninsured has an impact on utilization, financial barriers persist for those with insurance who seek care. The strengths and weaknesses of the MHI system in Moldova provide valuable lessons for policy makers in low- and middle-income countries addressing the challenges of achieving equitable coverage in health insurance schemes and the complex nature of financial barriers to access.

Empirical studies on informal patient payments for health care services: a systematic and critical review of research methods and instruments

Background

Empirical evidence demonstrates that informal patient payments are an important feature of many health care systems. However, the study of these payments is a challenging task because of their potentially illegal and sensitive nature. The aim of this paper is to provide a systematic review and analysis of key methodological difficulties in measuring informal patient payments.

Methods

The systematic review was based on the following eligibility criteria: English language publications that reported on empirical studies measuring informal patient payments. There were no limitations with regard to the year of publication. The content of the publications was analysed qualitatively and the results were organised in the form of tables. Data sources were Econlit, Econpapers, Medline, PubMed, ScienceDirect, SocINDEX.

Results

Informal payments for health care services are most often investigated in studies involving patients or the general public, but providers and officials are also sample units in some studies. The majority of the studies apply a single mode of data collection that involves either face-to-face interviews or group discussions.

One of the main methodological difficulties reported in the publication concerns the inability of some respondents to distinguish between official and unofficial payments. Another complication is associated with the refusal of some respondents to answer questions on informal patient payments.

We do not exclude the possibility that we have missed studies that reported in non-English language journals as well as very recent studies that are not yet published.

Conclusions

Given the recent evidence from research on survey methods, a self-administrated questionnaire during a face-to-face interview could be a suitable mode of collecting sensitive data, such as data on informal patient payments.

Predictors of informal health payments: the example from Turkey

Little is known about the factors that can affect informal health payments in Turkey, which is pertinent given that Turkey has been undergoing and considering a series of reforms in the health sector. This paper aims to examine the predictors of informal payments in Turkey. The study surveyed a random sample of 3,727 people in a medium-sized city, of whom 706 received medical care for illness and/or non-illness related reasons, using a Turkey-specific version of a model questionnaire focused exclusively on informal out-of-pocket payments. Using multivariable logistic model, household health expenditure, health insurance, service type and provider ownership were found to be statistically significant predictors of informal payment. The findings suggest the supply side factors as the main drivers of informal payments and thus a need for radical changes in the supply side as well as actions to rebuild lost confidence in the health care system of Turkey.

Informal payments for healthcare: differences in expenditures from consumers and providers perspectives for treatment of malaria in Nigeria

OBJECTIVES

To examine differences in malaria treatment expenditures from the perspectives of consumers and providers in southeast Nigeria.

METHODS

The study was conducted using household surveys, provider surveys and exit poll interviews. The amount of money that the providers claimed to charge their patients for malaria treatment services was compared with the expenditures that the respondents actually incurred for malaria treatment services from the same providers.

RESULTS

The average expenditure for malaria treatment from the consumers as elicited from both the household survey and exit poll interviews was $6.30, while it was $2.20 for the providers from information from the provider survey. The widest gaps between expenditures for consumers and amounts purportedly charged by providers were found in public healthcare facilities. All socio-economic status groups and residents of urban and rural areas were exposed to informal payments.

CONCLUSION

The differences in malaria treatment expenditures from consumers' and providers' perspectives point to high levels of informal payments, which worsen the economic burden of the disease and may predispose to catastrophic health spending. The informal payments are personal gains to the individual providers but represent a loss to the society, in terms of higher healthcare costs. Such payments should be addressed by policy makers so as to make treatment of malaria less costly to patients.

Formal and informal payments in health care facilities in two Russian cities, Tyumen and Lipetsk

Informal payments for health care services are common in many transition countries, including Russia. While the Russian government proclaims its policy goal of improving access to and quality of free-of-charge health services, it has approved regulations that give local authorities the right to provide services against payment. This paper reports the results of a population-based survey (n = 2001) examining the prevalence of the use of medical services for which people pay formally or informally in two regional capitals of different economic status. The purpose of the study was to reveal any differences in the forms of and reasons for payments between the two cities and between socio-economic groups. The results indicate that formal payments were more common in the capital of the wealthier region, Tyumen, while the prevalence of informal payments was higher in the capital of the poorer region, Lipetsk. Around 15% of respondents had made informal payments in the past 3 years. Being a female (OR = 1.57), having a chronic disease (OR = 1.62), being a pensioner (OR = 2.8) and being willing to pay for additional medical information (OR = 2.48) increased the probability of informal payments. The survey demonstrates that in Russia access to and quality of publicly funded health care services may be under serious threat due to the current unclear, non-transparent financial rules. The practice of informal payments exists along with the introduction of formal chargeable government services, which may hamper the government's efforts to enhance equality among health service users.

Understanding informal payments in health care: motivation of health workers in Tanzania

BACKGROUND

There is growing evidence that informal payments for health care are fairly common in many low- and middle-income countries. Informal payments are reported to have a negative consequence on equity and quality of care; it has been suggested, however, that they may contribute to health worker motivation and retention. Given the significance of motivation and retention issues in human resources for health, a better understanding of the relationships between the two phenomena is needed. This study attempts to assess whether and in what ways informal payments occur in Kibaha, Tanzania. Moreover, it aims to assess how informal earnings might help boost health worker motivation and retention.

METHODS

Nine focus groups were conducted in three health facilities of different levels in the health system. In total, 64 health workers participated in the focus group discussions (81% female, 19% male) and where possible, focus groups were divided by cadre. All data were processed and analysed by means of the NVivo software package.

RESULTS

The use of informal payments in the study area was confirmed by this study. Furthermore, a negative relationship between informal payments and job satisfaction and better motivation is suggested. Participants mentioned that they felt enslaved by patients as a result of being bribed and this resulted in loss of self-esteem. Furthermore, fear of detection was a main demotivating factor. These factors seem to counterbalance the positive effect of financial incentives. Moreover, informal payments were not found to be related to retention of health workers in the public health system. Other factors such as job security seemed to be more relevant for retention.

CONCLUSION

This study suggests that the practice of informal payments contributes to the general demotivation of health workers and negatively affects access to health care services and quality of the health system. Policy action is needed that not only provides better financial incentives for individuals but also tackles an environment in which corruption is endemic.

An inter-country comparison of unofficial payments: results of a health sector social audit in the Baltic States

BACKGROUND

Cross-country comparisons of unofficial payments in the health sector are sparse. In 2002 we conducted a social audit of the health sector of the three Baltic States.

METHODS

Some 10,320 household interviews from a stratified, last-stage-random, sample of 30 clusters per country, together with institutional reviews, produced preliminary results. Separate focus groups of service users, nurses and doctors interpreted these findings. Stakeholder workshops in each country discussed the survey and focus group results.

RESULTS

Nearly one half of the respondents did not consider unofficial payments to health workers to be corruption, yet one half (Estonia 43%, Latvia 45%, Lithuania 64%) thought the level of corruption in government health services was high. Very few (Estonia 1%, Latvia 3%, Lithuania 8%) admitted to making unofficial payments in their last contact with the services. Around 14% of household members across the three countries gave gifts in their last contact with government services.

CONCLUSION

This social audit allowed comparison of perceptions, attitudes and experience regarding unofficial payments in the health services of the three Baltic States. Estonia showed least corruption. Latvia was in the middle. Lithuania evidenced the most unofficial payments, the greatest mistrust towards the system. These findings can serve as a baseline for interventions, and to compare each country's approach to health service reform in relation to unofficial payments.

An inter-country comparison of unofficial payments: results of a health sector social audit in the Baltic States

BACKGROUND

Cross-country comparisons of unofficial payments in the health sector are sparse. In 2002 we conducted a social audit of the health sector of the three Baltic States.

METHODS

Some 10,320 household interviews from a stratified, last-stage-random, sample of 30 clusters per country, together with institutional reviews, produced preliminary results. Separate focus groups of service users, nurses and doctors interpreted these findings. Stakeholder workshops in each country discussed the survey and focus group results.

RESULTS

Nearly one half of the respondents did not consider unofficial payments to health workers to be corruption, yet one half (Estonia 43%, Latvia 45%, Lithuania 64%) thought the level of corruption in government health services was high. Very few (Estonia 1%, Latvia 3%, Lithuania 8%) admitted to making unofficial payments in their last contact with the services. Around 14% of household members across the three countries gave gifts in their last contact with government services.

CONCLUSION

This social audit allowed comparison of perceptions, attitudes and experience regarding unofficial payments in the health services of the three Baltic States. Estonia showed least corruption. Latvia was in the middle. Lithuania evidenced the most unofficial payments, the greatest mistrust towards the system. These findings can serve as a baseline for interventions, and to compare each country's approach to health service reform in relation to unofficial payments.

Analysis of healthcare financing, supply and utilisation trends in the new EU countries

The EU expanded in 2004 to include eight transition countries, i.e. Central and Eastern European (CEE) and newly independent states of the former Soviet Union, and two other CEE countries are scheduled to join the EU in 2007. Each of these countries has undertaken substantial healthcare reform efforts over the past 15 years. The paths of healthcare reform are diverse for a number of reasons including differences in initial economic, political and structural conditions. The objective of this article is to evaluate the process and preliminary outcomes of healthcare reform in the new EU and candidate countries by analysing trends in aggregate financing, supply and utilisation indicators using data drawn from the WHO Health for All database. The analysis is done in the context of an analytical framework built around common healthcare reform themes. The key reform measures examined include implementing social insurance systems, implementing payment systems that promote efficiency, and removal of excess capacity. The trend analysis highlights the importance of the economic, political and social context in driving the direction and pace of healthcare reform. For example, the transition to social insurance systems was smoother in countries with stronger economies and political commitment to reform. Policies aimed at improving the efficiency of the healthcare system, reducing utilisation and reducing excess capacity were met with some success in all of the countries. However, the reform effort continues as the countries are still addressing the initial challenges of insufficient funding, informal payments, excess capacity and inefficiencies in the provision of healthcare.