Socioeconomic inequality in informal payments for health services among Iranian households: a national pooled study

BACKGROUND

There is limited evidence on the prevalence and socioeconomic inequality in informal payments (IP) of households in the Iranian health system. This study was conducted to investigate the prevalence of IP and related socioeconomic inequalities among Iranian households in all provinces.

METHOD

Data on Household Income and Expenditure Surveys (HIES) for 91,360 households were used to examine the prevalence and inequality in informal health sector payments in the years 2016 to 2018. The Normalized Concentration Index (NC) was used to examine inequality in these payments and the decomposition analysis by the Wagstaff approach was used to determine the share of variables affecting the measured inequality.

RESULTS

Of the total households, 7,339 (7.9%) reported IP for using health services. Urban households had higher IP (10%) compared to rural ones (5.42%). Also, the proportion of households with IP in 2016 (11.69%) was higher than in 2017 (9.9%), and 2018 (4.60%). NC for the study population was 0.129, which shows that the prevalence of IP is significantly higher in well-off households. Also, NC was 0.213 (p < 0.0001) and -0.019 for urban and rural areas, respectively (p > 0.05). Decomposition analysis indicated that income, sex of head of household, and the province of residence have the highest positive contribution to measured inequality (with contributions of 156.2, 45.8, and 25.6%, respectively).

CONCLUSION

There are a significant prevalence and inequality in IP in Iran's health system and important variables have shaped it. On the whole, inequality was pro-rich. This may lead to increasing inequality in access to quality services in the country. Our findings showed that previous health policies such as regulatory tools, and the health transformation plan (HTP) have not been able to control IP in the health sector in the desired way. It seems that consumer-side policies focusing on affluent households, and high-risk provinces can play an important role in controlling this phenomenon.

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).

Alternative provision of public health care: the role of citizens' satisfaction with public services and the social responsibility of government

This paper explores the factors that influence citizens' attitudes toward the alternative provision of health care services, leading them to be willing to make extra, informal payments within the public health care system. We question whether these attitudes depend primarily on inherent normative preferences, such as beliefs about the government's responsibility to its citizens, or on certain aspects of the reality that they experience, such as satisfaction with the quality and quantity of services as well as the fairness of public systems. Analyzing the findings from a national survey, the paper shows that practical considerations and real-world conditions strongly relate to attitudes more than normative perceptions do.

From public vs. private to public/private mix in healthcare: lessons from the Israeli and the Spanish cases

BACKGROUND

Different forms of public/private mix have become a central mode of the privatization of healthcare, in both financing and provision. The present article compares the processes of these public/private amalgams in healthcare in Spain and Israel in order to better understand current developments in the privatization of healthcare.

MAIN TEXT

While in both Spain and Israel combinations between the public and the private sectors have become the main forms of privatization, the concrete institutional forms differ. In Spain, these institutional forms maintain relatively clear boundaries between the private and the public sectors. In Israel, the main forms of public/private mix have blurred such boundaries: nonprofit health funds sell private insurance; public nonprofit health funds own private for-profit hospitals; and public hospitals sell private services.

CONCLUSIONS

Comparison of the processes of privatization of healthcare in Spain and Israel shows their variegated characters. It reveals the active role played by national and regional state apparatuses as initiators and supporters of healthcare reforms that have adopted different forms of public/private mix. While in Israel, until recently, these processes have been perceived as mainly technical, in Spain they have created deep political rifts within both the medical community and the public. The present article contains lessons each country can learn from the other, to be adapted in each one's local context: The failure of the Alzira model in Spain warns us of the problems of for-profit HMOs and the Israeli private private/public mix shows the risk of eroding trust in the public system, thus reinforcing market failures and inefficient medical systems.

New insight into the informal patients' payments on the evidence of literature: a systematic review study

BACKGROUND

Nowadays, a growing literature reveals how patients use informal payments to seek either better treatment or additional services, but little systematic review has been accomplished for synthesizing the main factors. The purpose of this study was to analyze the content of literatures to demonstrate the factors for informal patient payments.

METHODS

In this systematic review study, PubMed, Web of Science, Wiley Online Library, Science Direct, Ovid, Scopus, and Iranian databases were investigated without time limitation for eligible English and Persian studies. Achieved data were analyzed using content analysis approach and MAXQDA 10 software.

RESULTS

Themes related to informal payments in external context of health system were demographic features of health service consumers, patient's personality features and social & cultural backgrounds of the community. Health system challenges' themes were about stewardship weakness, and sustainable financing and social protection weakness. These were followed by human resources' organizational behavior challenges, drugs, medical products, and services delivery provision process challenges and finally change management weakness for reducing and dealing with IPs.

CONCLUSION

It appears that improving the quality of health care services and accurate monitoring of delivery processes, along with performing some strategies for regulating payroll and medical tariffs, strict rules and regulations and improving health staff motivation, would be effective ways against informal payments. Improving the health insurance contribution, promoting transparency & accountability in health system especially in financing, identify precise control mechanism, using empower patient/public related approach, modifying community perception, reinforcing social resistance to unofficial payments and rebuilt lost social capital in health care are some of the other recommendations in this field. To practice these strategies, a comprehensive and systemic vision and approach is needed, however, the key point is that before applying any strategy the impact of this strategy on access, efficiency, equity, and other health systems' goals and policies should be investigated due to the consideration.

A critical interpretive synthesis of informal payments in maternal health care

Informal payments for healthcare are widely acknowledged as undercutting health care access, but empirical research is somewhat limited. This article is a critical interpretive synthesis that summarizes the evidence base on the drivers and impact of informal payments in maternal health care and critically interrogates the paradigms that are used to describe informal payments. Studies and conceptual articles identified both proximate and systems drivers of informal payments. These include norms of gift giving, health workforce scarcity, inadequate health systems financing, the extent of formal user fees, structural adjustment and the marketization of health care, and patient willingness to pay for better care. Similarly, there are proximal and distal impacts, including on household finances, patient satisfaction and provider morale. Informal payments have been studied and addressed from a variety of different perspectives, including anti-corruption, ethnographic and other in-depth qualitative approaches and econometric modelling. Summarizing and discussing the advantages and disadvantages of these and other paradigms illustrates the value of an inter-disciplinary approach. The same tacit, hidden attributes that make informal payments hard to measure also make them hard to discuss and address. A multidisciplinary health systems approach that leverages and integrates positivist, interpretivist and constructivist tools of social science research can lead to better insight. With this, we can challenge ‘master narratives’ and meet universalistic, equity-oriented global health objectives.