At first glance, informal payments experience on track: why accept or refuse? Patients' perceive in cardiac surgery department of public hospitals, northeast of Iran 2013

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.

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.

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.

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).

Designing an Informal Payment Model for Patients Admitted in the Iran Health System: A qualitative Study

BACKGROUND

Countries rely on out-of-pocket spending to different degrees and employ varying techniques. This study aimed at designing an out-of-pocket payment model of patients admitted to the Iran health system.

METHODS

This study was a combined qualitative and quantitative study. The statistical population of the qualitative section was 30 experts who were purposefully selected and continued by snowball method until data saturation, and in the quantitative section were 212 managers of the Ministry of Health. The questionnaire was designed based on qualitative analysis. Content validity was confirmed based on expert opinion and structural validity using exploratory factor analysis and confirmatory factor analysis. Reliability was confirmed using CRONBACH's alpha coefficient and composite reliability. For model adequacy, KMO index and Bartlett test were used, and for model fit, CFI and IFI fitness index were used.

RESULTS

Based on the results of 6 main themes, 20 Concept and 120 sub-themes of out of pocket payment of hospitalized patients were extracted. The value of chi-square was 4599.861, the degree of freedom was 2421 and the result of their ratio was 1.899 in the model, which was an acceptable value. CFI and IFI fitness indicators are acceptable. The SRMR index was 0.1153, which indicates the adequacy of the model.

CONCLUSION

The findings showed that the main dimensions of out of pocket payment of hospitalized patients include causal factors, underlying factors, intervening factors, pivotal categories, strategies and consequences. Therefore, the use of a paradigm model to pay attention to all the effective dimensions in reducing the payment of hospitalized patients is recommended.

A roadmap for implementing general policies of resistance economy in the Isfahan Universities of Medical Sciences

CONTEXT AND AIMS

The country development can be promoted through applying policies of the resistance economy in the health system and universities. Therefore, this paper aimed to provide a scientific analysis of resistance economy policies and providing a roadmap for their implementation in the field of health care of Isfahan University of Medical Sciences.

MATERIALS AND METHODS

This is a qualitative study. The basis, general purposes, and strategies of the resistance economy were extracted from the review of the policy of the resistance economy with a political research approach. Then, effective programs and indicators to achieve the goals of the resistance economy were proposed by holding 10 sessions of a centralized group discussion. Finally, the implementation of the resistance economy in the deputies of the University of Medical Sciences was approved by these programs and indicators along with other components and Delphi questionnaire to 30 experts. Framework analysis and descriptive statistics were used to analyze the data from the group discussion and the Delphi stage, respectively.

RESULTS

Implementation of general policies of resistance economy in the field of health and treatment of Isfahan University of Medical Sciences with eight thematic bases, 39 goals, 54 strategies, and 98 programs and indicators were approved by experts. The eight areas of people-centered, economic growth, economic justice, support for internal services, economic flexibility, economic stability, economic influence, and economic health were identified as the thematic bases of communicative policies of the resistance economy in the field of health.

CONCLUSION

The implementation of resistance economy policies entails planning in the long run, culture-building, appreciating the resistance economy in health issues, cooperation, and synergy among different institutions, restructuring the education system at different levels of the health system, and entrepreneurship training.

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.

Factors affecting informal patient payments: a systematic literature review

Purpose

Informal payments (IPs) for healthcare are a serious obstacle to equitable access and universal health coverage in developing countries. Policy makers need to know more about the hidden nature of informal patient payments (IPPs) before any policy adoption and implementation. The purpose of this paper is to systematically review the main factors affecting IPPs.

Design/methodology/approach

This systematic review was conducted in 2018 using the standard guideline of PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses. All English original articles on the determinants of IPPs published in the scientific journals, whose full text was available through Scopus, PubMed and Web of Science databases, which were given consideration for review.

Findings

The results showed that IPPs were greatly dependent on the characteristics of healthcare consumers, providers, healthcare system and services. Among healthcare consumers’ characteristics affecting IPPs, the income, age, education, gender, employment and health status were more cited factors, respectively. Among healthcare providers’ characteristics affecting IPPs, the providers’ experience, reputation, and salary satisfaction were better known, respectively. Among healthcare services features, the hospitalization, service specialty and the level of treatment urgency were more noted, respectively.

Originality/value

Policy making against IPs in the health sector requires precise attention to all components of healthcare market, including healthcare consumers, providers, healthcare system and services characteristics.

Evaluation of informal payments to health care professionals and the influential factors in Urmia city hospitals, Iran

Informal payments refer to sums that patients may pay to individual or organizational health care providers outside of the official payment channels or approved fee schedules. The aim of the current research was to investigate informal payments and related influential factors in Urmia city hospitals. The present study was a cross-sectional survey conducted among post-discharged patients from all Urmia city hospitals during one Iranian calendar month (January 21 to March 19, 2013). Simple random sampling was used to recruit 265 patients to undergo assessment via phone call interviews and complete a questionnaire. Data analysis was performed using SPSS software for descriptive reports, and EViews software for determination of factors affecting informal payments. Eleven percent of the patients had made informal payments to physicians (mean amount: 503,000 Tomans, equivalent of $412), 5% to nurses (mean amount: 20,000 Tomans, equivalent of $16), and 17% to other employees (mean amount: 16,000 Tomans, equivalent of $13). Hospital ownership, patients' place of residence, education and income significantly influenced the payments. Most substantially, patients receiving surgical care were 100 times more likely to make informal payments compared to those who had received non-surgical inpatient care. The present study showed that although informal payment is illegal in Iran, it is a common practice among hospitalized patients, and has now become a challenge for the health system. Considering the high prevalence of informal payments and their severe impacts on equity and justice, policymakers have focused on this phenomenon to reduce and eliminate it.