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

National Evaluation of HIV Service Resource Allocation in Tanzania

Using time-driven activity-based costing (TDABC), we examined resource allocation and costs for HIV services throughout Tanzania at patient and facility levels. This national, cross-sectional analysis of 22 health facilities quantified costs and resources associated with 886 patients receiving care for five HIV services: antiretroviral therapy, prevention of mother-to-child transmission, HIV testing and counseling, voluntary medical male circumcision, and pre-exposure prophylaxis. We also documented total provider-patient interaction time, the cost of services with and without inclusion of consumables, and conducted fixed-effects multivariable regression analyses to examine patient- and facility-level correlates of costs and provider-patient time. Findings showed that resources and costs for HIV care varied significantly throughout Tanzania, including as a function of patient- and facility-level characteristics. While some variation may be preferable (e.g., needier patients received more resources), other areas suggested a lack of equity (e.g., wealthier patients received more provider time) and presented opportunities to optimize care delivery protocols.

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.

Informal payments by patients, institutional trust and institutional asymmetry

The aim of this paper is to evaluate the extent of the practice of using informal payments for accessing the services of public clinics or hospitals across Europe and to explain the prevalence of this corrupt practice using the framework of institutional theory. To achieve this, a multi-level mixed-effect logistic regression on 25,744 interviews undertaken in 2020 with patients across 27 European Union countries is conducted. The finding is that the practice of making informal payments remains a prevalent practice, although there are large disparities in the usage of this practice in different European countries. However, informal payments by patients are more likely when there is a lower institutional trust and a higher degree of asymmetry between formal and informal institutions. The resultant proposal is that policy makers need to address the institutional environment to tackle such informal payments. How this can be achieved is outlined.

Informal Payments for Outpatient Health Care: Country-Wide Evidence from Iran

Background: Reliance heavily on out-of-pocket (OOP) payments, including informal payments (IPs), has undesired effects on financial risk protection and access to care. While a significant share of total health expenditure is spent on outpatient services, there is scant evidence of the patient's amount paid informally in outpatient services. Such evidence is available for inpatient services, showing the high prevalence of informal payments, ranging from 14 to 48% in the whole hospital. This study aimed to investigate the extent of OOP and IPs for outpatient services in Iran. Methods: A secondary data analysis of the 2015 IR Iran's Utilization of Healthcare Services (IrUHS) survey was conducted. A sample of 11,782 individuals with basic health insurance who were visited at least once by a physician in two private and public health care centers was included in this analysis. The percentage of OOP was determined and compared with the defined copayment (30%). The frequency of IPs was determined regarding the number of individuals who paid more than the defined copayments. The Mann-Whitney test also investigated the relationships between OOP percentage and IPs frequency with demographic variables. Results: The share that insured patients in Iran pay for a general practitioner (GP) visit was 38% in public versus 61% in the private sector, while for a specialist practitioner visit, the figures were 80% and 96%, respectively, which is higher than defined copayment (30%). This share was significantly higher in females, urban areas, highly educated people, private service providers, and specialist visits. The frequency of IPs, who paid more than the defined copayments, was 73% for a GP in public versus 86% in the private sector, while for a specialist practitioner visit, these were 90% and 93%, respectively. Conclusion: Informal patient payments for outpatient services are prevalent in Iran. Hence, more interventions are required to eliminate or control the IPs in outpatient services, particularly in the private sector. In this regard, making a well-regulated market, reinforcing the referral system, and developing an equity-oriented essential health services package would be fundamental.

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.

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.

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.

Gender Differences in Informal Payments for Healthcare: Evidence from 36 African Countries

Informal payments are widespread in many healthcare systems and can impede access to healthcare and thwart progress to achieving Universal Health Coverage, a major element of the health-related Sustainable Development Goals. Gender may be an important driver in determining who pays informally for care, but few studies have examined this, particularly in low- and middle-income countries. Our study aimed to examine gender disparities in paying informally for healthcare in Africa. We used Afrobarometer Round 7 survey data collected between September 2016 and August 2018 from 34 African countries. The final sample was 44 715 adults. We used multiple logistic regression to evaluate associations between gender and paying informally to obtain healthcare. Our results show that 12% of women and 14% of men reported paying informally for healthcare. Men were more likely to pay informally for healthcare than women in African countries (OR 1.22 [95% CI 1.13-1.31]), irrespective of age, residential location, educational attainment, employment status, occupation, and indicators of poverty. To make meaningful progress towards improving Universal Healthcare Coverage in African countries, we must improve our understanding of the gendered aspects of informal payments in healthcare, which can act as both a barrier to accessing care and a determinant of poor health.

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.

Civil Servants and Non-Western Migrants' Perceptions on Pathways to Health Care in Serbia-A Grounded Theory, Multi-Perspective Study

(1) Background: Informal patient payments continue to persist in the Serbian health care system, exposing vulnerable groups to private spending on health care. Migrants may in particular be subject to such payments, as they often experience barriers in access to health care. Little is known about migrants paying informally to access health care in Serbia. The study aims to explore pathways of accessing health care, including the role of informal patient payments, from the perspectives of civil servants and non-western migrants in Serbia. (2) Methods: Respondents (n = 8 civil servants and n = 6 migrants) were recruited in Belgrade in 2018, where semi-structured interviews were conducted. The interviews were analysed applying the grounded theory methodological steps. (3) Results: Data reveal different pathways to navigate the Serbian health care system, and ultimately whether paying informally occurs. Migrants appear less prone to paying informally and receive the same or better-quality health care. Locals experience the need to pay informal patient payments, quasi-formal payments and to bring medicine, materials or equipment when in health facilities. (4) Conclusions: Paying informally or using private care in Serbia appear to have become common. Despite a comprehensive health insurance coverage, high levels of out-of-pocket payments show barriers in accessing health care. It is highly important to not confuse the cultural beliefs with forced spending on health care and such private spending should be reduced to not push people into poverty.

Quantifying the Influence of Informal Payments on Self-Rated Health: Evidence from 26 Post-Communist Countries

In contrast to previous studies that have focused on proximal outcomes such as access to and the utilization of healthcare, this study establishes and quantifies the influence of informal payments (IP) directly on population self-rated health, which can be considered the ultimate outcome. More specifically, we examine how making informal payments influences self-rated health by testing several theoretically-grounded explanations of the influence of making IP. Using the quasi-experimental instrumental variable technique increases the likelihood that our findings are not the result of reverse causality, omitted variable problem, and measurement error. Our main finding is that overall, making informal payments have a negative influence on self-rated health. However, this influence is higher for men, those who are poorer, live in rural areas, have a university education, and have lower social capital. Theoretical approaches that have stood out in explanations regarding the effects of making IP on self-rated health are Public Choice Theory, Institutional Theory, and Sociological Theories of Differences in Life Opportunities, Social Determinants of Health, and Social Capital.

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

OBJECTIVE

The 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.

SETTING

This 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.

PARTICIPANTS

A total of 152 health posts and health extension workers serving selected enumeration areas were included.

OUTCOME MEASURES

We used the Context Assessment for Community Health (COACH) tool and the Service Availability and Readiness Assessment tool.

RESULTS

Internal 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.

CONCLUSION

The 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.

Effectiveness of hospital payment reforms in low- and middle-income countries: a systematic review

Payment mechanisms have attracted substantial research interest because of their consequent effect on care outcomes, including treatment costs, admission and readmission rates and patient satisfaction. Those mechanisms create the incentive environment within which health workers operate and can influence provider behaviour in ways that can facilitate achievement of national health policy goals. This systematic review aims to understand the effects of changes in hospital payment mechanisms introduced in low- and middle-income countries (LMICs) on hospital- and patient-level outcomes. A standardised search of seven databases and a manual search of the grey literature and reference lists of existing reviews were performed to identify relevant articles published between January 2000 and July 2019. We included original studies focused on hospital payment reforms and their effect on hospital and patient outcomes in LMICs. Narrative descriptions or studies focusing only on provider payments or primary care settings were excluded. The authors used the Risk of Bias in Non-Randomized Studies of Interventions tool to assess the risk of bias and quality. Results were synthesized in a narrative description due to methodological heterogeneity. A total of 24 articles from seven middle-income countries were included, the majority of which are from Asia. In most cases, hospital payment reforms included shifts from passive (fee-for-service) to active payment models-the most common being diagnosis-related group payments, capitation and global budget. In general, hospital payment reforms were associated with decreases in hospital expenditures, out-of-pocket payments, length of hospital stay and readmission rates. The majority of the articles scored low on quality due to weak study design. A shift from passive to active hospital payment methods in LMICs has been associated with lower hospital and patient costs as well as increased efficiency without any apparent compromise on quality. However, there is an important need for high-quality studies in this area.

Patients' attitude toward informal payments in Iran: an application of the cluster analysis method

INTRODUCTION

Attitude is a factor affecting the behaviour of consumers. In the literature, the effect of health care consumer's attitude on making informal payments has been highlighted. The purpose of this study was to investigate the attitude of Iranian patients regarding informal payments and socio-demographic factors associated with it.

METHODS

In this cross-sectional study, conducted in 2017 in Tehran, 450 patients who were admitted to the clinics of four public hospitals for post-surgical care and follow-up, were invited to participate in the study. The data collection tool was a questionnaire, which validity and reliability were confirmed. Cluster analysis was used to identify the main attitudinal groups. To investigate the effect of socio-demographic factors on patients' attitudes, generalized linear model regression analysis was carried out in SPSS 22.

RESULTS

Our findings showed that 57.3% of patients had agreeing attitude, 24.2% indifferent attitude, and 18.4% opposing attitude toward informal payments. Patients from rural areas and those from the high-income group had higher odds of having an agreeing attitude. There was a significant association between informal payment history and attitude. The odds of having agreeing attitude among patients with a history of informal payment were two times higher than among patients who did not have an informal payment history (p ≤ 0.05).

CONCLUSION

A positive attitude towards informal payments is an obstacle to the fight against this phenomenon. Therefore, changes in public attitudes regarding informal payments will be an essential strategy, among other strategies, for eradicating these payments. This could be achieved through public campaigns for raising people's awareness and knowledge.