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Ogbozor PA, Hutchinson E, Goodman C, McKee M, Onwujekwe O, Balabanova D. The nature, drivers and equity consequences of informal payments for maternal and child health care in primary health centres in Enugu, Nigeria. Health Policy Plan 2023; 38:ii62-ii71. [PMID: 37995265 PMCID: PMC10666910 DOI: 10.1093/heapol/czad048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 06/28/2023] [Accepted: 07/03/2023] [Indexed: 11/25/2023] Open
Abstract
In Nigeria, most basic maternal and child health services in public primary health-care facilities should be either free of charge or subsidized. In practice, additional informal payments made in cash or in kind are common. We examined the nature, drivers and equity consequences of informal payments in primary health centres (PHC) in Enugu State. We used three interlinked qualitative methods: participant observation in six PHC facilities and two local government area (LGA) headquarters; in-depth interviews with frontline health workers (n = 19), managers (n = 4) and policy makers (n = 10); and focus group discussions (n = 2) with female service users. Data were analysed thematically using NVivo 12. Across all groups, informal payments were described as routine for immunization, deliveries, family planning consultations and birth certificate registration. Health workers, managers and policy makers identified limited supervision, insufficient financing of facilities, and lack of receipts for formal payments as enabling this practice. Informal payments were seen by managers and health workers as a mechanism to generate discretionary revenue to cover operational costs of the facility but, in practice, were frequently taken as extra income by health workers. Health workers rationalized informal payments as being of small value, and not a burden to users. However, informal payments were reported to be inequitable and exclusionary. Although they tended to be lower in rural PHCs than in wealthier urban facilities, participant observation revealed how, within a PHC, the lowest earners paid the same as others and were often left unattended if they failed to pay. Some female patients reported that extra payments excluded them from services, driving them to seek help from retail outlets or unlicensed health providers. As a result, informal payments reduced equity of access to essential services. Targeted policies are needed to improve financial risk protection for the poorest groups and address drivers of informal payments and unfairness in the health system.
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Affiliation(s)
- Pamela Adaobi Ogbozor
- Department of Psychology, Enugu State University of Science and Technology, PMB 01600, Agbani, Enugu, Nigeria
- Health Policy Research Group, College of Medicine, University of Nigeria, Enugu Campus, PMB 01129, Enugu, Nigeria
| | - Eleanor Hutchinson
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, United Kingdom
| | - Catherine Goodman
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, United Kingdom
| | - Martin McKee
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, United Kingdom
| | - Obinna Onwujekwe
- Health Policy Research Group, College of Medicine, University of Nigeria, Enugu Campus, PMB 01129, Enugu, Nigeria
- Department of Health Administration and Management, University of Nigeria, Enugu Campus, PMB 410001, Enugu, Nigeria
| | - Dina Balabanova
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, United Kingdom
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Binyaruka P, Angell B, McKee M, Andreoni A, Mamdani M, Hutchinson E, Balabanova D. How can we elicit health workers' preferences for measures to reduce informal payments? A mixed methods approach to developing a discrete choice experiment in Tanzania. BMJ Open 2023; 13:e068781. [PMID: 37419635 PMCID: PMC10335481 DOI: 10.1136/bmjopen-2022-068781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 06/02/2023] [Indexed: 07/09/2023] Open
Abstract
OBJECTIVE While discrete choice experiments (DCEs) have been used in other fields as a means of eliciting respondent preferences, these remain relatively new in studying corrupt practices in the health sector. This study documents and discusses the process of developing a DCE to inform policy measures aimed at addressing informal payments for healthcare in Tanzania. DESIGN A mixed methods design was used to systematically develop attributes for the DCE. It involved five stages: a scoping literature review, qualitative interviews, a workshop with health providers and managers, expert review and a pilot study. SETTING Dar es Salaam and Pwani regions in Tanzania. PARTICIPANTS Health workers and health managers. RESULTS A large number of factors were identified as driving informal payments in Tanzania and thus represent potential areas for policy intervention. Through iterative process involving different methods (qualitative and quantitative) and seeking consensus views by diverse actors, we derived six attributes for a DCE: mode of payment, supervision at the facility level, opportunity for private practice, awareness and monitoring, disciplinary measures against informal payments and incentive payment for staff if a facility has less informal payments. 12 choice sets were generated and piloted with 15 health workers from 9 health facilities. The pilot study revealed that respondents could easily understand the attributes and levels, answered all the choice sets and appeared to be trading between the attributes. The results from the pilot study had expected signs for all attributes. CONCLUSIONS We elicited attributes and levels for a DCE to identify the acceptability and preferences of potential policy interventions to address informal payments in Tanzania through a mixed-methods approach. We argue that more attention is needed to the process of defining attributes for the DCE, which needs to be rigorous and transparent in order to derive reliable and policy-relevant findings.
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Affiliation(s)
- Peter Binyaruka
- Department of Health System, Impact Evaluation and Policy, Ifakara Health Institute, Ifakara, Tanzania
| | - Blake Angell
- University of New South Wales Sydney, The George Institute for Global Health, Newtown, New South Wales, Australia
| | - Martin McKee
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Antonio Andreoni
- Department of Economics, SOAS University of London, London, UK
- College of Business and Economics, University of Johannesburg, South African Chair in Industrial Development, Auckland Park, Gauteng, South Africa
| | - Masuma Mamdani
- Department of Health System, Impact Evaluation and Policy, Ifakara Health Institute, Ifakara, Tanzania
| | - Eleanor Hutchinson
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Dina Balabanova
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
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Binyaruka P, Andreoni A, Balabanova D, McKee M, Hutchinson E, Angell B. Re-aligning Incentives to Address Informal Payments in Tanzania Public Health Facilities: A Discrete Choice Experiment. Int J Health Policy Manag 2022; 12:6877. [PMID: 37579473 PMCID: PMC10125169 DOI: 10.34172/ijhpm.2022.6877] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 10/24/2022] [Indexed: 08/16/2023] Open
Abstract
BACKGROUND Informal payments for healthcare are typically regressive and limit access to quality healthcare while increasing risk of catastrophic health expenditure, especially in developing countries. Different responses have been proposed, but little is known about how they influence the incentives driving this behaviour. We therefore identified providers' preferences for policy interventions to overcome informal payments in Tanzania. METHODS We undertook a discrete choice experiment (DCE) to elicit preferences over various policy options with 432 health providers in 42 public health facilities in Pwani and Dar es Salaam region. DCE attributes were derived from a multi-stage process including a literature review, qualitative interviews with key informants, a workshop with health stakeholders, expert opinions, and a pilot test. Each respondent received 12 unlabelled choice sets describing two hypothetical job-settings that varied across 6-attributes: mode of payment, supervision at facility, opportunity for private practice, awareness and monitoring, measures against informal payments, and incentive payments to encourage noninfraction. Mixed multinomial logit (MMNL) models were used for estimation. RESULTS All attributes, apart from supervision at facility, significantly influenced providers' choices (P<.001). Health providers strongly and significantly preferred incentive payments for non-infraction and opportunities for private practice, but significantly disliked disciplinary measures at district level. Preferences varied across the sample, although all groups significantly preferred the opportunity to practice privately and cashless payment. Disciplinary measures at district level were significantly disliked by unit in-charges, those who never engaged in informal payments, and who were not absent from work for official trip. 10% salary top-up were preferred incentive by all, except those who engaged in informal payments and absent from work for official trip. CONCLUSION Better working conditions, with improved earnings and career paths, were strongly preferred by all, different respondents groups had distinct preferences according to their characteristics, suggesting the need for adoption of tailored packages of interventions.
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Affiliation(s)
- Peter Binyaruka
- Department of Health System, Impact Evaluation and Policy, Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Antonio Andreoni
- Department of Economics, SOAS University of London, London, UK
- South African Research Chair in Industrial Development, University of Johannesburg, Johannesburg, South Africa
| | - Dina Balabanova
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Martin McKee
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Eleanor Hutchinson
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Blake Angell
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
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Horodnic AV, Williams CC, Ciobanu CI, Druguș D. Informal payments by patients, institutional trust and institutional asymmetry. Front Psychol 2022; 13:1015208. [PMID: 36337539 PMCID: PMC9632436 DOI: 10.3389/fpsyg.2022.1015208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 10/03/2022] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
- Adrian V. Horodnic
- Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, Iași, Romania
- *Correspondence: Adrian V. Horodnic,
| | - Colin C. Williams
- Management School, University of Sheffield, Sheffield, United Kingdom
| | - Claudia Ioana Ciobanu
- Faculty of Civil Engineering and Building Services, Gheorghe Asachi Technical University of Iași, Iași, Romania
| | - Daniela Druguș
- Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, Iași, Romania
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Horodnic AV, Williams CC, Drugă RI. The Companion Pandemic to COVID-19: The Use of Informal Practices to Access Public Healthcare Services in the European Union. Int J Public Health 2022; 67:1604405. [DOI: 10.3389/ijph.2022.1604405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 10/06/2022] [Indexed: 11/13/2022] Open
Abstract
Objectives: The objective of this paper is to evaluate the use of informal payments and personal connections to gain preferential access to public health services during the COVID-19 pandemic and to propose effective policy measures for tackling this phenomenon.Methods: Using data from 25,744 patients in the European Union, six different scenarios are analyzed in relation to making informal payments and/or relying on personal connections to access public healthcare services. To evaluate the propensity to engage in informal practices in healthcare, probit regressions with sample selection and predicted probabilities are used. Robustness checks are also performed to test the reliability of the findings.Results: For each scenario, a statistically significant association is revealed between the propensity to make informal payments and/or rely on personal connections and the asymmetry between the formal rules and the patients’ personal norms and trust in public authorities.Conclusion: To tackle informal practices in healthcare, policy measures are required to reduce the asymmetry between the formal rules and personal norms by raising trust in public authorities.
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Yuan M, Xu H. Gender differences in response to medical red packets (Hongbao, monetary gifts): a questionnaire study on young doctors in China. BMC Med Ethics 2022; 23:44. [PMID: 35440041 PMCID: PMC9019946 DOI: 10.1186/s12910-022-00781-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 03/30/2022] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND The acceptance of informal payments by doctors is usually viewed as unethical behavior. However, in China, such behavior is a common practice. In this study, we focus on the gender differences in accepting red packets (informal payments) by young doctors in China. METHODS A total of 413 young doctors were selected for the study, all of whom were grouped by gender. The questionnaire was designed to include general demographic characteristics, whether they had ever been offered red packets, whether they had ever accepted red packets, the reasons for accepting red packets and so on. Wilcoxon rank-sum test, Pearson's chi-squared test, univariable and multi-variable logistic regressions were used for all analyses by Stata 17.0 SE and p-value < 0.05 was considered statistically significant. RESULTS Compared to women, men were more likely to be offered red packets (69.5% [180/259] vs.53.9% [83/154]), and the odds ratio (OR) was statistically significant after adjusting for age, education, position and geographical areas (adjusted OR 1.81, p = 0.012). In terms of the question of whether or not they had accepted red packets, more male doctors answered "yes" compared to female doctors (33.3% [60/180] vs.15.7% [13/83], adjusted OR 2.80, p = 0.004). However, among those who had accepted red packets, we found that only 42.0% [25/60] of male doctors considered that it was normal to accept such red packets, compared to 85.0% [11/13] of women (adjusted OR 12.01, p = 0.023). CONCLUSION The study revealed that Chinese patients and their families were more likely to offer red packets to male doctors. Secondly, among doctors who had been offered red packets, male doctors were more likely to accept red packets than female doctors. In addition, among doctors who had accepted red packets, female doctors were more likely to believe that it was not morally wrong to accept such red packets.
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Affiliation(s)
- Mengci Yuan
- School of Medicine, Nankai University, Tianjin, 300071, China
| | - Hanhui Xu
- School of Medicine, Nankai University, Tianjin, 300071, China.
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Li M, Li Z, Yip CMW. Informal payments and patients' perceptions of the physician agency problem: Evidence from rural China. Soc Sci Med 2022; 298:114853. [PMID: 35231782 DOI: 10.1016/j.socscimed.2022.114853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 02/18/2022] [Accepted: 02/22/2022] [Indexed: 11/16/2022]
Abstract
Informal payment for medical services is a common phenomenon in China. Patients make informal payments, in cash or in kind, to physicians in addition to official charges billed for medical services. This paper assesses the associations between patients' perceptions of the physician as an agent for the patient's interests (physician agency problem) and informal payment behavior. Using data of 24,000 and 6700 rural households respectively from the Health Development of Rural China Program database (collected in 2008) and Ningxia data source (collected in 2015), we find that patients' concern about physician agency problems is significantly associated with informal payments. The data shows that patients are more likely to make informal payments when they show low trust towards their physicians. For example, in the surgical cases, among patients who strongly distrusted the physicians, 17.9% (95% confidence interval [CI]:]: 13.5, 22.3) initiated informal payments, compared to 8.0% (95% CI: 5.1, 10.9) who expressed "strong trust" in their physicians. Poor communication was also significantly associated with an increase in the informal payment rate. For example, in the non-surgical setting, among the patients who rated the physicians' explaining skills as "poor," 5.9% (95% CI: 5.0, 6.9) of them made informal payments, significantly higher than the patients who rated "excellent" (of whom 1.8% made informal payments 95% CI, 0.9, 2.7). In this study, we provide an explanation for this finding: patients may initiate informal payments to physicians in order to mitigate the physician agency problem. It suggests that to mitigate informal payments, improving alignment between doctors' incentives and patients' interests would be essential.
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Affiliation(s)
- Mingqiang Li
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Zhihui Li
- Vanke School of Public Health, Tsinghua University, Beijing, China.
| | - Chi-Man Winnie Yip
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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Busse CE, Onyango D, Tumlinson K. Informal payments for modern family planning methods at public facilities in Tanzania: room for improvement. HUMAN RESOURCES FOR HEALTH 2022; 20:13. [PMID: 35093091 PMCID: PMC8800329 DOI: 10.1186/s12960-022-00712-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 01/18/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Financial access to family planning (FP) is essential to the health and well-being of women in Tanzania. Tanzanian policy dictates that FP methods and services obtained at public facilities are provided for free. However, public sector FP is no longer free when providers solicit informal payments. In this analysis, we investigate the prevalence and amount of informal payments for FP in Tanzania. METHODS We used data from the 2015-2016 Tanzania Demographic and Health Survey to investigate whether informal payments for FP had been effectively eliminated by this policy. RESULTS We found that, at public sector facilities, the majority (84.6%) of women received their current FP method for free (95% confidence interval (CI): 81.9, 87.3), but this proportion varied meaningfully by facility and method type. Injectable contraception was the most commonly used method by women in the lowest wealth quintiles and was most frequently sought by these women from a government dispensary. One in four women (25.8%) seeking injectable contraception from government dispensaries reported paying a fee (95% CI: 19.5, 32.1). Among injectable users who reported payment for their current method, the mean cost at public sector facilities was 1420 Tanzanian Shillings (TSh) and the mean cost at private sector facilities was TSh 1930 (approximately 0.61 United States Dollars (USD) and 0.83 USD, respectively). Among implant users who reported payment for their current method, the mean cost at public sector facilities was TSh 4127 and the mean cost at private sector facilities was TSh 6194 (approximately 1.78 USD and 2.68 USD, respectively). CONCLUSION These findings suggest that the majority of women visiting public facilities in Tanzania did not pay informal payments for FP methods or services; however, informal payments at public facilities did occur, varying by facility and method type. Adherence to existing policies mandating free FP methods and services at public facilities, especially government dispensaries, is critical for ensuring contraceptive access among the most economically vulnerable women.
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Affiliation(s)
- Clara E Busse
- Carolina Population Center, University of North Carolina at Chapel Hill, NC, Chapel Hill, United States of America
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, NC, Chapel Hill, United States of America
| | - Dickens Onyango
- Kisumu County Department of Health, P.O. BOX 3670, Kisumu, 40100, Kenya.
- Utrecht University, Utrecht, The Netherlands.
- Institute of Tropical Medicine, Antwerp, Belgium.
| | - Katherine Tumlinson
- Carolina Population Center, University of North Carolina at Chapel Hill, NC, Chapel Hill, United States of America
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, NC, Chapel Hill, United States of America
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Kabia E, Goodman C, Balabanova D, Muraya K, Molyneux S, Barasa E. The hidden financial burden of healthcare: a systematic literature review of informal payments in Sub-Saharan Africa. Wellcome Open Res 2021; 6:297. [PMID: 36199622 PMCID: PMC9513412 DOI: 10.12688/wellcomeopenres.17228.1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/22/2021] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Evelyn Kabia
- Health Economics Research Unit, KEMRI Wellcome Trust Research Programme, Nairobi, Kenya
| | - Catherine Goodman
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Dina Balabanova
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Kui Muraya
- Health Systems & Research Ethics Department, KEMRI Wellcome Trust Research Programme, Nairobi, Kenya
| | - Sassy Molyneux
- Health Systems & Research Ethics Department, KEMRI Wellcome Trust Research Programme, Kilifi, Kenya
- Center for Tropical Medicine and Global Health,Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Edwine Barasa
- Health Economics Research Unit, KEMRI Wellcome Trust Research Programme, Nairobi, Kenya
- Center for Tropical Medicine and Global Health,Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Horodnic AV, Williams CC, Drugă RI, Incaltarau C. Informal Payments by Patients in Central and Eastern Europe during the COVID-19 Pandemic: An Institutional Perspective. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:10914. [PMID: 34682651 PMCID: PMC8535994 DOI: 10.3390/ijerph182010914] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 10/01/2021] [Accepted: 10/15/2021] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Adrian V. Horodnic
- Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania; (R.I.D.); (C.I.)
| | | | - Răzvan Ionuț Drugă
- Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania; (R.I.D.); (C.I.)
- Faculty of Economics and Business Administration, “Alexandru Ioan Cuza” University of Iași, 700505 Iași, Romania
| | - Cristian Incaltarau
- Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania; (R.I.D.); (C.I.)
- Centre for European Studies, “Alexandru Ioan Cuza” University of Iași, 700507 Iași, Romania
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Buch Mejsner S, Kristiansen M, Eklund Karlsson L. Civil Servants and Non-Western Migrants' Perceptions on Pathways to Health Care in Serbia-A Grounded Theory, Multi-Perspective Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:10247. [PMID: 34639551 PMCID: PMC8547138 DOI: 10.3390/ijerph181910247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 09/15/2021] [Accepted: 09/26/2021] [Indexed: 11/16/2022]
Abstract
(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.
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Affiliation(s)
- Sofie Buch Mejsner
- Unit for Health Promotion Research, University of Southern Denmark, Degnevej 14, 6705 Esbjerg, Denmark;
| | - Maria Kristiansen
- Department of Public Health, Center for Healthy Aging, University of Copenhagen, Øster Farimagsgade 5, 1353 Copenhagen, Denmark;
| | - Leena Eklund Karlsson
- Unit for Health Promotion Research, University of Southern Denmark, Degnevej 14, 6705 Esbjerg, Denmark;
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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? BIOMED RESEARCH INTERNATIONAL 2021; 2021:5763003. [PMID: 34485519 PMCID: PMC8416363 DOI: 10.1155/2021/5763003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 07/22/2021] [Accepted: 07/28/2021] [Indexed: 11/17/2022]
Abstract
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).
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McKee M. Building back better: why we need to fix the health worker divide in Europe. Eur J Public Health 2021; 31:669. [PMID: 34389842 DOI: 10.1093/eurpub/ckab088] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Martin McKee
- Professor of European Public Health, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
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Binyaruka P, Balabanova D, McKee M, Hutchinson E, Andreoni A, Ramesh M, Angell B, Kapologwe NA, Mamdani M. Supply-side factors influencing informal payment for healthcare services in Tanzania. Health Policy Plan 2021; 36:1036-1044. [PMID: 34021334 PMCID: PMC8359751 DOI: 10.1093/heapol/czab034] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 01/30/2021] [Accepted: 02/25/2021] [Indexed: 11/13/2022] Open
Abstract
Informal payments for healthcare are widespread in sub-Saharan Africa. They are often regressive, potentially limiting access to quality healthcare, particularly for the most vulnerable, and can have catastrophic consequences for households. Yet there is little empirical research that uses theory-driven hypotheses to explore what influences informal payments and, especially, from health workers' perspectives. Consequently, we have explored the characteristics of health workers and facilities influencing informal payments in Tanzania, examining two hypotheses: health workers with power and position in the system are more likely to receive informal payments, and transparency and accountability measures can be bypassed by those who can game the system. We conducted a cross-sectional survey of 432 health workers from 42 public health facilities (hospitals and health centres) in 12 district councils from Pwani and Dar es Salam regions in Tanzania. Our dependent variable was whether the health worker has ever asked for or been given informal payments or bribes, while explanatory variables were measured at the individual and facility level. Given the hierarchical structure of the data, we used a multilevel mixed-effect logistic regression to explore the determinants. Twenty-seven percent of 432 health workers ever engaged in informal payment. This was more common amongst younger (<35 years) health workers and those higher in the hierarchy (specialists and heads of departments). Those receiving entitlements and benefits in a timely manner and who were subject to continued supervision were significantly less likely to receive informal payments. The likelihood of engaging in informal payments varied among health workers, consistent with our first hypothesis, but evidence on the second hypothesis remains mixed. Thus, policy responses should address both individual and system-level factors, including ensuring adequate and progressive health sector financing, better and timely remuneration of frontline public health providers, and enhanced governance and supervision.
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Affiliation(s)
- Peter Binyaruka
- Department of Health System, Impact Evaluation and Policy, Ifakara Health Institute, PO Box 78373, Dar es Salaam, Tanzania
| | - Dina Balabanova
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK
| | - Martin McKee
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK
| | - Eleanor Hutchinson
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK
| | - Antonio Andreoni
- UCL Institute for Innovation and Public Purpose, 11 Montague Street, London WC1B 5BP, UK
| | - Mary Ramesh
- Department of Health System, Impact Evaluation and Policy, Ifakara Health Institute, PO Box 78373, Dar es Salaam, Tanzania
| | - Blake Angell
- The George Institute for Global Health, University of New South Wales Sydney, Sydney, Australia
- UCL Institute for Global Health, 30 Guilford Street, London WC1N 1EH, UK
| | - Ntuli A Kapologwe
- President’s Office—Regional Administration and Local Government (PO-RALG), Dodoma, Tanzania
| | - Masuma Mamdani
- Department of Health System, Impact Evaluation and Policy, Ifakara Health Institute, PO Box 78373, Dar es Salaam, Tanzania
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Hsu W, Yang CH, Fan WP. A Study of Patients' Willingness to Pay for a Basic Outpatient Copayment and Medical Service Quality in Taiwan. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18126604. [PMID: 34205325 PMCID: PMC8296397 DOI: 10.3390/ijerph18126604] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 06/15/2021] [Accepted: 06/16/2021] [Indexed: 11/24/2022]
Abstract
Patients might be willing to pay more to obtain better quality medical services when they recognize that high-level hospitals have better quality. However, published papers have not found solid empirical evidence to support this possibility. Therefore, the purpose of this study is to empirically investigate patients’ willingness to pay (WTP) for an outpatient copayment. The study aims to analyze the difference between the two WTP values: to implement a hierarchy of medical care and to improve the quality of medical services. This study administered a questionnaire using the contingent valuation method with a quasi-bidding game for patients’ WTP and the SERVQUAL scale for medical service quality. The Wilcoxon signed-rank test was employed to test the difference between the two WTP values, notably to implement a hierarchy of medical care and to improve the quality of medical services. Both of the WTP values are higher than the academic medical centre’s current copayment NT$420 (approximately US$14); the percentage of respondents willing to pay a higher copayment declined when the outpatient copayment was increased, and the patients’ WTP to have better medical service quality was significantly higher than that to implement a hierarchy of medical care. Patients’ desire to receive better medical services from higher-level hospitals might be stronger than their desire to implement hierarchical medical care. This study reported the relationship between the respondents’ perceived medical service quality and WTP for having better service quality by using regression models. The respondents’ perceptions of medical service quality, especially for “reliability” and “assurance,” would positively affect their WTP. Policy makers should focus on improving the quality of medical services.
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Affiliation(s)
- Wei Hsu
- Department of Health Care Management, National Taipei University of Nursing & Health Sciences, Beitou, Taipei 112303, Taiwan;
- Correspondence:
| | - Chih-Hao Yang
- Department of Accounting, Ming Chuan University, Shilin, Taipei 111005, Taiwan;
| | - Wen-Ping Fan
- Department of Health Care Management, National Taipei University of Nursing & Health Sciences, Beitou, Taipei 112303, Taiwan;
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Rajan S, Ricciardi W, McKee M. The SDGs and health systems: the last step on the long and unfinished journey to universal health care? Eur J Public Health 2021; 30:i28-i31. [PMID: 32391906 PMCID: PMC7213413 DOI: 10.1093/eurpub/ckaa035] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
In 2015, the world’s governments committed, in the Sustainable Development Goals (SDGs), to achieve universal health coverage by 2030, something they will be held accountable for. We examine progress in the WHO European Region using data from several sources. We assess effective coverage using data from the Global Burden of Disease Programme, including access to 9 key interventions for maternal and child health and communicable and non-communicable diseases and mortality from 32 conditions amenable to health care. Progress is mixed; while Finland and Iceland have already achieved the 2030 target already, other countries, including in the Caucasus and Central Asia have not yet, and are unlikely to by 2030. We then examine financial protection, where progress lags in Central and South East Europe and the former Soviet Union, where high out-of-pocket healthcare payments and catastrophic spending are still common. We stress the need to consider inequalities within countries, with the most vulnerable groups, such as Roma or newly arrived migrants (from the Middle East and Africa) often underserved, while their needs are frequently undocumented. To make progress on the SDGs, governments must invest more heavily in health services research and support the infrastructure and capacity required to enable it.
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Affiliation(s)
- Selina Rajan
- Centre for Global Chronic Conditions, London School of Hygiene & Tropical Medicine, London, UK
| | - Walter Ricciardi
- Department of Public Health, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Martin McKee
- Centre for Global Chronic Conditions, London School of Hygiene & Tropical Medicine, London, UK.,European Observatory on Health Systems and Policies, Brussels, Belgium
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Gaal P, Velkey Z, Szerencses V, Webb E. The 2020 reform of the employment status of Hungarian health workers: Will it eliminate informal payments and separate the public and private sectors from each other? Health Policy 2021; 125:833-840. [PMID: 34030886 DOI: 10.1016/j.healthpol.2021.04.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 03/24/2021] [Accepted: 04/23/2021] [Indexed: 11/28/2022]
Abstract
Hungary, like many countries, features a complex mix of the public and private sector in the financing and provision of health care services. At the same time, the health system also faces challenges related to shortages of health professionals, low public financing, and informal payments. With the added pressure from the COVID-19 pandemic, Hungarian policymakers acted rapidly to pass a sweeping regulation aimed at these issues. Over two days, the Hungarian parliament introduced and unanimously approved a new regulation, Act C of 2020 on the Employment Status of Health Workers, that replaces the existing public employment relationship between health professionals, public providers and their controlling authorities. The Act, passed on 6 October 2020, brings the employment of health workers under strict central control by introducing a new employment status similar to that of the armed forces. The Act also provides doctors with an unprecedented 120% salary increase and criminalizes informal payments. The reception has been overwhelmingly negative, with thousands of health professionals indicating that they would not sign the new contracts, and the policy also contains serious technical and feasibility concerns. Although the first statistics show that only about 3-5% of the active workforce did not sign the contract by 1 March 2021, the implementation of the reform still faces serious challenges.
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Affiliation(s)
- Peter Gaal
- Health Services Management Training Centre, Faculty of Health and Public Administration, Semmelweis University, Kútvölgyi út 2, H-1125 Budapest, Hungary; Department of Applied Social Sciences, Faculty of Technical and Human Sciences, Sapientia Hungarian University of Transylvania, Targu Mures, Romania.
| | - Zita Velkey
- Health Services Management Training Centre, Faculty of Health and Public Administration, Semmelweis University, Kútvölgyi út 2, H-1125 Budapest, Hungary
| | - Viktoria Szerencses
- Health Services Management Training Centre, Faculty of Health and Public Administration, Semmelweis University, Kútvölgyi út 2, H-1125 Budapest, Hungary
| | - Erin Webb
- European Observatory on Health Systems and Policies, Berlin University of Technology, Germany; Department of Health Care Management, Berlin University of Technology, Germany
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Giannouchos TV, Ukert B, Vozikis A, Steletou E, Souliotis K. Informal out-of-pocket payments experience and individuals' willingness-to-pay for healthcare services in Greece. Health Policy 2021; 125:693-700. [PMID: 33838935 DOI: 10.1016/j.healthpol.2021.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 03/19/2021] [Accepted: 04/01/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Informal out-of-pocket payments to healthcare providers are not uncommon in the Greek health system. We explore individuals' willingness-to-pay (WTP) to secure zero out-of-pocket full coverage for healthcare services and medications and we estimate the impact of past informal payments and individuals' opinion about the legalization of informal payments on WTP. METHODS We conducted a survey of 2841 participants from November 2016 to February 2017. We obtained information on WTP using the contingent valuation method. A two-part regression model was used to estimate the association between WTP, informal payments, and respondents' opinion about legalizing such payments. RESULTS About 80% of the respondents were willing to pay an average of €95 per month to obtain free access to full healthcare coverage and medications. About 65% of the respondents were involved in an informal payment at least once during the past four months with an average payment of €247. Higher informal payments and supportive opinions towards the legalization of informal payments increased the likelihood of WTP and were also positively associated with increased WTP amounts overall (p < 0.001). CONCLUSIONS This survey reveals that individuals' WTP is critically affected by previous experiences and attitudes towards informal payments. Our results imply that the potential introduction of official fees might not suffice to limit informal payments and suggest the need for stricter regulatory policies.
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Affiliation(s)
- Theodoros V Giannouchos
- Pharmacotherapy Outcomes Research Center, College of Pharmacy, University of Utah, 30 S 2000 E, Salt Lake City, 84112, UT, USA; Population Informatics Lab, Texas A&M University, 212 Adriance Lab Rd, College Station, 77843, TX, USA; Laboratory of Health Economics & Management, Economics Department, University of Piraeus, Karaoli ke Dimitriou 80, 185 34, Piraeus, Greece.
| | - Benjamin Ukert
- Department of Health Policy & Management, School of Public Health, Texas A&M University, 212 Adriance Lab Rd, 77843, College Station, TX, USA
| | - Athanassios Vozikis
- Laboratory of Health Economics & Management, Economics Department, University of Piraeus, Karaoli ke Dimitriou 80, 185 34, Piraeus, Greece
| | - Evangelia Steletou
- University Regional General Hospital of Patras, University of Patras, 26504, Patras, Rion, Greece
| | - Kyriakos Souliotis
- Department of Social and Education Policy, University of Peloponnese, Damaskinou & Kolokotroni Str., 20100, Corinth, Greece
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Informal payments for primary health services in Zambia: Evidence from a health facility patient exit survey. HEALTH POLICY OPEN 2020. [DOI: 10.1016/j.hpopen.2020.100020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Yuan B, Jian W, Martinez-Alvarez M, McKee M, Balabanova D. Health system reforms in China a half century apart: Continuity but adaptation. Soc Sci Med 2020; 265:113421. [PMID: 33190927 DOI: 10.1016/j.socscimed.2020.113421] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 08/09/2020] [Accepted: 08/16/2020] [Indexed: 01/22/2023]
Abstract
Well-functioning governance arrangements are an essential, but often overlooked or poorly understood contributor to high quality health systems. Yet governance systems are embedded in institutional structures and shaped by cultural norms that can be difficult to change. We look at a country that has implemented two major health system reforms separated by half a century during which it has undergone remarkable political, economic, and social change. These are the Chinese Patriotic Health Campaign (PHC), beginning in the 1950s, and the New Cooperative Medical Scheme (NCMS), in the 2000s. We use these as case studies to explore how governance arrangements supported the design and implementation of policies implemented on a large scale in these quite different contexts. Drawing on review of archival documents, published literature, and semi-structured interviews with key policy makers, we conclude that few aspects of governance underwent fundamental changes. In both periods, the policy design stage included encouragement of sub-national tiers of government to pilot policy options, accumulate evidence, and disseminate it to others facing similar challenges, all facilitated by clear lines of accountability and a willingness by those at the top of the hierarchy to learn lessons from lower levels. At the implementation stage, rapid scaling up benefitted from leadership by national institutions that could enact regulations and set policy goals and targets for lower tiers of government, evaluating the performance of local government officers in terms of their ability to implement policy, while encouraging local government to pilot innovative measures. These findings highlight the importance of a detailed understanding of governance and how it is shaped by context, demonstrating continuity over long periods even at times of major social, political, and economic change. This understanding can inform future policy development in China and measures to strengthen governance aspects of reforms elsewhere.
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Affiliation(s)
- Beibei Yuan
- China Center for Health Development Studies, Peking University, China
| | - Weiyan Jian
- Department of Health Policy and Management, School of Public Health, Peking University Health Science Center, China.
| | | | - Martin McKee
- The London School of Hygiene & Tropical Medicine, UK
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Tripathi N, John D, Chatterjee PK, Murthy S, Parganiha N, Brokar A. Informal Payments for Maternal and Neonatal Health Services in Public Hospitals in Central India. JOURNAL OF HEALTH MANAGEMENT 2020. [DOI: 10.1177/0972063420908158] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Informal payments are unauthorised ‘unregistered’ out-of-pocket payments, outside the official payment system, for purchase or service meant to be covered/provided by the healthcare system. This study attempts to measure and report the extent and magnitude of informal payments based on the entitlements in Janani-Shishu Suraksha Karyakram (JSSK) in the Indian context. Methods: A cross-sectional study using convenience sampling and a semi-structured interview schedule was conducted among 281 participants in 2016 in 26 JSSK-notifying health facilities from all five divisions of Chhattisgarh. Pregnant women and women who delivered in the previous year, and provided informed consent, were included. After reviewing various definitions, informal payment was operationally defined in the context of JSSK for India as ‘payments made in cash or kind, unregistered or non-reimbursed, made by/on behalf of the beneficiary or someone related thereof, for free and cashless entitlements in a JSSK-listed health facility, to an individual or institutional healthcare provider/staff who provides/arranges for provision of the service’. Results: Of 281 participants, 91.8 per cent reported informal payments across all JSSK entitlements categories. A relative majority of these payments was made at the district hospital (37%), ranging from ₹2 to ₹6,500 (US$0.03–101). Investigations incurred the greatest median amount of informal payments, at, ₹455 (US$7). Informal payments ranged between three and seven times higher than the JSSK price cap in Chhattisgarh. No significant association was found between participant characteristics and informal payments. Conclusion: Further research is required to understand the magnitude and motivation of informal payments made in programmes like JSSK.
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Affiliation(s)
| | - Denny John
- Evidence Synthesis Specialist, Campbell South Asia, New Delhi, India
- ICMR-National Institute of Medical Statistics, New Delhi, India
| | | | - Shruti Murthy
- Department of Statistics, Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, India
| | | | - Arti Brokar
- State Health Resource Centre, Raipur, Chhattisgarh, India
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Alternative provision of public health care: the role of citizens' satisfaction with public services and the social responsibility of government. HEALTH ECONOMICS POLICY AND LAW 2020; 17:121-140. [PMID: 32686632 DOI: 10.1017/s1744133120000201] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
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.
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Doshmangir L, Sajadi HS, Ghiasipour M, Aboutorabi A, Gordeev VS. Informal payments for inpatient health care in post-health transformation plan period: evidence from Iran. BMC Public Health 2020; 20:539. [PMID: 32312238 PMCID: PMC7171751 DOI: 10.1186/s12889-020-8432-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Accepted: 02/28/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In 2014, a revision of the national medical tariffs for inpatient health care services took place in Iran, and a new hotline was set up to report informal payments. It was expected that such measures would eliminate or decrease informal payments prevalence. This study estimates the prevalence of informal payments for inpatient health care services in the post-reform period, explores factors associated with informal payments and examines patients' and healthcare providers' views regarding the causes of informal payments and possible practical solutions for their reduction. METHODS We surveyed by phone patients who used inpatient health care services in seven Iranian hospitals in 2016. Descriptive and regression analyses were used to estimate the prevalence and determine factors associated with informal payments. We conducted a qualitative analysis through thematic analyses based on focus group discussions and in-depth interviews. RESULTS Of 2696 respondents, 14% reported paying informally for inpatient services. Informal payments were reported more frequently among private hospital users, given more frequently to physicians in public teaching hospitals and 'other staff' in private hospitals, in the form of cash and voluntary. Being an adult, hospital or treatment type, being insured, and household head's education influenced the probability of paying informally. The amount paid informally was associated with being insured, the educational status of the household's head, household size, service, and hospital types. Based on qualitative findings, the leading causes of informal payments reported by patients and healthcare providers can be categorized into four groups - financing challenges; governance challenges; service delivery challenges; and actors and stakeholders. Modifying, adjusting and applying policy interventions; supervision, monitoring and evaluation; and actors and stakeholders were identified as possible solutions for tackling informal payment in the inpatient health care services. CONCLUSION The prevalence of informal patient payments for inpatient services in the post-reform period seems to have reduced; however, they remain to be common. Regular monitoring, reviewing of payment policies to the physicians, informing patients, changing the behaviour of healthcare providers and patients, and developing ethical guidelines to prevent informal payments were suggested for reduction and elimination of informal payments in the Iranian healthcare sector.
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Affiliation(s)
- Leila Doshmangir
- Social Determinants of Health Research Center, Tabriz Health Services Management Research Center, Iranian Center of Excellence in Health Management, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Haniye Sadat Sajadi
- Knowledge Utilization Research Center, University Research and Development Center, Tehran University of Medical Sciences, Tehran, Iran.
| | - Maryam Ghiasipour
- Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Aboutorabi
- School of Management and Medical Informatics, Iran University of Medical Sciences, Tehran, Iran
| | - Vladimir Sergeevich Gordeev
- Department of Infectious Disease Epidemiology, The London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.,Institute of Population Health Sciences, Queen Mary University of London, Mile End Road, London, E1 4NS, UK
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Tumlinson K, Gichane MW, Curtis SL. "If the Big Fish are Doing It Then Why Not Me Down Here?": Informal Fee Payments and Reproductive Health Care Provider Motivation in Kenya. Stud Fam Plann 2020; 51:33-50. [PMID: 32043621 DOI: 10.1111/sifp.12107] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Informal fees are payments made by patients to their health care provider that are over and above the official cost of services. Payments may be motivated by a combination of factors such as low supervision, weak sanctions, and inadequate provider salaries. The practice of soliciting informal fees from patients may result in restricted access to medical care and reduced care-seeking behavior among vulnerable populations. The objective of this study is to examine nuanced health care provider perspectives on informal fee payments solicited from reproductive health patients in Kenya. We conducted in-depth semistructured interviews in 2015-2016 among a sample of 20 public and private-sector Kenyan health care workers. Interviews were coded and analyzed using an iterative thematic approach. More than half of participants reported that solicitation of informal fees is common practice in health care facilities. Providers reported low public-sector wages were a primary driver of informal fee solicitation coupled with collusion among senior staff. Additionally, patients may be unaware that they are being asked to pay more than the official cost of services. Strategies for reducing this behavior include more adequate and timely remuneration within the public sector, educating patient populations of free or low-cost services, and evidence-based methods to increase provider motivation.
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Pourtaleb A, Jafari M, Seyedin H, Akhavan Behbahani A. New insight into the informal patients' payments on the evidence of literature: a systematic review study. BMC Health Serv Res 2020; 20:14. [PMID: 31902368 PMCID: PMC6943960 DOI: 10.1186/s12913-019-4647-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 10/16/2019] [Indexed: 10/27/2022] Open
Abstract
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.
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Affiliation(s)
- Arefeh Pourtaleb
- Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran
- Health Managers Development Institute, Ministry of Health and Medical Education, Tehran, Iran
| | - Mehdi Jafari
- Health Managers Development Institute, Ministry of Health and Medical Education, Tehran, Iran
- Department of Health Services Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Hesam Seyedin
- Department of Health in Disaster and Emergencies, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
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Abstract
Corruption is embedded in health systems. Throughout my life-as a researcher, public health worker, and a Minister of Health-I have been able to see entrenched dishonesty and fraud. But despite being one of the most important barriers to implementing universal health coverage around the world, corruption is rarely openly discussed. In this Lecture, I outline the magnitude of the problem of corruption, how it started, and what is happening now. I also outline people's fears around the topic, what is needed to address corruption, and the responsibilities of the academic and research communities in all countries, irrespective of their level of economic development. Policy makers, researchers, and funders need to think about corruption as an important area of research in the same way we think about diseases. If we are really aiming to achieve the Sustainable Development Goals and ensure healthy lives for all, corruption in global health must no longer be an open secret.
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Schaaf M, Topp SM. A critical interpretive synthesis of informal payments in maternal health care. Health Policy Plan 2019; 34:216-229. [PMID: 30903167 PMCID: PMC6528746 DOI: 10.1093/heapol/czz003] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2019] [Indexed: 01/01/2023] Open
Abstract
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.
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Affiliation(s)
- Marta Schaaf
- Program on Global Health Justice and Governance, Department of Population and Family Health, Mailman School of Public Health, Columbia University, 60 Haven Avenue, B3, New York, NY, USA
| | - Stephanie M Topp
- College of Public Health, Medical and Veterinary Sciences, James Cook University, James Cook Drive, Townsville, Australia
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Vogler S, Schneider P, Dedet G, Bak Pedersen H. Affordable and equitable access to subsidised outpatient medicines? Analysis of co-payments under the Additional Drug Package in Kyrgyzstan. Int J Equity Health 2019; 18:89. [PMID: 31196109 PMCID: PMC6567501 DOI: 10.1186/s12939-019-0990-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 05/23/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Out-of-pocket (OOP) payments can constitute a major barrier for affordable and equitable access to essential medicines. Household surveys in Kyrgyzstan pointed to a perceived growth in OOP payments for outpatient medicines, including those covered by the benefits package scheme (the Additional Drug Package, ADP). The study aimed to explore the extent of co-payments for ADP-listed medicines and to explain the reasons for developments. METHODS A descriptive statistical analysis was performed on prices and volumes of prescribed ADP-listed medicines dispensed in pharmacies during 2013-2015 (1,041,777 prescriptions claimed, data provided by the Mandatory Health Insurance Fund). Additionally, data on the value and volume of imported medicines in 2013-2015 (obtained from the National Medicines Regulatory Agency) were analysed. RESULTS In 2013-2015, co-payments for medicines dispensed under the ADP grew, on average, by 22.8%. Co-payments for ADP-listed medicines amounted to around 50% of a reimbursed baseline price, but as pharmacy retail prices were not regulated, co-payments tended to be higher in practice. The increase in co-payments coincided with a reduction in the number of prescriptions dispensed (by 14%) and an increase in average amounts reimbursed per prescription in nearly all therapeutic groups (by 22%) in the study period. While the decrease in prescriptions suggests possible underuse, as patients might forego filling prescriptions due to financial restraints, the growth in average amounts reimbursed could be an indication of inefficiencies in public funding. Variation between the regions suggests regional inequity. Devaluation of the national currency was observed, and the value of imported medicines increased by nearly 20%, whereas volumes of imports remained at around the same level in 2013-2015. Thus, patients and public procurers had to pay more for the same amount of medicines. CONCLUSIONS The findings suggest an increase in pharmacy retail prices as the major driver for higher co-payments. The national currency devaluation contributed to the price increases, and the absence of medicine price regulation aggravated the effects of the depreciation. It is recommended that Kyrgyzstan should introduce medicine price regulation and exemptions for low-income people from co-payments to ensure a more affordable and equitable access to medicines.
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Affiliation(s)
- Sabine Vogler
- WHO Collaborating Centre for Pharmaceutical Pricing and Reimbursement Policies, Pharmacoeconomics Department, Gesundheit Österreich GmbH (GÖG / Austrian Public Health Institute), Vienna, Austria
| | - Peter Schneider
- WHO Collaborating Centre for Pharmaceutical Pricing and Reimbursement Policies, Pharmacoeconomics Department, Gesundheit Österreich GmbH (GÖG / Austrian Public Health Institute), Vienna, Austria
| | - Guillaume Dedet
- Organisation for Economic Co-operation and Development (OECD), Paris, France
| | - Hanne Bak Pedersen
- World Health Organization, Regional Office for Europe, Copenhagen, Denmark
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Schaaf M, Dasgupta J. "Our fear is finished," but nothing changes: efforts of marginalized women to foment state accountability for maternal health care in a context of low state capacity. BMC Public Health 2019; 19:732. [PMID: 31185954 PMCID: PMC6560750 DOI: 10.1186/s12889-019-7028-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 05/22/2019] [Indexed: 11/20/2022] Open
Abstract
Background Women in India are often asked to make informal payments for maternal health care services that the government has mandated to be free. This paper is a descriptive case study of a social accountability project undertaken by SAHAYOG, a nongovernmental organization in Uttar Pradesh, India. SAHAYOG worked with community-based organizations and a grassroots forum comprised of low caste, Muslim, and tribal women to decrease the prevalence of health provider demands that women and their families make informal payments. Methods The study entailed document review; interviews and focus group discussions with program implementers, governmental stakeholders, and community activists; and participant observation in health facilities. Results The study found that SAHAYOG adapted their strategy over time to engender greater empowerment and satisfaction among program participants, as well as greater impact on the health system. Participants gained knowledge resources and agency; they learned about their entitlements, had access to mechanisms for complaints, and, despite risk of retaliation, many felt capable of demanding their rights in a variety of fora. However, only program participants seemed successfully able to avoid making informal payments to the health sector; health providers still demanded that other women make payments. Several features of the micro and macro context shaped the trajectory of SAHAYOG’s efforts, including deeply rooted caste dynamics, low provider commitment to ending informal payments, the embeddedness of informal payments, human resources scarcity, and the overlapping private interests of pharmaceutical companies and providers. Conclusion Though changes were manifest in certain fora, providers have not necessarily embraced the notion of low caste, tribal, or Muslim women as citizens with entitlements, especially in the context of free government services for childbirth. Grassroots advocates, CBOs, and SAHAYOG assumed a supremely difficult task. Project strategy changes may have made the task somewhat less difficult, but given the population making the rights claims and the rights they were claiming, widespread changes in demands for informal payments may require a much larger and stronger coalition.
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Affiliation(s)
- Marta Schaaf
- Program on Global Health Justice and Governance, Heilbrunn Department of Population and Family Health (HDPFH), Mailman School of Public Health, Columbia University, 60 Haven Ave, B3, New York, NY, 10032, USA.
| | - Jashodhara Dasgupta
- National Foundation for India, Core 4A (Upper Ground Floor), India Habitat Centre, Lodi Road, New Delhi, 110003, India
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Meskarpour Amiri M, Bahadori M, Motaghed Z, Ravangard R. Factors affecting informal patient payments: a systematic literature review. INTERNATIONAL JOURNAL OF HEALTH GOVERNANCE 2019. [DOI: 10.1108/ijhg-01-2019-0006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Mocumbi S, McKee K, Munguambe K, Chiau R, Högberg U, Hanson C, Wallin L, Sevene E, Bergström A. Ready to deliver maternal and newborn care? Health providers' perceptions of their work context in rural Mozambique. Glob Health Action 2019; 11:1532631. [PMID: 30387378 PMCID: PMC6225433 DOI: 10.1080/16549716.2018.1532631] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background: Deficiencies in the provision of evidence-based obstetric care are common in low-income countries, including Mozambique. Constraints relate to lack of human and financial resources and weak health systems, however limited resources alone do not explain the variance. Understanding the healthcare context ahead of implementing new interventions can inform the choice of strategies to achieve a successful implementation. The Context Assessment for Community Health (COACH) tool was developed to assess modifiable aspects of the healthcare context that theoretically influence the implementation of evidence. Objectives: To investigate the comprehensibility and the internal reliability of COACH and its use to describe the healthcare context as perceived by health providers involved in maternal care in Mozambique. Methods: A response process evaluation was completed with six purposively selected health providers to uncover difficulties in understanding the tool. Internal reliability was tested using Cronbach’s α. Subsequently, a cross-sectional survey using COACH, which contains 49 items assessing eight dimensions, was administered to 175 health providers in 38 health facilities within six districts in Mozambique. Results: The content of COACH was clear and most items were understood. All dimensions were near to or exceeded the commonly accepted standard for satisfactory internal reliability (0.70). Analysis of the survey data indicated that items on all dimensions were rated highly, revealing positive perception of context. Significant differences between districts were found for the Work culture, Leadership, and Informal payment dimensions. Responses to many items had low variance and were left-skewed. Conclusions: COACH was comprehensible and demonstrated good reliability, although biases may have influenced participants’ responses. The study suggests that COACH has the potential to evaluate the healthcare context to identify shortcomings and enable the tailoring of strategies ahead of implementation. Supplementing the tool with qualitative approaches will provide an in-depth understanding of the healthcare context.
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Affiliation(s)
- Sibone Mocumbi
- a Department of Obstetrics and Gynaecology, Faculty of Medicine , Universidade Eduardo Mondlane (UEM) , Maputo , Mozambique.,b Department of Women's and Children's Health , Uppsala University , Uppsala , Sweden
| | - Kevin McKee
- c School of Education, Health and Social Studies , Dalarna University , Falun , Sweden
| | - Khátia Munguambe
- d Department of Public Health , Faculty of Medicine, Universidade Eduardo Mondlane (UEM) , Maputo , Mozambique.,e Centro de Investigação em Saúde de Manhiça (CISM) , Manhiça , Mozambique
| | - Rogério Chiau
- e Centro de Investigação em Saúde de Manhiça (CISM) , Manhiça , Mozambique
| | - Ulf Högberg
- b Department of Women's and Children's Health , Uppsala University , Uppsala , Sweden
| | - Claudia Hanson
- f Department of Public Health Sciences , Karolinska Institutet , Stockholm , Sweden.,g Department of Disease Control , London School of Hygiene and Tropical Medicine , London , UK
| | - Lars Wallin
- c School of Education, Health and Social Studies , Dalarna University , Falun , Sweden.,h Department of Neurobiology, Care Sciences and Society, Division of Nursing , Karolinska Institutet , Stockholm , Sweden.,i Department of Health and Care Sciences , The Sahlgrenska Academy, University of Gothenburg , Gothenburg , Sweden
| | - Esperança Sevene
- e Centro de Investigação em Saúde de Manhiça (CISM) , Manhiça , Mozambique.,j Department of Physiological Science, Clinical Pharmacology , Faculty of Medicine, Universidade Eduardo Mondlane (UEM) , Maputo , Mozambique
| | - Anna Bergström
- b Department of Women's and Children's Health , Uppsala University , Uppsala , Sweden.,k Institute for Global Health , University College London , London , UK
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Hutchinson E, Balabanova D, McKee M. We Need to Talk About Corruption in Health Systems. Int J Health Policy Manag 2019; 8:191-194. [PMID: 31050963 PMCID: PMC6499907 DOI: 10.15171/ijhpm.2018.123] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 12/09/2018] [Indexed: 11/09/2022] Open
Abstract
The health sector consistently appears prominently in surveys of perceived corruption, with considerable evidence that this has serious adverse consequences for patients. Yet this issue is far from prominent in the international health policy discourse. We identify five reasons why the health policy community has been reluctant to talk about it. These are the problem of defining corruption, the fact that some corrupt practices are actually ways of making dysfunctional systems work, the serious challenges to researching corruption, concerns that a focus on corruption is a form of victim blaming that ignores larger issues, and a lack of evidence about what works to tackle it. We propose three things that can be done to address this situation. First, seek consensus on the scale and nature of corruption. Second, decide on priorities, taking account the importance of the particular problem and the feasibility of doing something about it. Third, take a holistic view, drawing on a wide range of disciplines.
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Affiliation(s)
- Eleanor Hutchinson
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Dina Balabanova
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Martin McKee
- Department of Public Health & Policy, London School of Hygiene and Tropical Medicine, London, UK
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Meskarpour Amiri M, Teymourzadeh E, Ravangard R, Bahadori M. Health informal payments and their main determinants: The case of Iran. PROCEEDINGS OF SINGAPORE HEALTHCARE 2019. [DOI: 10.1177/2010105818822594] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Affiliation(s)
| | - Ehsan Teymourzadeh
- Health Management Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Ramin Ravangard
- Health Human Resources Research Center, School of Management & Information Sciences, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohammadkarim Bahadori
- Health Management Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
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Sharma G, Penn-Kekana L, Halder K, Filippi V. An investigation into mistreatment of women during labour and childbirth in maternity care facilities in Uttar Pradesh, India: a mixed methods study. Reprod Health 2019; 16:7. [PMID: 30674323 PMCID: PMC6345007 DOI: 10.1186/s12978-019-0668-y] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 01/09/2019] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES To investigate the nature and context of mistreatment during labour and childbirth at public and private sector maternity facilities in Uttar Pradesh, India. METHODS This study analyses mixed-methods data obtained through systematic clinical observations and open-ended comments recorded by the observers to describe care provision for 275 mothers and their newborns at 26 hospitals in three districts of Uttar Pradesh from 26 May to 8 July 2015. We conducted a bivariate descriptive analysis of the quantitative data and used a thematic approach to analyse qualitative data. FINDINGS All women in the study encountered at least one indicator of mistreatment. There was a high prevalence of not offering birthing position choice (92%) and routine manual exploration of the uterus (80%) in facilities in both sectors. Private sector facilities performed worse than the public sector for not allowing birth companions (p = 0.02) and for perineal shaving (p = < 0.001), whereas the public sector performed worse for not ensuring adequate privacy (p = < 0.001), not informing women prior to a vaginal examination (p = 0.01) and for physical violence (p = 0.04). Prepared comments by observers provide further contextual insights into the quantitative data, and additional themes of mistreatment, such as deficiencies in infection prevention, lack of analgesia for episiotomy, informal payments and poor hygiene standards at maternity facilities were identified. CONCLUSIONS Mistreatment of women frequently occurs in both private and public sector facilities. This paper contributes to the literature on mistreatment of women during labour and childbirth at maternity facilities in India by articulating new constructs of overtreatment and under-treatment. There are five key implications of this study. First, a systematic and context-specific effort to measure mistreatment in public and private sector facilities in high burden states in India is required. Second, a training initiative to orient all maternity care personnel to the principles of respectful maternity care would be useful. Third, innovative mechanisms to improve accountability towards respectful maternity care are required. Fourth, participatory community and health system interventions to support respectful maternity care would be useful. Lastly, we note that there needs to be a long-term, sustained investment in health systems so that supportive and enabling work-environments are available to front- line health workers.
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Affiliation(s)
- Gaurav Sharma
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, WC 1E 7HT UK
| | - Loveday Penn-Kekana
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, WC 1E 7HT UK
| | - Kaveri Halder
- Deputy Manager-Research, Sambodhi Research and Communications, O-2, Lajpat Nagar-II, New Delhi, 110024 India
| | - Véronique Filippi
- Deputy Manager-Research, Sambodhi Research and Communications, O-2, Lajpat Nagar-II, New Delhi, 110024 India
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Sibeudu FT, Uzochukwu BS, Onwujekwe OE. Rural-urban comparison of routine immunization utilization and its determinants in communities in Anambra States, Nigeria. SAGE Open Med 2019; 7:2050312118823893. [PMID: 30719291 PMCID: PMC6348577 DOI: 10.1177/2050312118823893] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 12/17/2018] [Indexed: 11/17/2022] Open
Abstract
Objectives: The study determined the levels of geographic differences in the utilization of routine immunization between households in an urban and a rural community. It also identified and compared the determinants of utilization of routine immunization in the two geographic areas. Method: The study was undertaken in two randomly selected communities (one rural and one urban) in Anambra State, Nigeria. Interviewer-administered questionnaires were used to collect information on utilization of immunization services from households. Data were analyzed using descriptive and multiple logistic regression analyses. Result: Households in the urban community had a higher level of utilization of routine immunization (95.5%) than those in the rural community (75.3%) and the difference was statistically significant (p < 0.05). It was also found that more rural dwellers (83.3%) received immunization services from public health facilities compared to the urban dwellers (42%; p < 0.05). Health facilities were nearer to households in the urban community than the rural community (p < 0.05). Mean cost of service per visit was higher in the urban community (p < 0.05), but the difference in the mean cost of transportation per visit was not significant (p = 0.125). Regression analysis shows that place of residence was highly significant for utilization of routine immunization services (p < 0.05). Conclusion: Urban–rural differences exist in utilization of routine immunization services. Health facilities are more proximal to consumers in the urban community than the rural community, with higher travel costs among rural dwellers. Ensuring that there is a functional primary healthcare center in every ward and provision of routine immunization services in market places on local market days can help to increase utilization and reduce rural–urban differences in utilization of immunization services.
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Affiliation(s)
- Florence Tochukwu Sibeudu
- Department of Nursing Science, College of Health Sciences, Nnamdi Azikiwe University, Nnewi, Nigeria.,Department of Health Administration and Management, College of Medicine, University of Nigeria, Enugu, Nigeria
| | - Benjamin Sc Uzochukwu
- Department of Health Administration and Management, College of Medicine, University of Nigeria, Enugu, Nigeria.,Department of Community Medicine, College of Medicine, University of Nigeria, Enugu, Nigeria
| | - Obinna E Onwujekwe
- Department of Health Administration and Management, College of Medicine, University of Nigeria, Enugu, Nigeria.,Health Policy Research Group, Department of Pharmacology and Therapeutics, College of Medicine, University of Nigeria, Enugu, Nigeria
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Meskarpour Amiri M, Assari A, Bahadori M, Ravangard R, Hosseini-Shokouh SM. Informal payments for health care in Iran. INTERNATIONAL JOURNAL OF HEALTH GOVERNANCE 2018. [DOI: 10.1108/ijhg-02-2018-0007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
Reducing informal payments (IPs) for health services has always been a top priority for health policymakers all over the world. As the newest attempts to reduce IPs, Iran’s Government applied a set of reforms in the health care system in 2014 called “Health Sector Evolution Plan” (HSEP). The purpose of this paper is to investigate the prevalence and nature of IPs one year after implementing this plan.
Design/methodology/approach
This descriptive and cross-sectional study was a nationwide survey on Iran's health sector informal payments carried out in 2016. To do this, a sample of 1,112 Iranain households was selected from all over the country using a multistage cluster-stratified sampling method. The prevalence and nature of IPs were determined through conducting face-to-face interviews using a standard questionnaire.
Findings
One year after implementing the HSEP, about 27.7 percent of sampled Iranians had at least one experience of IPs for health services. The prevalences of compulsory and voluntary IPs were 21.4 and 11.5 percent, respectively. IPs were reported by 26.1 and 12.5 percent in the inpatient and outpatient services, respectively.
Originality/value
According to the results, compulsory IPs are still prevalent in both the outpatient and inpatient services of Iran’s health system and it seems that the HSEP has not been completely successful in achieving the goal of eradicating IPs. It can be said that the HSEP has been the first step toward eradicating IPs in Iran and should not be the last one. The study provides useful results of the prevalence and nature of IPs after implementing the HSEP, which should be considered in designing the next steps.
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Horodnic AV, Williams CC. Informal payments by patients for health services: prevalence and determinants. SERVICE INDUSTRIES JOURNAL 2018. [DOI: 10.1080/02642069.2018.1450870] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Adrian V. Horodnic
- Faculty of Medicine, ‘Grigore T. Popa’ University of Medicine and Pharmacy, Iasi, Romania
| | - Colin C. Williams
- Sheffield University Management School (SUMS), University of Sheffield, Sheffield, UK
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Horodnic AV, Mazilu S, Oprea L. Drivers behind widespread informal payments in the Romanian public health care system: From tolerance to corruption to socio‐economic and spatial patterns. Int J Health Plann Manage 2018. [DOI: 10.1002/hpm.2509] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- Adrian V. Horodnic
- Faculty of Medicine“Grigore T. Popa” University of Medicine and Pharmacy Iasi Romania
| | - Sorin Mazilu
- Research Department, Center for European Studies, Faculty of Law“Alexandru Ioan Cuza” University of Iasi Romania
| | - Liviu Oprea
- Faculty of Medicine“Grigore T. Popa” University of Medicine and Pharmacy Iasi Romania
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Buch Mejsner S, Eklund Karlsson L. Informal Patient Payments and Bought and Brought Goods in the Western Balkans - A Scoping Review. Int J Health Policy Manag 2017; 6:621-637. [PMID: 29179289 PMCID: PMC5675581 DOI: 10.15171/ijhpm.2017.73] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2016] [Accepted: 06/18/2017] [Indexed: 11/09/2022] Open
Abstract
Introduction: Informal patient payments for healthcare are common in the Western Balkans, negatively affecting public health and healthcare.
Aim: To identify literature from the Western Balkans on what is known about informal patient payments and bought and brought goods, to examine their effects on healthcare and to determine what actions can be taken to tackle these payments.
Methods: After conducting a scoping review that involved searching websites and databases and filtering with eligibility criteria and quality assessment tools, 24 relevant studies were revealed. The data were synthesized using a narrative approach that identified key concepts, types of evidence, and research gaps.
Results: The number of studies of informal patient payments increased between 2002 and 2015, but evidence regarding the issues of concern is scattered across various countries. Research has reported incidents of informal patient payments on a wide scale and has described various patterns and characteristics of these payments. Although these payments have typically been small – particularly to providers in common areas of specialized medicine – evidence regarding bought and brought goods remains limited, indicating that such practices are likely even more common, of greater magnitude and perhaps more problematic than informal patient payments. Only scant research has examined the measures that are used to tackle informal patient payments. The evidence indicates that legalizing informal patient payments, introducing performance-based payment systems, strengthening reporting, changing mentalities and involving the media and the European Union (EU) or religious organizations in anti-corruption campaigns are understood as some of the possible remedies that might help reduce informal patient payments.
Conclusion: Despite comprehensive evidence regarding informal patient payments, data remain scattered and contradictory, implying that informal patient payments are a complex phenomenon. Additionally, the data on bought and brought goods illustrate that not much is known about this matter. Although informal patient payments have been studied and described in several settings, there is still little research on the effectiveness of such strategies in the Western Balkans context.
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Affiliation(s)
- Sofie Buch Mejsner
- Unit for Health Promotion Research, University of Southern Denmark, Esbjerg, Denmark
| | - Leena Eklund Karlsson
- Unit for Health Promotion Research, University of Southern Denmark, Esbjerg, Denmark
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40
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Piroozi B, Rashidian A, Moradi G, Takian A, Ghasri H, Ghadimi T. Out-of-Pocket and Informal Payment Before and After the Health Transformation Plan in Iran: Evidence from Hospitals Located in Kurdistan, Iran. Int J Health Policy Manag 2017; 6:573-586. [PMID: 28949473 PMCID: PMC5627785 DOI: 10.15171/ijhpm.2017.16] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 02/01/2017] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND One of the objectives of the health transformation plan (HTP) in Iran is to reduce out-of-pocket (OOP) payments for inpatient services and eradicate informal payments. The HTP has three phases: the first phase (launched in May 5, 2014) is focused on reducing OOP payments for inpatient services; the second phase (launched in May 22, 2014) is focused on primary healthcare (PHC) and the third phase utilizes an updated relative value units for health services (launched in September 29, 2014) and is focused on the elimination of informal payments. This aim of this study was to determine the OOP payments and the frequency of informal cash payments to physicians for inpatient services before and after the HTP in Kurdistan province, Iran. METHODS This quasi-experimental study used multistage sampling method to select and evaluate 265 patients discharged from hospitals in Kurdistan province. The study covered 3 phases (before the HTP, after the first, and third phases of the HTP). Part of the data was collected using a hospital information system form and the rest were collected using a questionnaire. Data were analyzed using Fisher exact test, logistic regression, and independent samples t test. RESULTS The mean OOP payments before the HTP and after the first and third phases, respectively, were US$59.4, US$17.6, and US$14.3 in hospital affiliated to the Ministry of Health and Medical Education (MoHME), US$39.6, US$33.7, and US$13.7 in hospitals affiliated to Social Security Organization (SSO), and US$153.3, US$188.7, and US$66.4 in private hospitals. In hospitals affiliated to SSO and MoHME there was a significant difference between the mean OOP payments before the HTP and after the third phase (P<.05). The percentage of informal payments to physicians in hospitals affiliated to MoHME, SSO, and private sector, respectively, were 4.5%, 8.1%, and 12.5% before the HTP, and 0.0%, 7.1%, and 10.0% after the first phase. Contrary to the time before the HTP, no informal payment was reported after the third phase. CONCLUSION It seems that the implementation of the HTP has reduced the OOP payments for inpatient services and eradicated informal payments to physician in Kurdistan province.
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Affiliation(s)
- Bakhtiar Piroozi
- Department of Health Services Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Arash Rashidian
- Department of Health Services Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
- Knowledge Utilization Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Ghobad Moradi
- Social Determinants of Health Research Center, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - Amirhossein Takian
- Department of Global Health and Public Policy, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
- National Academy of Medical Sciences, Tehran, Iran
- College of Health and Life Sciences, Brunel University London, London, UK
| | - Hooman Ghasri
- Deputy of Treatment, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - Tayyeb Ghadimi
- Department of Surgery, Faculty of Medicine, Kurdistan University of Medical Sciences, Sanandaj, Iran
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Informal cash payments for birth in Hungary: Are women paying to secure a known provider, respect, or quality of care? Soc Sci Med 2017; 189:86-95. [DOI: 10.1016/j.socscimed.2017.07.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Revised: 07/09/2017] [Accepted: 07/20/2017] [Indexed: 01/09/2023]
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42
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Stepurko T, Pavlova M, Gryga I, Gaál P, Groot W. Patterns of informal patient payments in Bulgaria, Hungary and Ukraine: a comparison across countries, years and type of services. Health Policy Plan 2017; 32:453-466. [PMID: 27993960 DOI: 10.1093/heapol/czw147] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/23/2016] [Indexed: 11/12/2022] Open
Abstract
Informal payments for health care are a well-known phenomenon in many health care systems around the world. While informal payments could be an important source of health care financing, they have an adverse impact on efficiency and access to care, and are a major impediment to ongoing health care reforms. This paper aims to study the scale and patterns of informal patient payments for out-patient and in-patient services in three former-socialist countries: Bulgaria, Hungary and Ukraine. The data are collected in 2010 and 2011 based on national representative samples and are analysed in pooled models to explain variations in payments. The results of the cross-country comparison suggest a relatively higher prevalence of informal patient payments in Ukraine and Hungary than in Bulgaria, where patients also have to pay formal user charges in the public sector. Nevertheless, informal payments for hospitalization in Bulgaria are quite extensive. We observe some differences in informal payments across the years. Variations in payment size are mainly explained by the nature, type and need for services, fee awareness and, on some occasions, by household income. Interpreted within the context of structural differences (e.g. reform paths, regulations, funding, user fees, anti-corruption policies), the findings of our study have implications on how to address informal payments for health care.
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Affiliation(s)
- Tetiana Stepurko
- School of Public Health, National University of 'Kyiv-Mohyla Academy'; Ukraine, Skovorody street 2, Kiev, Ukraine.,Department of Health Services Research, CAPHRI, Maastricht University Medical Center, Faculty of Health, Medicine and Life Sciences, Maastricht University, The Netherlands
| | - Milena Pavlova
- Department of Health Services Research, CAPHRI, Maastricht University Medical Center, Faculty of Health, Medicine and Life Sciences, Maastricht University, The Netherlands
| | - Irena Gryga
- School of Public Health, National University of 'Kyiv-Mohyla Academy'; Ukraine, Skovorody street 2, Kiev, Ukraine
| | - Péter Gaál
- Faculty of Health and Public Services, Semmelweis University, Budapest, Hungary
| | - Wim Groot
- Department of Health Services Research, CAPHRI, Maastricht University Medical Center, Faculty of Health, Medicine and Life Sciences, Maastricht University, The Netherlands.,Top Institute Evidence-Based Education Research (TIER); Maastricht University, The Netherlands
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43
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Vafaei Najar A, Ebrahimipour H, Pourtaleb A, Esmaily H, Jafari M, Nejatzadegan Z, Taleghani YM. 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. BMC Health Serv Res 2017; 17:205. [PMID: 28292289 PMCID: PMC5351263 DOI: 10.1186/s12913-017-2108-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2016] [Accepted: 02/22/2017] [Indexed: 11/29/2022] Open
Abstract
Background Patient’s Informal payments is among the main source of health care financing in some countries. This paper aimed at determining the patient informal payments and relative factors in Cardiac Surgery Departments (CSD) in hospitals affiliated to Mashhad University of Medical Sciences (MUMS) in 2013. Methods In this cross-sectional study, 316 discharged patients were selected using multi-stage sampling. Data gathering tool was a questionnaire which was filled by structured telephone interviews. We used quantitative content analysis for open-ended questions besides descriptive statistics and nonparametric tests by SPSS 16 at 0.05 Sig level. Results Sixteen (5.93%) patients made voluntary informal payments. The purpose of payment was: “gratitude” (43.75%), satisfaction with health services provided” (31.25%) and (18.75%) for better quality of services. About 75% of the payments were occurred during receiving health care services. The main causes were “no request for informal payments” (98.14%), “not affording to pay for informal payments” (73.33%) and “paying the hospital expenses by taking out a loan” (55.91%). Responders said they would pay informally in demand situation (51.85%) just for patient’s health priority, 40.71% would also “search for other alternative solutions” and 27.33% “accepted the demand as a kind of gratitude culture”. Twenty four patients (8.9%) had experienced mandatory informal payments during the last 6 months. The minimum amount of payment was 62.5$ and the maximum was 3125$. There was a significant relationship between the way of referring to medical centers and informal patient's payment (P ≤0.05). Conclusion Despite the widespread prevalent belief about informal payments in public hospitals —particularly to the well-known physicians — such judgment cannot be generalized. The main reasons for the low informal payments in the current study were the personality characteristics of the physicians and hospital staff, their moral conscience and commitment to professional ethics, cultural factors and social-economic status of the patients. Health care system should notify people about their rights specially the payments calculation mechanism and methods. Better communication with the public and especially the media can help to correct attitude toward these payments.
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Affiliation(s)
- Ali Vafaei Najar
- Department of Management Sciences and Health Economics, School of Health, Social Determinants of Health Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Hossein Ebrahimipour
- Department of Management Sciences and Health Economics, School of Health, Social Determinants of Health Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Arefeh Pourtaleb
- Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran. .,School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran.
| | - Habibollah Esmaily
- Biostatics and Epidemiology Department, School of Health, Social Determinants of Health Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mehdi Jafari
- Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran.,School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Zohre Nejatzadegan
- Department of Management Sciences and Health Economics, School of Health, Social Determinants of Health Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Yasamin Molavi Taleghani
- Health Management and Economics Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
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Stepurko T, Pavlova M, Groot W. Overall satisfaction of health care users with the quality of and access to health care services: a cross-sectional study in six Central and Eastern European countries. BMC Health Serv Res 2016; 16:342. [PMID: 27485751 PMCID: PMC4971706 DOI: 10.1186/s12913-016-1585-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 07/27/2016] [Indexed: 01/17/2023] Open
Abstract
Background The measurement of consumer satisfaction is an essential part of the assessment of health care services in terms of service quality and health care system responsiveness. Studies across Europe have described various strategies health care users employ to secure services with good quality and quick access. In Central and Eastern European countries, such strategies also include informal payments to health care providers. This paper analyzes the satisfaction of health care users with the quality of and access to health care services. The study focuses on six Central and Eastern European countries (Bulgaria, Hungary, Lithuania, Poland, Romania and Ukraine). Methods We use data on past experience with health care use collected in 2010 through uniform national surveys in these countries. Based on these data, we carry out a multi-country analysis to investigate factors associated with the satisfaction of health care users in the six countries. Results The results indicate that about 10-14 % of the service users are not satisfied with the quality of, or access to health care services they used in the preceding year. However, significant differences across countries and services are observed, e.g. the highest level of dissatisfaction with access to outpatient services (16.4 %) is observed among patients in Lithuania, while in Poland, the level of dissatisfaction with quality of outpatient and inpatient services are much lower than dissatisfaction with access. The study also analyses the association of users’ satisfaction with factors such as making informal payments, inability to pay and relative importance of service attributes stated by the service users. Conclusions These multi-country findings provide evidence for health policy making in the Central and Eastern European countries. Although the average rates of satisfactions per country are relatively high, the results suggest that there is ample room for improvements. Specifically, many service-users still report dissatisfaction especially those who pay informally and those unable to pay. The high shares of informal payments and inability of users to deal with the health expenditures lead to doubts about the fairness of the health care provision in Central and Eastern Europe. There is an urgent need for policy makers in the region to not only acknowledge but also to effectively address this key problem. Electronic supplementary material The online version of this article (doi:10.1186/s12913-016-1585-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Tetiana Stepurko
- School of Public Health, National University of Kyiv-Mohyla Academy, Kyiv, Ukraine.
| | - Milena Pavlova
- Department of Health Services Research, CAPHRI, Maastricht University Medical Center, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Wim Groot
- Department of Health Services Research, CAPHRI, Maastricht University Medical Center, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands.,Topinstitute Evidence-Based Education Research (TIER), Maastricht University, Maastricht, The Netherlands
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45
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Antonova N. Access to Healthcare in Russia: A Pilot Study in Ekaterinburg. Cent Eur J Public Health 2016; 24:152-5. [PMID: 27434248 DOI: 10.21101/cejph.a3942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Accepted: 03/01/2016] [Indexed: 11/15/2022]
Abstract
AIM The aim of the study was to analyze accessibility of medical assistance in Russian polyclinics (a case study of the city of Ekaterinburg). METHODS The research included an anonymous survey of patients in five polyclinics of Ekaterinburg (N=500) conducted by applying a specially developed standardised interview. RESULTS The following factors of medical care accessibility were analyzed: the patient's financial status and administrative and managerial resources of medical institutions. Medical aid in polyclinics is provided within the framework of the Compulsory Medical Insurance Programme. 72% of the patients polled, however, had to pay for medical services. In order to pay less for medical services and to obtain services faster patients use informal payments: they either pay their doctors directly (4%) or make gifts (58%). Low-income population groups refuse to pay for medical services or to make gifts to the medical staff. They also tend not to follow their doctors' recommendations. The most significant indicators of the organizational and managerial work of a medical institution which limit accessibility are the following: queues in front of doctors' offices (41%) and difficulties with making appointments (17%). CONCLUSIONS To solve the problem of medical aid accessibility in the Russian state healthcare system, it is necessary to develop information and reference materials for patients available in every polyclinic listing the terms of provision of free medical aid and types of free medical services. The difficulties to obtain medical services could be resolved at the management level by using the material and human resources of the administration of medical institutions.
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Affiliation(s)
- Natalia Antonova
- Institute for Social and Political Sciences, Ural Federal University, named after the first President of Russia Boris Yeltsin, Ekaterinburg, Russia
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46
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Souliotis K, Golna C, Tountas Y, Siskou O, Kaitelidou D, Liaropoulos L. Informal payments in the Greek health sector amid the financial crisis: old habits die last.. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2016; 17:159-170. [PMID: 25644967 DOI: 10.1007/s10198-015-0666-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Accepted: 01/05/2015] [Indexed: 06/04/2023]
Abstract
BACKGROUND Under-the-table informal payments are commonplace as reimbursements for health care services in Greece. As the country faces a severe financial crisis, the need to investigate the extent of such payments, their incidence and their impact on household income is pressing. METHODS A survey of 2,741 persons from across the country was conducted between December 2011 and February 2012. The sample was defined via a multistage selection process using a quota for municipality of residence, sex and age. The maximum error margin was 2.41% with a confidence interval of 95%. RESULTS The survey reports under-the-table payments for approximately 32.4% of public hospital admissions. Private clinics, which display the bulk of out-of-pocket payments, naturally display the lowest under-the-table payments. The highest percentage of under-the-table payments in the private sector appears at visits to private practitioners and dentists (36%). Informal payments are most frequently made upon request, prior to service provision, to facilitate access to care and to reduce waiting times, and at a much lower percentage, to post-service provision, and out of gratitude. CONCLUSIONS This survey reveals that, due to severe financial pressure, there is a growing unwillingness of citizens to pay informally and an increasing demand for these payments as a prerequisite for access to services or to redeem services provided. This "hidden" financial burden of at least 27% impacts negatively on the living conditions of households and is not reported as purchasing ability or cost of living.
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Affiliation(s)
- Kyriakos Souliotis
- Faculty of Social and Political Sciences, University of Peloponnese, Corinth, Greece.
- Centre for Health Services Research, Medical School, National and Kapodistrian University of Athens, Athens, Greece.
| | - Christina Golna
- Centre for Health Services Research, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Yannis Tountas
- Centre for Health Services Research, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Olga Siskou
- Centre for Health Services Management and Evaluation, National and Kapodistrian University of Athens, 123 Papadiamantopoulou str., 11527, Athens, Greece.
| | - Daphne Kaitelidou
- Centre for Health Services Management and Evaluation, National and Kapodistrian University of Athens, 123 Papadiamantopoulou str., 11527, Athens, Greece
| | - Lycourgos Liaropoulos
- Centre for Health Services Management and Evaluation, National and Kapodistrian University of Athens, 123 Papadiamantopoulou str., 11527, Athens, Greece
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Abstract
While corruption has been at the center of academic studies and on the agenda of international organizations for a couple of decades, in the health care sector corruption has not generated much interest or progress. At the centre of this issue is the lack of an interdisciplinary approach, which is warranted given the complexity of the issue and the lack of cooperation between STET scientifically rigorous academics and policy-makers, leaving room for more cooperation and progress.
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Affiliation(s)
- Dagmar Radin
- Associate Professor, Faculty of Political Science, University of Zagreb, Croatia
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48
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Hope KR. Contextualizing Corruption in the Health Sector in Developing Countries: Reflections on Policy to Manage the Risks. WORLD MEDICAL & HEALTH POLICY 2015. [DOI: 10.1002/wmh3.165] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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49
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Arsenijevic J, Pavlova M, Groot W. Out-of-pocket payments for health care in Serbia. Health Policy 2015; 119:1366-74. [DOI: 10.1016/j.healthpol.2015.07.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Revised: 03/02/2015] [Accepted: 07/19/2015] [Indexed: 11/26/2022]
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Vian T, Feeley FG, Domente S, Negruta A, Matei A, Habicht J. Barriers to universal health coverage in Republic of Moldova: a policy analysis of formal and informal out-of-pocket payments. BMC Health Serv Res 2015; 15:319. [PMID: 26260324 PMCID: PMC4531477 DOI: 10.1186/s12913-015-0984-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Accepted: 08/02/2015] [Indexed: 11/25/2022] Open
Abstract
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.
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Affiliation(s)
- Taryn Vian
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown Building 3rd floor, Boston, MA, 02118, USA.
| | - Frank G Feeley
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown Building 3rd floor, Boston, MA, 02118, USA.
| | - Silviu Domente
- World Health Organization Country Office in Republic of Moldova, Sfatul Tarii Str. 29, MD-2012, Chisinau, Republic of Moldova.
| | - Ala Negruta
- National Bureau of Statistics, 106 Grenoble Str., MD-2019, Chisinau, Republic of Moldova.
| | - Andrei Matei
- World Health Organization Country Office in Republic of Moldova, Sfatul Tarii Str. 29, MD-2012, Chisinau, Republic of Moldova.
| | - Jarno Habicht
- World Health Organization Country Office in Republic of Moldova, Sfatul Tarii Str. 29, MD-2012, Chisinau, Republic of Moldova.
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