1
|
Yahyavi Dizaj J, Khoramrooz M, Ramezani-Doroh V, Rezaei S, Hashempour R, Irandoust K, Soltani S, Kazemi-Karyani A. Socioeconomic inequality in informal payments for health services among Iranian households: a national pooled study. BMC Public Health 2023; 23:381. [PMID: 36823578 PMCID: PMC9948334 DOI: 10.1186/s12889-023-15071-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 01/17/2023] [Indexed: 02/25/2023] Open
Abstract
BACKGROUND There is limited evidence on the prevalence and socioeconomic inequality in informal payments (IP) of households in the Iranian health system. This study was conducted to investigate the prevalence of IP and related socioeconomic inequalities among Iranian households in all provinces. METHOD Data on Household Income and Expenditure Surveys (HIES) for 91,360 households were used to examine the prevalence and inequality in informal health sector payments in the years 2016 to 2018. The Normalized Concentration Index (NC) was used to examine inequality in these payments and the decomposition analysis by the Wagstaff approach was used to determine the share of variables affecting the measured inequality. RESULTS Of the total households, 7,339 (7.9%) reported IP for using health services. Urban households had higher IP (10%) compared to rural ones (5.42%). Also, the proportion of households with IP in 2016 (11.69%) was higher than in 2017 (9.9%), and 2018 (4.60%). NC for the study population was 0.129, which shows that the prevalence of IP is significantly higher in well-off households. Also, NC was 0.213 (p < 0.0001) and -0.019 for urban and rural areas, respectively (p > 0.05). Decomposition analysis indicated that income, sex of head of household, and the province of residence have the highest positive contribution to measured inequality (with contributions of 156.2, 45.8, and 25.6%, respectively). CONCLUSION There are a significant prevalence and inequality in IP in Iran's health system and important variables have shaped it. On the whole, inequality was pro-rich. This may lead to increasing inequality in access to quality services in the country. Our findings showed that previous health policies such as regulatory tools, and the health transformation plan (HTP) have not been able to control IP in the health sector in the desired way. It seems that consumer-side policies focusing on affluent households, and high-risk provinces can play an important role in controlling this phenomenon.
Collapse
Affiliation(s)
- Jafar Yahyavi Dizaj
- grid.412112.50000 0001 2012 5829Research Center for Environmental Determinants of Health, Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Maryam Khoramrooz
- grid.411950.80000 0004 0611 9280Department of Health Management and Economics, School of Public Health, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Vajihe Ramezani-Doroh
- grid.411950.80000 0004 0611 9280Department of Health Management and Economics, School of Public Health, Hamadan University of Medical Sciences, Hamadan, Iran ,grid.411950.80000 0004 0611 9280Modeling of Noncommunicable Diseases Research Center, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Satar Rezaei
- grid.412112.50000 0001 2012 5829Research Center for Environmental Determinants of Health, Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Reza Hashempour
- Office in Treatment Affairs, Esfarayen Faculty of Medical Sciences, Esfarayen, Iran
| | - Kamran Irandoust
- grid.411746.10000 0004 4911 7066Department of Health Economics, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Shahin Soltani
- grid.412112.50000 0001 2012 5829Research Center for Environmental Determinants of Health, Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Ali Kazemi-Karyani
- Research Center for Environmental Determinants of Health, Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran.
| |
Collapse
|
2
|
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.
Collapse
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
| |
Collapse
|
3
|
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.
Collapse
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
| |
Collapse
|
4
|
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.
Collapse
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
| | | |
Collapse
|