Rethinking informal payments by patients in Europe: An institutional approach

Equal waiting times for all? Empirical evidence for elective surgeries in the Austrian public healthcare system

OBJECTIVES

This study analyses waiting times for elective surgeries and potential determinants, including supplementary private health insurance, visits in the operating physician's private practice and informal payments for faster treatment.

STUDY DESIGN

Retrospective patient questionnaire survey.

METHODS

The survey was conducted in eleven Austrian rehabilitation centres in 2019. Data was analysed based on bivariate tests (n = 400) and a multivariate negative-binomial regression model (n = 310) with institution- and patient-related characteristics as independent variables.

RESULTS

Median waiting times were 8.9 weeks (IQR: 4.5-18.0) for hip replacement and 8.4 weeks (IQR: 5.0-20.0) for knee replacement surgery. 10.9% of the patients reported having received an offer to shorten their waiting time through a visit in the operating physician's private practice before the surgery or through an informal payment directly to the operating physician. Surgery in private for-profit hospitals, supplementary private health insurance and severe pain were associated with shorter waiting times.

CONCLUSIONS

While waiting times for elective surgeries in Austria are below international levels, shorter waits for patients with private health insurance and offers to reduce waiting times through informal payments point to equitable access concerns in a public healthcare system.

Informal payments by patients, institutional trust and institutional asymmetry

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

The Companion Pandemic to COVID-19: The Use of Informal Practices to Access Public Healthcare Services in the European Union

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.

Corruption In Health Care Systems: Trends In Informal Payments Across Twenty-Eight EU Countries, 2013-19

Corruption is a major challenge in health care systems across the European Union (EU), where it manifests most visibly as informal payments from patients to providers. A higher prevalence of informal payments has been associated with lower public health care expenditure. EU member states have experienced significant changes in public health care expenditure throughout the 2000s. Given the lack of research on the topic, we explored trends in informal payments using representative data from twenty-eight EU member states during the period 2013-19 and in relation to changes in public health care expenditure. Overall, we found that informal payments increased in 2019 compared with 2013, whereas the perception of corruption decreased. Although higher public health care expenditure was associated with less corruption, we found a smaller effect size between informal payments and this expenditure throughout the study period. Our results suggest that informal payments may be driven by other factors, although the directionality of this relationship requires further investigation. Moreover, additional public health care investments may be insufficient to confront corruption unless coupled with measures to limit wasteful spending and increase transparency. Policy makers should understand that factors external to health systems, including media coverage and cultural and political factors, should be explored to explain country-level differences in corruption.

Corruption in the health sector: A problem in need of a systems-thinking approach

Health systems are comprised of complex interactions between multiple different actors with differential knowledge and understanding of the subject and system. It is exactly this complexity that makes it particularly vulnerable to corruption, which has a deleterious impact on the functioning of health systems and the health of populations. Consequently, reducing corruption in the health sector is imperative to strengthening health systems and advancing health equity, particularly in low- and middle-income countries (LMICs). Although health sector corruption is a global problem, there are key differences in the forms of and motivations underlying corruption in health systems in LMICs and high-income countries (HICs). Recognizing these differences and understanding the underlying system structures that enable corruption are essential to developing anti-corruption interventions. Consequently, health sector corruption is a problem in need of a systems-thinking approach. Anti-corruption strategies that are devised without this understanding of the system may have unintended consequences that waste limited resources, exacerbate corruption, and/or further weaken health systems. A systems-thinking approach is important to developing and successfully implementing corruption mitigation strategies that result in sustainable improvements in health systems and consequently, the health of populations.

Trends in Informal Payments by Patients in Europe: A Public Health Policy Approach

Background: A new institutional approach toward informal payments in healthcare views informal payments as arising when there is a misalignment between values/norms (informal institutions) and the formal rules (formal institutions) of patients. However, less knowledge is available on the effectiveness of this approach in tackling informal payments in healthcare. This study aimed to fill this gap by evaluating the trends in the effect of institutional misalignment on informal payments made by patients. Methods: A quantitative study design with data extracted from the last three waves of special Eurobarometer surveys on corruption was used to model the propensity of European patients in 27 European Union countries and the United Kingdom to make informal payments. Multilevel logistic regression analysis was employed in order to test the relationship between the formal-informal institution misalignment and the likelihood to make informal payments. Sensitivity analyses were also performed to test the robustness of the findings. Results: The finding is that there is a strong association between the formal-informal institution misalignment and the likelihood to make informal payments for public healthcare services. Similarly, social norms play a pivotal role. When patients perceive that informal practices are widespread in the public healthcare sector they are more likely to make informal payments themselves. Conclusion: The outcome is a call for complementing deterrence measures toward informal payments in healthcare with measures aiming to reduce the formal-informal institution misalignment and to change the social norms. This can be achieved by improving the structural conditions at country level and by changing values/norms and beliefs of patients.

Institutional Determinants of Informal Payments for Health Services: An Exploratory Analysis across 117 Countries

Healthcare accessibility and equity remain important issues, as corruption in the form of informal payments is still prevalent in many countries across the world. This study employs a panel data analysis over the 2006-2013 period to explore the role of different institutional factors in explaining the prevalence of informal payments. Covering 117 countries, our findings confirm the significant role of both formal and informal institutions. Good governance, a higher trust among individuals, and a higher commitment to tackling corruption are associated with diminishing informal payments. In addition, higher shares of private finance, such as out-of-pocket and domestic private health expenditure, are also correlated with a lower prevalence of informal payments. In policy terms, this displays how correcting institutional imperfections may be among the most efficient ways to tackle informal payments in healthcare.

Knowing and Unknowing Purchases of Undeclared Healthcare Goods and Services: The Role of Vertical and Horizontal Trust

Although major advances have been made in relation to explaining the supply side of the informal economy, this is not the case for the demand-side of the informal economy. This study analyses for the first time the purchasers of undeclared goods and services in the healthcare sector. To evaluate the purchase of undeclared healthcare goods and services, logistic regression analysis and robustness tests are used on 3048 interviews in Cyprus, Greece, Italy and Malta. The finding is that an important share of the purchasers make this type of purchase unknowingly. However, no difference in terms of socio-economics characteristics of those who knowingly and those who unknowingly made purchases of undeclared healthcare goods and services was identified. Meanwhile a significant influence of trust (in government and in other citizens) has been identified in relation to those who made these purchases knowingly. As such, policy measures aimed at decreasing unknowing purchases and at nurturing trust are discussed in the concluding section.

Unpacking the red packets: institution and informal payments in healthcare in China

Informal cash payments from patient to healthcare providers for services provided by the healthcare system have attracted increasing scholarly interest. However, the root and mechanism of informal payments are not well understood. This paper contributes to the literature by positing informal payments as informal institutions. We use a nationally representative longitudinal survey in 28 provinces in China to explore the root of informal payments. Our empirical findings suggest that patients' informal payments for healthcare services may originate from information acquisition and processing, failure of government and market in allocating healthcare resources, and disparities in utilization. Further, this informal institution could be changed by the self-reinforcement of individual patients. These findings suggest that policies to facilitate transparency and to remove institutional barriers, such as the introduction of market competition, may reduce the incidence of informal payments.

Informal Payments by Patients in Central and Eastern Europe during the COVID-19 Pandemic: An Institutional Perspective

Confronted with a global pandemic, public healthcare systems are under pressure, making access to healthcare services difficult for patients. This provides fertile ground for using illegal practices such as informal payments to gain access. This paper aims to evaluate the use of informal payments by patients during the COVID-19 pandemic and the institutions that affect the prevalence of this practice. Various measurements of formal and informal institutions are here investigated, namely the acceptability of corruption, the level of trust, transparency, and performance of the healthcare system. To do so, a logistic regression of 10,859 interviews with patients conducted across 11 Central and Eastern Europe countries in October-December 2020 is employed. The finding is that there are large disparities between countries in the prevalence of informal payments, and that the practice is more likely to occur where there are poorer formal and informal institutions, namely higher acceptability of corruption, lower trust in authorities, lower perceived transparency in handling the COVID-19 pandemic, difficult access to, and poor quality of, healthcare services, and higher mortality rates due to the COVID-19 pandemic. These findings suggest that policy measures for tackling informal payments need to address the current state of the institutional environment.

Explaining consumer motives to purchase in the informal economy

Usually, studies on the informal economy focus mainly upon those working in the informal economy (supply side). However, many exchanges in the informal economy are initiated by purchasers asking how much a good or service costs if paid cash in hand. Therefore, the aim of this paper is to advance understanding of who make purchases in the informal economy and the reasons of the consumers making these purchases (demand side). Two potential explanations are evaluated. Firstly, consumers are explained as rational economic actors seeking a more convenient deal or profit maximisation (i.e., lower price or better value for money), making purchases from the informal economy due to the lack of availability of the product or service they need on the formal market, or they make such purchases involuntarily, due to the lack of perfect information necessary to make a fully rational economic decision when purchasing. Secondly, the consumers are portrayed as social actors pursuing community help. Using a multilevel mixed-effects logistic regression analysis on a 2019 Eurobarometer interviews in 27 EU member states and the UK reveal how the prevalence of these motives significantly varies across populations and regions. The theoretical and policy implications of the findings are discussed in the concluding section.

The problematic place of private payment for healthcare in Australia

Private funding and private hospital provision play a key role in Australian healthcare. However, this role is inherently inequitable, creating a two-speed health system. Canada should avoid expanding private involvement in paying for healthcare.

Does health insurance coverage reduce informal payments? Evidence from the "red envelopes" in China

BACKGROUND

Representing a major threat to both equity and efficiency of health systems, the corrupt practice of informal payments is widely found in developing and transition countries. As informal payments are more likely to occur in health systems characterized by a high out-of-pocket payment rate, it is argued that formalized prepaid health insurance programs may help to curb such practice.

METHODS

Using panel data from the China Health and Retirement Longitudinal Survey, this study examined the association between changes in health insurance coverage on patient's behavior proxied with informal payments.

RESULTS

The statistical results reveal that health insurance status in fact increases the probability of patients making informal payments to physicians. However, this association varies among population groups and insurance programs, particularly between social health insurance and private health insurance status.

CONCLUSIONS

In a health system characterized by unequal allocation of medical resources, the dual pursuit of cost saving and quality of care may drive patients to make informal payments for personal gains. This study argues that health policy interventions aimed at curbing informal payments must be based on a thorough understanding of their complex socioeconomic causes and attack the perverse incentives in a coherent and bona fide manner.

Health system factors and caesarean sections in Kosovo: a cross-sectional study

OBJECTIVE

To investigate the association of caesarean section rates with the health system characteristics in the public hospitals of Kosovo.

DESIGN

Cross-sectional survey.

SETTING

Five largest public hospitals in Kosovo.

PARTICIPANTS

859 women with low-risk deliveries who delivered from April to May 2015 in five public hospitals in Kosovo.

OUTCOME MEASURES

The prespecified outcomes were the crude and adjusted OR of births delivered with caesarean section by health system characteristics such as delivery by the physician who provided antenatal care, health insurance status and other. Additional prespecified outcomes were caesarean section rates and crude ORs for delivery with caesarean in each public hospital.

RESULTS

Women with personal monthly income had increased odds for caesarean (OR 1.55, 95% CI 1.06 to 2.27), as did women with private health insurance coverage (OR 3.44, 95% CI 1.20 to 9.85). Women instructed by a midwife on preparation for delivery had decreasing odds (OR 0.32, 95% CI 0.19 to 0.51) while women having preference for a caesarean had increasing odds for delivery with caesarean (OR 3.84, 95% CI 1.96 to 7.51). The odds for caesarean increased also in the case of delivery by a physician who provided antenatal care (OR 2.06, 95% CI 1.16 to 3.67) and delivery during office hours (OR 2.36, 95% CI 1.37 to 4.05), while delivery at the University Clinical Centre of Kosovo decreased the odds for caesarean (OR 0.46, 95% CI 0.24 to 0.90).

CONCLUSIONS

We found that several health system characteristics are associated with the increase of caesarean sections in a low-risk population of delivering women in public hospitals of Kosovo. These findings should be explored further and addressed via policy measures that would tackle provision of unnecessary caesareans. The study findings could assist Kosovo to develop corrective policies in addressing overuse of caesareans and may provide useful information for other middle-income countries.