Informal payments by patients for health services: prevalence and determinants

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.

Reasons for informal payments from the perspective of health care providers and recipients: a qualitative study in Iran

Background

Informal payments are one of the major obstacles to health system reform in many developing countries, and its elimination is on the agenda of health system policymakers in many countries, including Iran. This study was conducted to identify the causes of informal payments in the Iranian health system.

Methods

This was a qualitative and exploratory study. The study environment included the Ministry of Health, physicians' offices, medical universities, and hospitals and health centers. The study population included health care providers (physicians and hospital staff, managers, supervisors, and nurses) and health care recipients (patients or patients who had a history of dealing with informal payments). Data were collected using open-ended questions and semi-structured interviews. Snowball sampling method was used to select managers, chief executive officers (CEOs) and nurses. Convenience sampling was used to select physicians due to their lack of participation and cooperation. Content analysis method was used to analyze the data.

Results

Reasons for informal payments were divided into 4 themes including: Economic factors (improper tariff valuation of services; failure to increase tariffs proportionate to inflation; lack of comprehensive participation of stakeholders in determining tariffs; tariff inconsistency in the public, private and charity sectors; etc.); socio-cultural factors (decreased social capital of the medical community among the people; improving the quality of life; incorrect comparison of providers' income levels with the income of doctors in other countries; existence of a culture of gratitude and appreciation; health as a priority for society; pride of service recipients; pride of service providers; etc.); service delivery challenges (high professional skills of the doctor; use of modern medical equipment; the monopoly of some doctors, etc.) and legal-political factors (inadequate monitoring by upstream organizations; lack of strict rules; difficulty of proving informal payments; presence of stakeholders in management and policy making processes).

Conclusions

Knowing the causes of informal payments can help reduce or eliminate it. The results of this study identified the causes of informal payments in the Iranian health system. Accurate knowledge of the needs and motivations of both health care providers and recipients can be effective in accurately identifying and eliminating this phenomenon.

The red packet phenomenon from the perspective of young Chinese doctors: a questionnaire study

Background

In China, informal payments in the medical profession, which workers in the public health care system receive from patients in the course of performing profession-related activities, are usually referred to as “red packets” (Hongbao 红包). The phenomenon of red packets is widespread and has become one of the most negative factors affecting the doctor-patient relationship in China. Our study aims to explore the situation concerning the phenomenon of red packets in China after the “Red Packet Ban”.

Methods

A questionnaire was developed including general demographic characteristics, asking whether they had ever been offered red packets, whether they had ever accepted red packets, their reasons for accepting the first red packet and so on. We recruited a total of 413 doctors to complete this questionnaire and conducted in-depth telephone interviews with 18 doctors from the initial group.

Results

Our data shows that 73 doctors claimed to have accepted red packets, accounting for 17.7% (73/413) of all respondents and 27.8% (73/263) of doctors who had been provided with red packets. 23.2% of red packets were offered after the operation and 67.1% of the doctors declared that the main reason for accepting the red packet was that they “refused the red packets more than once, but the patients/family members were sincere and it was difficult to refuse.” The total amount of the red packets they received each month accounted for no more than 5% of their income.

Conclusions

(1) The acceptance of red packets does exist among young doctors in China, but shows a significant decrease compared to previous studies. (2) There has been a sharp rise in the proportion of gratitude red packets. (3) Patients should also be educated regarding their behaviour in providing red packets.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12910-022-00793-w.

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.

A comparison using standardized measures for patients with irritable bowel syndrome: Trust in the gastroenterologist and reliance on the internet

BACKGROUND

Irritable bowel syndrome (IBS) patients' use of the Internet for health information interacts with the way they trust their gastroenterologist. No standardized measure has targeted IBS patients and gastroenterologists specifically, nor their use of the Internet. The aims of this paper were as follows: the development of a scale that measures an IBS patient's trust in their gastroenterologist, the development of a scale measuring an IBS patient's reliance on Internet health information, and testing the hypothesis that IBS patients, who use the Internet for IBS-related information, trust their gastroenterologist less than those who do not.

METHOD

A total of 82 patients (mean age 49, SD = 14.62) diagnosed with IBS completed two questionnaires: one about trust in their gastroenterologist and the other about the reliance on Internet health information regarding IBS. The two questionnaires were built using current literature as well as our previous qualitative research. The statistical computations were performed using the SPSS 20 program.

KEY RESULTS

Both questionnaires proved to be reliable in measuring gastroenterologist-IBS patient trust (alpha = 0.87) and Internet information reliance (alpha = 0.88), respectively. The IBS patients who did not look for information about IBS over the Internet had significantly higher trust in their gastroenterologist compared with those who did (U = 535.5; z = -2.26; P < 0.05).

CONCLUSIONS

We developed two ready-to-use scales to measure both the gastroenterologist-IBS patient's trust and the IBS patient's reliance on the Internet. Further studies will be able to explore the interaction among all variables in IBS patients' trust.

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.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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