Informal payments in health facilities in Peru in 2018: Analysis of a cross-sectional survey

BACKGROUND

The Latin American region demonstrates the lowest levels of trust in health systems globally. Institutional corruption is a major factor in eroding trust. Corruption in health services, including extracting bribes and informal payments from patients, directly harms health outcomes and weakens services intended as public goods. In this study, we aim to characterize the frequency and distribution of informal payments within public health services in Peru.

METHODS

We conducted a secondary analysis of a nationally representative cross-sectional survey, the 2018 National Household Survey of Living Conditions and Poverty, and identified all individuals reporting health insurance from the Ministry of Health (SIS-MINSA) or Social Security (ESSALUD). We defined self-reported informal payments in 2 ways: 1) being asked to pay a bribe at a health establishment in the past year (direct method), and 2) creating an overall indicator for non-zero cost of care for services that should be free (indirect method). We used descriptive statistics to quantify informal payments and bivariate analysis to identify sociodemographic characteristics of those most frequently reporting such payments.

FINDINGS

132,355 people were surveyed, including 69,839 (52.8%) with coverage from SIS-MINSA and 30,461 (23.03%) from ESSALUD. Less than 1% of participants directly reported informal payments, either at SIS-MINSA services (0.22%); or at ESSALUD (0.42%). Indirect reporting was more prevalent, including up to 10% of surgery patients and 17% of those hospitalized in SIS-MINSA facilities. Wealthier patients (19%) were more likely to report such payments.

INTERPRETATION

While direct reporting of bribery was uncommon, we found moderate prevalence of informal payments in public health services in Peru using an indirect assessment method. Indirect reporting may exceed direct reporting due to difficulty in distinguishing appropriate and inappropriate payments, fear of reporting health care workers' behavior, or social tolerance of informal payments. Informal payments were more common among those with greater financial capital, indicating they may obtain enhanced services. Further research on patients' perception and reporting of informal payments is a key step towards accurate measurement and evidence-based intervention.

A systematic review of population and patient perspectives and experiences as measured in Latin American and Caribbean surveys

High-quality health systems must provide accessible, people-centred care to both improve health and maintain population trust in health services. Furthermore, accurate measurement of population perspectives is vital to hold health systems accountable and to inform improvement efforts. To describe the current state of such measures in Latin America and the Caribbean (LAC), we conducted a systematic review of facility and population-based assessments that included patient-reported experience and satisfaction measures. Five databases were searched for publications on quantitative surveys assessing healthcare quality in Spanish- or Portuguese-speaking LAC countries, focusing on the domains of processes of care and quality impacts. We included articles published since 2011 with a national sampling frame or inclusion of multiple subnational regions. We tabulated and described these articles, identifying, classifying and summarizing the items used to assess healthcare quality into the domains mentioned earlier. Of the 5584 publications reviewed, 58 articles met our inclusion criteria. Most studies were cross-sectional (95%), assessed all levels of healthcare (57%) and were secondary analyses of existing surveys (86%). The articles yielded 33 unique surveys spanning 12 LAC countries; only eight of them are regularly administered surveys. The most common quality domains assessed were satisfaction (in 33 out of 58 articles, 57%), evidence-based/effective care (34%), waiting times (33%), clear communication (33%) and ease of use (31%). Items and reported ratings varied widely among instruments used, time points and geographical settings. Assessment of patient-reported quality measures through population- and facility-based surveys is present but heterogeneous in LAC countries. Satisfaction was measured frequently, although its use in accountability or informing quality improvement is limited. Measurement of healthcare quality in LAC needs to be more systematic, regular, comprehensive and to be led collaboratively by researchers, governments and policymakers to enable comparison of results across countries and to effectively inform policy implementation.

Women's report of mistreatment during facility-based childbirth: validity and reliability of community survey measures

Background

Accountability for mistreatment during facility-based childbirth requires valid tools to measure and compare birth experiences. We analyse the WHO ‘How women are treated during facility-based childbirth’ community survey to test whether items mapping the typology of mistreatment function as scales and to create brief item sets to capture mistreatment by domain.

Methods

The cross-sectional community survey was conducted at up to 8 weeks post partum among women giving birth at hospitals in Ghana, Guinea, Myanmar and Nigeria. The survey contained items assessing physical abuse, verbal abuse, stigma, failure to meet professional standards, poor rapport with healthcare workers, and health system conditions and constraints. For all domains except stigma, we applied item-response theory to assess item fit and correlation within domain. We tested shortened sets of survey items for sensitivity in detecting mistreatment by domain. Where items show concordance and scale reliability ≥0.60, we assessed convergent validity with dissatisfaction with care and agreement of scale scores between brief and full versions.

Results

2672 women answered over 70 items on mistreatment during childbirth. Reliability exceeded 0.60 in all countries for items on poor rapport with healthcare workers and in three countries for items on failure to meet professional standards; brief scales generally showed high agreement with longer versions and correlation with dissatisfaction. Brief item sets were ≥85% sensitive in detecting mistreatment in each country, over 90% for domains of physical abuse and health system conditions and constraints.

Conclusion

Brief scales to measure two domains of mistreatment are largely comparable with longer versions and can be informative for these four distinct settings. Brief item sets efficiently captured prevalence of mistreatment in the five domains analysed; stigma items can be used and adapted in full. Item sets are suitable for confirmation by context and implementation to increase accountability and inform efforts to eliminate mistreatment during childbirth.

Advances in the measurement of coverage for RMNCH and nutrition: from contact to effective coverage

Current methods for measuring intervention coverage for reproductive, maternal, newborn, and child health and nutrition (RMNCH+N) do not adequately capture the quality of services delivered. Without information on the quality of care, it is difficult to assess whether services provided will result in expected health improvements. We propose a six-step coverage framework, starting from a target population to (1) service contact, (2) likelihood of services, (3) crude coverage, (4) quality-adjusted coverage, (5) user-adherence-adjusted coverage and (6) outcome-adjusted coverage. We support our framework with a comprehensive review of published literature on effective coverage for RMNCH+N interventions since 2000. We screened 8103 articles and selected 36 from which we summarised current methods for measuring effective coverage and computed the gaps between ‘crude’ coverage measures and quality-adjusted measures. Our review showed considerable variability in data sources, indicator definitions and analytical approaches for effective coverage measurement. Large gaps between crude coverage and quality-adjusted coverage levels were evident, ranging from an average of 10 to 38 percentage points across the RMNCH+N interventions assessed. We define effective coverage as the proportion of individuals experiencing health gains from a service among those who need the service, and distinguish this from other indicators along a coverage cascade that make quality adjustments. We propose a systematic approach for analysis along six steps in the cascade. Research to date shows substantial drops in effective delivery of care across these steps, but variation in methods limits comparability of the results. Advancement in coverage measurement will require standardisation of effective coverage terminology and improvements in data collection and methodological approaches.

Impact of expanded antiretroviral use on incidence and prevalence of tuberculosis in children with HIV in Kenya

SETTING

Antiretroviral therapy (ART) reduces pulmonary tuberculosis (PTB) in human immunodeficiency virus (HIV) infected children. Recent ART recommendations have increased the number of children on ART.

OBJECTIVE

To determine the prevalence and incidence of TB in HIV-infected children after the implementation of expanded ART guidelines.

DESIGN

A prospective cohort study including HIV-infected children aged 6 weeks to 14 years was conducted in Kenya. The primary outcome measure was clinically diagnosed TB. Study participants were screened for prevalent TB at enrollment using Kenya's national guidelines and followed at monthly intervals to detect incident TB. Predictors of TB were assessed using logistic regression and Cox proportional hazards regression.

RESULTS

Of 689 participants (median age 6.4 years), 509 (73.9%) were on ART at baseline. There were 51 cases of prevalent TB (7.4%) and 10 incident cases, with over 720.3 child-years of observation (incidence 1.4 per 100 child-years). Months on ART (adjusted hazard ratio [aHR] 0.91, P = 0.003; aOR 0.91, P< 0.001) and months in care before ART (aHR 0.87, P= 0.001; aOR 0.92, P < 0.001) were protective against incident and prevalent TB.

CONCLUSIONS

ART was protective against TB in this cohort of HIV-infected children with high levels of ART use. Optimal TB prevention strategies should emphasize early ART in children.

Social participation and drug use in a cohort of Brazilian sex workers

BACKGROUND

Structural interventions focused on community mobilisation to engender an enabling social context have reduced sexual risk behaviours among sex workers. Interventions to date have increased social participation and shown an association between participation and safer sex. Social participation could modify risk for other health behaviours, particularly drug use. We assessed social participation and drug use before and after implementation of a clinical, social and structural intervention with sex workers intended to prevent sexually transmitted infections/HIV infection.

METHODS

We followed 420 sex workers participating in the Encontros intervention in Corumbá, Brazil, between 2003 and 2005. We estimated the association of participation in external social groups with drug use at baseline and follow-up using logistic regression and marginal modelling. Follow-up analyses of preintervention/postintervention change in drug use employed inverse probability weighting to account for censoring and were stratified by exposure to the intervention.

RESULTS

Social participation showed a protective association with drug use at baseline (1 SD higher level of social participation associated with 3.8% lower prevalence of drug use, 95% CI -0.1 to 8.3). Among individuals exposed to Encontros, higher social participation was associated with an 8.6% lower level of drug use (95% CI 0.1 to 23.3). No significant association was found among the unexposed.

CONCLUSIONS

A structural intervention that modified sex workers' social environment, specifically participation in external social groups, was associated with reduced drug use. These findings suggest that sexual risk prevention initiatives that enhance social integration among marginalised populations can produce broad health impacts, including reductions in drug use.