Drivers behind widespread informal payments in the Romanian public health care system: From tolerance to corruption to socio‐economic and spatial patterns

In order to explain informal payments in public health care services in Romania, this paper evaluates the relationship between extra payments or valuable gifts (apart from official fees) and the level of tolerance to corruption, as well as the socio‐economic and spatial patterns across those individuals offering informal payments. To evaluate this, a survey undertaken in 2013 is reported. Using logistic regression analysis, the findings are that patients with a high tolerance to corruption, high socio‐economic risk (those divorced, separated, or with other form of marital status, and those not working), and located in rural or less affluent areas are more likely to offer (apart from official fees) extra payments or valuable gifts for health care services. The paper concludes by discussing the health policy implications.     

Informal payments in government health facilities in Albania: results of a qualitative study

As governments seek to expand access to quality health care services, policy makers in many countries are confronting the problem of informal payments to medical personnel. The aim of this study was to help health planners in Albania understand informal payments occurring in government health facilities. Researchers used in-depth interviews and focus groups with 131 general public and provider informants in three districts. The results suggest that factors promoting informal payments in Albania include perceived low salaries of health staff; a belief that good health is worth any price; the desire to get better service; the fear of being denied treatment; and the tradition of giving a gift to express gratitude. Members of the general public also believe informal payments create uncertainties and anxiety during the care-seeking process, while providers perceive that informal payments harm their professional reputation, induce unnecessary medical interventions, and create discontinuity of care. The study showed that focusing on the most harmful effects and targeting the most vulnerable populations may be one way to gain consensus for policy reform. Understanding citizens' and caregivers' viewpoints is an important step in designing regulatory and bureaucratic interventions.     

The link between past informal payments and willingness of the Hungarian population to pay formal fees for health care services: results from a contingent valuation study

We examine the willingness of health care consumers to pay formal fees for health care use and how this willingness to pay is associated with past informal payments. We use data from a survey carried out in Hungary in 2010 among a representative sample of 1,037 respondents. The contingent valuation method is used to elicit the willingness to pay official charges for health care services covered by the social health insurance if certain quality attributes (regarding the health care facility, access to the services and health care personnel) are guaranteed. A bivariate probit model is applied to examine the relationship between willingness to pay and past informal payments. We find that 66 % of the respondents are willing to pay formal fees for specialist examinations and 56 % are willing to pay for planned hospitalizations if these services are provided with certain quality and access attributes. The act of making past informal payments for health care services is positively associated with the willingness to pay formal charges. The probability that a respondent is willing to pay official charges for health care services is 22 % points higher for specialist examinations and 45 % points higher for hospitalization if the respondent paid informally during the last 12 months. The introduction of formal fees should be accompanied by adequate service provision to assure acceptance of the fees. Furthermore, our results suggest that the problem of informal patient payments may remain even after the implementation of user fees.     

Economic transition should come with a health warning: the case of Vietnam

STUDY OBJECTIVE:s: To assess the affordability of health care to poor rural households in Vietnam under conditions of transition from a planned to a market economy and, in light of other transitional experience, inform policy on increasing access of the poor to affordable care of acceptable quality. DESIGN: Observational study by cross sectional socioeconomic survey, longitudinal healthcare seeking survey, and qualitative semi-structured interviews and focus group discussions; qualitative follow up over six years. SETTING: Four rural communes in north of Vietnam between 1992 and 1998. SURVEY PARTICIPANTS: 656 households (2995 people) selected by systematic random sampling. MAIN RESULTS: Compared with non-poor households, poor households had significantly lower average per capita rates of healthcare consultation and expenditure (p<0.01 in both cases). Poor households delayed and minimised healthcare seeking, especially of expensive hospital services. Two thirds of average healthcare spending by poor households was on relatively inexpensive but frequent acts of local ambulatory care. The poor restrained their healthcare seeking but not in proportion to income: for households reporting illness, the average proportion of income devoted to health care was 21.9% for the poor compared with 8.2% for the non-poor (p<0.01). To meet healthcare costs, many poor households reduced essential consumption, sold assets and incurred debt, threatening their future livelihood. CONCLUSIONS: In the short-term the poor need exemption from public sector user fees in both primary and hospital care. In the longer run the government budget and prepayment schemes should replace direct user charges in healthcare finance. Transitional economies like Vietnam should preserve the public health services built up under the planned economy. Market reforms that stimulate growth in the economy appear inappropriate to reform of social sectors.     

Private health expenditure in the Greek health care system: Where truth ends and the myth begins

Greece today has the most “privatized” health care system among EU countries. Given the country's universal coverage by a public system this may be called “the Greek paradox”. The Objective of this paper is to analyze private health payments by provider and type of service in order to bring to light the reasons for and the nature of the extraordinary private expenditure in Greece. Methods: We used a randomized countrywide sample of 1616 households. Regression analysis was used to determine the extent to which social and economic household characteristics influence the frequency of use of certain health services and the size of household payments for such services. In all statistical analyses we used the p < 0.05 level of significance. Results: Out of the total private household health expenditure (€6141 million), 66% is for outpatient services, with the largest share for dental services, absorbing 31.1% (€1912 million or 1.5% of GDP) of the total out-of-pocket health expenditure. Rural dwellers seek private outpatient care more often, because of the understaffed public primary facilities. The hospital sector absorbs less than 15% (or €884 million) of household private health expenditure. A significant part (20%) of hospital care financed privately concerns informal payments within public hospitals, an amount almost equal with formal payments in the form of cost sharing. Admissions to private hospitals are only 16% of total admissions. Our results indicate that this is a result of the political emphasis in public hospitals and of the considerably high cost of private hospital care. Conclusions: The rise in private health expenditure and the development of the private sector during the last 20 years in Greece is associated with public under financing. The gap was filled by the private sector through increased investment, mostly in upgraded amenities and new technology. Today, the complementary nature of private care in Greece is no longer disputed, but is a matter of serious concern, as it undermines the constitutionally guaranteed free access and equitable distribution of health resources.     

The political process and the private health sector's role in Vietnam

Vietnam has experienced a period of economic and political transition from a command economy to one of market socialism. This transition has precipitated a shift in the policies concerning the private sector, as well as increased demand for services from the private health sector. The private sector has evolved, though more rapidly in the Ho Chi Minh City area, with the passing of laws and regulations concerning private practice. The policy maker's concern is to maintain the equity gains realized under the public health system while using the private sector growth to make improvements in the system's efficiency. The political process enabling expansion of the private health sector has been slow, and will continue to be measured as it seeks to create a national health system with a rational integration of the public and private sectors.     

Barriers to access and the purchasing function of health equity funds: lessons from Cambodia

Problem

High out-of-pocket payments and user fees with unfunded exemptions limit access to health services for the poor. Health equity funds (HEF) emerged in Cambodia as a strategic purchasing mechanism used to fund exemptions and reduce the burden of health-care costs on people on very low incomes. Their impact on access to health services must be carefully examined.

Approach

Evidence from the field is examined to define barriers to access, analyse the role played by HEF and identify how HEF address these barriers.

Local setting

Two-thirds of total health expenditure consists of patients’ out-of-pocket spending at the time of care, mainly for self-medication and private services. While the private sector attracts most out-of-pocket spending, user fees remain a barrier to access to public services for people on very low incomes.

Relevant changes

HEF brought new patients to public facilities, satisfying some unmet health-care needs. There was no perceived stigma for HEF patients but many of them still had to borrow money to access health care.

Lessons learned

HEF are a purchasing mechanism in the Cambodian health-care system. They exercise four essential roles: financing, community support, quality assurance and policy dialogue. These roles respond to the main barriers to access to health services. The impact is greatest where a third-party arrangement is in place. A strong and supportive policy environment is needed for the HEF to exercise their active purchasing role fully.     

The promise and limits of private medicine: health policy dilemmas in Nigeria

Developments in health are easily among the best known human development indicators. Comparisons of life expectancy, infant mortality, access to safe water and similar data indicate the positions of individual countries. The political and economic processes which these indices reflect, or which inform the nature of health policy, are often not as clear or visible. These structural factors are either frequently ignored or mentioned only in passing, as illustrated in a recent paper published in this journal on the private medical enterprise in Nigeria (Ogunbekun et al. 1999). According to the authors, the generally low quality of public health services and high user fees have combined to make private medicine the 'unavoidable choice' of Nigerians. They identify benefits of private medicine as higher technical efficiency and contributing to fill the gap created by inadequate public sector services and to medical training. This paper argues that these claims are exaggerated, and that the authors seem to ignore Nigeria's political and economic processes, the health seeking behaviour of Nigerians, as well as the prevailing causes of morbidity and mortality. It is suggested that whereas the contributions of private medicine are significant, there are also several limitations, some of which originate from its for-profit raison d'être. The ultimate aim of health development must include improved access to services and better health status for the majority of the people. Without any form of public supported programme of payments in Nigeria, these objectives are circumscribed, especially with high fees in the private system. It is concluded that while private medicine will continue to be available for those who can afford it, it is unlikely to provide solutions to Nigeria's morbidity and mortality problems, particularly in relation to epidemics such as the growing burden of HIV/AIDS.     

Impact of Medicare's prospective payment system on hospitals, skilled nursing facilities, and home health agencies: how the Balanced Budget Act of 1997 may have altered service patterns for Medicare providers

The prospective payment system is one of many changes in reimbursement that has affected the delivery of health care. Originally developed for the payment of inpatient hospital services, it has become a major factor in how all health insurance is reimbursed. The policy implications extend beyond the Medicare program and affect the entire health care delivery system. Initially implemented in 1982 for payments to hospitals, prospective payment system was extended to payments for skilled nursing facility and home health agency services by the Balanced Budget Act of 1997. The intent of the Balanced Budget Act was to bring into balance the federal budget through reductions in spending. The decisions that providers have made to mitigate the impact are a function of ownership type, organizational mission, and current level of Medicare participation. This article summarizes the findings of several initial studies on the Balanced Budget Act's impact and discusses how changes in Medicare reimbursement policy have influenced the delivery of health care for the general public and for Medicare beneficiaries.     

How do supply‐side factors influence informal payments for healthcare? The case of HIV patients in Cameroon

Direct out‐of‐pocket payments for healthcare continue to be a major source of health financing in low‐income and middle‐income countries. Some of these direct payments take the form of informal charges paid by patients to access the needed healthcare services. Remarkably, however, little is known about the extent to which these payments are exercised and their determinants in the context of Sub‐Saharan Africa. This study attempts therefore to shed light on the role of supply‐side factors in the occurrence of informal payments while accounting for the demand‐side factors. The study relies on data taken from a nationally representative survey conducted among people living with HIV/AIDS in Cameroon. A multilevel mixed‐effect logistic model is employed to identify the factors associated with the incidence of informal payments. Results reveal that circa 3.05% of the surveyed patients incurred informal payments for the consultations made on the day of the survey. The amount paid informally represents up to four times the official tariff. Factors related to the following: (i) human resource management of the health facilities (e.g., task shifting); (ii) health professionals' perceptions vis‐à‐vis the remunerations of HIV care provision; and (iii) reception of patients (e.g., waiting time) significantly influence the probability of incurring informal payments. Also of note, the type of healthcare facilities is found to play a role: informal payments appear to be significantly lower in private non‐profit facilities compared with those belonging to public sector. Our findings allude to some policy recommendations that can help reduce the incidence of informal payments. Copyright © 2014 John Wiley & Sons, Ltd.     

Out of pocket health expenditures in Turkey following introduction of co-payments along with improved primary care services

In 2002, Turkey started to implement reforms in health care aiming to improve access and increase efficiency. Reforms increased health insurance coverage and resulted in higher number of outpatient and inpatient treatments at both public and private hospitals. Later, to change preference towards the use of secondary and tertiary care over primary care and rein in increasing health expenditures, a series of co-payments were instituted along with an extension of primary care services through a family-medicine system that provided free access to all. This work aims to measure the impact of these two simultaneous policy measures on out-of-pocket expenditures. We find that while contributory payments resulted in higher OOP health expenditures, especially for lower income households, the impact was small. We also observe that inability to consult a physician and to visit a hospital, especially for monetary reasons, was reduced after the policy change.     

“If the Big Fish are Doing It Then Why Not Me Down Here?”: Informal Fee Payments and Reproductive Health Care Provider Motivation in Kenya

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.     

Making abortions safe: a matter of good public health policy and practice

Globally, abortion mortality accounts for at least 13% of all maternal mortality. Unsafe abortion procedures, untrained abortion providers, restrictive abortion laws and high mortality and morbidity from abortion tend to occur together. Preventing mortality and morbidity from abortion in countries where these remain high is a matter of good public health policy and medical practice, and constitutes an important part of safe motherhood initiatives. This article examines the changes in policy and health service provision required to make abortions safe. It is based on a wide-ranging review of published and unpublished sources. In order to be effective, public health measures must take into account the reasons why women have abortions, the kind of abortion services required and at what stages of pregnancy, the types of abortion service providers needed, and training, cost and counselling issues. The transition from unsafe to safe abortions demands the following: changes at national policy level; abortion training for service providers and the provision of services at the appropriate primary level health service delivery points; and ensuring that women access these services instead of those of untrained providers. Public awareness that abortion services are available is a crucial element of this transition, particularly among adolescent and single women, who tend to have less access to reproductive health services generally.     

Reform strategies in Georgia and their impact on health care provision in rural areas: evidence from a household survey

The transition resulting from the break-up of the Soviet Union significantly affected the health care systems and population health status in the newly independent States. The available body of evidence suggests that contraction of public resources resulting from economic slowdown has led to the proliferation of out-of-pocket payments and private spending becoming a major source of finance to health service provision to the population. Emerging financial access barriers impede adequate utilization of health care services. Most transition countries embarked on reforming health systems and health care financing in order to tackle this problem. However, little evidence is available about the impact of these reforms on improved access and health outcomes. This paper aims to contribute to the assessment of the impact of health sector reforms in Georgia. It mainly focuses on changes in the patterns of health services utilization in rural areas of the country as a function of implemented changes in health care financing on a primary health care (PHC) level. Our findings are based on a household survey which was carried out during summer 2002. Conclusions derived from the findings could be of interest to policy makers in transitional countries. The paper argues that health financing reforms on the PHC level initiated by the Government of Georgia, aimed at decreasing financial access barriers for the population in the countryside, have rendered initial positive results and improved access to essential PHC services. However, to sustain and enhance this attainments the government should ensure equity, improve the targeting mechanisms for the poor and mobilize additional public and private funds for financing primary care in the country.     

Informal payments and the financing of health care in developing and transition countries

Informal, under-the-table payments to public health care providers are increasingly viewed as a critically important source of health care financing in developing and transition countries. With minimal funding levels and limited accountability, publicly financed and delivered care falls prey to illegal payments, which require payments that can exceed 100 percent of a country's median income. Methods to address the abuse include establishing official fees, combined with improved oversight and accountability for public health care providers, and a role for communities in holding providers accountable.     

An analysis of the role of health care in reducing socioeconomic inequalities in health: the case of the Netherlands.

The aim of this article is to analyze the role of the health care system in reducing socioeconomic inequalities in health in countries with good access to health services, using the Dutch example. In the past, health care has contributed substantially to reducing a number of health problems in the population, paticularly health problems leading to mortality. Data on trends in mortality from selected conditions by socioeconomic group show that both higher and lower socioeconomic groups have profited from these mortality reductions, probably because of largely equal access to essential health car services, and that absolute inequalities in mortality from these conditions have declined notably. The current situation is still one of largely equal financial access to health care services, with relatively small differences between socioeconomic groups in health care utilization, after adjustment for differences in prevalence of health problems. There is no evidence that inequalities in health care utilization contribute to a widening of socioeconomic inequalities in health. Financing of the health care system, however, is slightly regressive, and out-of-pocket payments contribute to the poor financial situation of the chronically ill. For the future, three possible contributions of the health care system to reducing socioeconomic inequalities in health are described: preservation of equal access to high-quality health care; development of specific care packages for lower socioeconomic groups; promotion and support of intersectoral activities.     

The role of health insurance in the growth of the private health sector in Korea

The Korean health care system has been recognized by other countries for its rapid expansion of national health insurance. The government's policy of promoting the private sector, relying on market forces for various allocation decisions, and using the fee-for-service payment system has created a number of challenges for the Korean health system. Among these are rapid growth of health care expenditure, proliferation and duplication of medical technology, and lack of access for low-income groups due to high out-of-pocket payments for services covered by insurance. A number of recommendations are made concerning national health policy, modifying health insurance, and developing political consensus for bringing about health reform.     

Meeting information needs in health policy and public health: Priorities for the national library of medicine and the national network of libraries of medicine

Those seeking information in health policy and public health are not as well served as those seeking clinical information. Problems inhibiting access to health policy and public health information include the heterogeneity of professionals seeking the information, the distribution of relevant information across disciplines and information sources, scarcity of synthesized information useful to practitioners, lack of awareness of available services or training in their use, and lack of access to information technology or to knowledgeable librarians and information specialists. Since 1990, the National Library of Medicine and the National Network of Libraries of Medicine have been working to enhance information services in health policy and public health through expanding the coverage of the NLM collection, building new databases, and engaging in targeted outreach and training initiatives directed toward segments of the health policy and public health communities. Progress has been made, but more remains to be done. Recommendations arising from the meeting,Accessing Useful Information: Challenges in Health Policy and Public Health, will help NLM and the National Network of Libraries of Medicine to establish priorities and action plans for the next several years.     

Exploring the influence of context and policy on health district productivity in Cambodia

Background

Cambodia has been reconstructing its economy and health sector since the end of conflict in the 1990s. There have been gains in life expectancy and increased health expenditure, but Cambodia still lags behind neighbours One factor which may contribute is the efficiency of public health services. This article aims to understand variations in efficiency and the extent to which changes in efficiency are associated with key health policies that have been introduced to strengthen access to health services over the past decade.

Methods

The analysis makes use of data envelopment analysis (DEA) to measure relative efficiency and changes in productivity and regression analysis to assess the association with the implementation of health policies. Data on 28 operational districts were obtained for 2008–11, focussing on the five provinces selected to represent a range of conditions in Cambodia. DEA was used to calculate efficiency scores assuming constant and variable returns to scale and Malmquist indices to measure productivity changes over time. This analysis was combined with qualitative findings from 17 key informant interviews and 19 in-depth interviews with managers and staff in the same provinces.

Results

The DEA results suggest great variation in the efficiency scores and trends of scores of public health services in the five provinces. Starting points were significantly different, but three of the five provinces have improved efficiency considerably over the period. Higher efficiency is associated with more densely populated areas. Areas with health equity funds in Special Operating Agency (SOA) and non-SOA areas are associated with higher efficiency. The same effect is not found in areas only operating voucher schemes. We find that the efficiency score increased by 0.12 the year any of the policies was introduced.

Conclusions

This is the first study published on health district productivity in Cambodia. It is one of the few studies in the region to consider the impact of health policy changes on health sector efficiency. The results suggest that the recent health financing reforms have been effective, singly and in combination. This analysis could be extended nationwide and used for targeting of new initiatives. The finding of an association between recent policy interventions and improved productivity of public health services is relevant for other countries planning similar health sector reforms.