The inequity of informal payments for health care: the case of Hungary

As in most countries of Central and Eastern Europe, informal payments have been a characteristic feature of the Hungarian health care system both during and since the demise of Soviet type socialist rule. Although informal payments continue to be so characteristic in the region, little empirical evidence exists on their scope or working. As far as equity is concerned, it has sometimes been suggested that physicians play a 'Robin Hood' role and subsidise the poor at the expense of the rich. With the aid of an interview survey of a representative sample of the Hungarian population, we examine the distribution of the burden of informal payments across income groups. Results indicate that informal payments are a highly regressive way of funding health care, with Kakwani progressivity indices of -0.38, -0.39, -0.35 and -0.36 for GP, outpatient specialist, hospital, and total care, respectively. The finding that people with lower income pay proportionally more for public health care through informal payments underlines the emptiness of the 'Robin Hood' claims and the need for reform.     

Understanding informal payments for health care: the example of Bulgaria

INTRODUCTION: Throughout the 1990s, in response to funding deficits, out-of-pocket payment has grown as a share of total expenditure in countries in transition. A clear policy response to informal payments is, however, lacking. The current study explores informal payments in Bulgaria within a conceptual framework developed by triangulating information using a variety of methodologies. OBJECTIVE: To estimate the scale and determinants of informal payments in the health sector of Bulgaria and to identify who benefits, the characteristics and timing of payments, and the reasons for paying. DESIGN: Data were derived from a national representative survey of 1547 individuals complemented by in-depth interviews and focus groups with over 100 respondents, conducted in Bulgaria in 1997. Informal payments are defined as a monetary or in-kind transaction between a patient and a staff member for services that are officially free of charge in the state sector. RESULTS: Informal payments are relatively common in Bulgaria, especially if in the form of gifts. Informal cash payments are universal for operations and childbirth, clear-cut and life-threatening procedures, in hospitals or elite urban facilities or well-known physicians. Most gifts were given at the end of treatment and most cash payments-before or during treatment. Wealthier, better educated, younger respondents tend to pay more often, as a means of obtaining better-quality treatment in a de facto two-tier system. Since the transition, informal payments had become frequent, explicit, solicited by staff, increasingly in cash, and less affordable. Informal payments stem from the low income of staff, patients seeking better treatment; acute funding shortages; and from tradition. Attitudes to informal payments range from strongly negative (if solicited) to tolerant (if patient-initiated), depending on the circumstances. CONCLUSIONS: The study provides important new insights into the incidence and nature of informal payments in the health sector in Bulgaria. Payments were less than expected, very complex, organised in a chaotic, although adaptive, system, and relatively equitable. The timing of payment and the presence of compulsion is a key factor in distinguishing between informal payments given in gratitude or as a bribe, and the latter are seen as problematic, needing to be addressed. Paying informally appeared to be a product of socio-economic reality rather than culture and tradition. The study showed that the principle of comprehensive free coverage existing in Bulgaria until 1989 has been significantly eroded. Initiating a public debate on informal payments is important in a health care reform process that purports to increase accountability.     

Informal payments for healthcare services and short-term effects of the introduction of visit fee on these payments in Hungary

The objective of this paper is to study the short-term effects of the introduction of the visit fee in Hungary in 2007 on informal patient payments. We present the pattern of informal payments in primary, out-patient specialist and in in-patient care in the period before and shortly after the visit fee was introduced. We also analyse whether in the short run, the introduction of visit fee decreased the probability of paying informally. For the analysis, we use a dataset for a representative sample of 2500 respondents collected in 2007 shortly after the introduction of the visit fee, which contains data on informal payments for healthcare services. According to our results, 9% of the patients paid informally during their last visit to GP (2 Euros on average), 14% paid informally for specialist care (35 Euros on average) and 50% paid informally for hospitalisation (58 Euros on average). We find a significant reduction in the probability of paying informally only for elderly patients in case of in-patient care. Our results suggest that informal payments are widely spread in Hungary, especially in in-patient care. The short run potential of the introduction of the visit fee to reduce informal payments seems to be minor.     

Conditional cash transfers,spillovers, and informal health care: Evidence from Peru

Conditional cash transfer programs have become instrumental in encouraging the use of formal health services in developing countries, but little is known about their effect on the use of low‐quality informal care. Using a large survey of Peruvian rural households and a regression discontinuity design, we find a sizeable reduction in the use of informal health care providers not only by targeted but also by nontargeted members of households that qualify for the program. This indicates the existence of spillover effects within the household. We also provide evidence that beyond the direct increase in income, the availability of better information about institutional services is a potential mechanism that drives these effects.     

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.     

The economic value of informal care: a study of informal caregivers' and patients' willingness to pay and willingness to accept for informal care

We provide a new test of the feasibility of using contingent valuation to value informal care. We start with a theoretical model of informal caregiving and derive that willingness to pay depends positively on wealth and negatively on own health, whereas the effect of other's health is sign-ambiguous. These predictions are tested in two new data sets on patients' and caregivers' willingness to pay (WTP) and willingness to accept (WTA) for informal care. The data are generally consistent with the theoretical predictions: wealth generally has a positive impact and own health a negative impact. Other's health has a mixed effect. We find only small differences between WTP and WTA. Our findings suggest that contingent valuation may be a useful technique to value informal care in economic evaluations of health care.     

Investigating the relationship between formal and informal care: An application using panel data for people living together

There is limited evidence on the relationship between formal and informal care using panel data in a U.K. setting and focused specifically on people living together (co‐residents). Using all 18 waves of the British Household Panel Survey (1991–2009), we analyse the effect of informal care given by co‐residents on the use of formal home care and health care services more generally. To account for endogeneity, we estimate models using random effects instrumental variable regression using the number of daughters as a source of exogenous variation. We find that a 10% increase in the monthly provision of informal care hours decreases the probability of using home help (formal home care) by 1.02 percentage points (p < .05), equivalent to a 15.62% relative reduction. This effect was larger for home help provided by the state (β = ?.117) compared with non‐state home help (β = ?.044). These results provide evidence that significant increases in the supply of informal care would reduce the demand for home‐help provision.     

Economic costs of informal care for people with chronic diseases in the community: Lost income,extra welfare payments,and reduced taxes in Australia in 2015–2030

We estimated the economic costs of informal care in the community from 2015 to 2030, using an Australian microsimulation model, Care&WorkMOD. The model was based on data from three Surveys of Disability, Ageing, and Carers (SDACs) for the Australian population aged 15–64 years old. Estimated national income lost was AU$3.58 billion in 2015, increasing to $5.33 billion in 2030 (49% increase). Lost tax payments were estimated at AU$0.99 billion in 2015, increasing to AU$1.44 billion in 2030 (45% increase), and additional welfare payments were expected to rise from $1.45 billion in 2015 to AU$1.94 in 2030 (34% increase). There are substantial economic costs both to informal carers and the government due to carers being out of the labour‐force to provide informal care for people with chronic diseases. Health and social policies supporting carers to remain in the labour force may allow governments to make substantial savings, while improving the economic situation of carers.     

Zero-inflated endogenous count in censored model: effects of informal family care on formal health care

If informal family health care is a substitute for formal health care, then there is a scope to reduce formal health care cost by promoting informal family health care. With the use of Korean data for the elderly, this paper estimates the effects of informal family health care on formal health care, where the former is measured by the number of caregivers and the latter is measured by the formal health care expenditure. This task, however, poses a number of difficulties. The first is that the number of the family caregivers is an endogenous count regressor. The second is that there are too many zeros in the count (85%). The third is that the response variable also has a nontrivial proportion of zeros (14%). This paper overcomes these problems by combining 'control function approach', 'zero-inflated' counts, and a semiparametric estimator for censored models. The resulting procedure avoids strong parametric assumptions and behaves well computationally. Our main empirical finding is that informal family health care has a large substitute effect for diabetics and that there are also weak evidences that informal family health care has substitute effects for high blood pressure and mental diseases.     

Access to health care in a system transition: the case of Bulgaria

OBJECTIVE: Throughout the 1990s, the Soviet-style model in central and eastern Europe that provided free health services has been subject to radical reforms. Socio-economic inequalities have also increased but there is little information on inequalities in health care utilization. This paper examines the pattern of illness behaviour in Bulgaria, seeking evidence of inequalities in access to services and eliciting users' pathways to care. DESIGN: Analysis drew on a representative population survey in Bulgaria (1997). The financial determinants of service use were tested in a multivariate model adjusted first for age, and then for age, marital status and self-reported health. In-depth interviews with users and providers addressed pathways to care, use of connections and other informal strategies to obtain care. RESULTS: As expected, rates of illness vary with income, with highest rates among the poor. After adjustment for illness, consultation rates are relatively equal across income levels, with the exception of worse-off women who tend to consult more. For first contact, there are few differences according to income, with the better off preferring secondary level. Pathways slightly differ, with women more often treated in primary care. Private sector utilization is low. Qualitative research reveals well-established strategies to obtain more advanced care, including use of connections, informal payments and use of emergency services. CONCLUSIONS: An apparent lack of inequalities in access to care conceals a more complex picture in which income and gender influence the pathways taken through the system.     

Review of corruption in the health sector: theory, methods and interventions

There is increasing interest among health policymakers, planners and donors in how corruption affects health care access and outcomes, and what can be done to combat corruption in the health sector. Efforts to explain the risk of abuse of entrusted power for private gain have examined the links between corruption and various aspects of management, financing and governance. Behavioural scientists and anthropologists also point to individual and social characteristics which influence the behaviour of government agents and clients. This article presents a comprehensive framework and a set of methodologies for describing and measuring how opportunities, pressures and rationalizations influence corruption in the health sector. The article discusses implications for intervention, and presents examples of how theory has been applied in research and practice. Challenges of tailoring anti-corruption strategies to particular contexts, and future directions for research, are addressed.     

Empirical studies on informal patient payments for health care services: a systematic and critical review of research methods and instruments

Background  

Empirical evidence demonstrates that informal patient payments are an important feature of many health care systems. However, the study of these payments is a challenging task because of their potentially illegal and sensitive nature. The aim of this paper is to provide a systematic review and analysis of key methodological difficulties in measuring informal patient payments.     

Relational aspects of mastery for frail,older adults: The role of informal caregivers in the care process

Frail, older care recipients are often thought of as individuals with a decreased mastery of everyday life skills. Various authors have proposed to acknowledge a relational dimension of mastery, defined as the ability to maintain control over one's life with the help of others. This study explores how frail, older adults experience relational aspects of mastery and the role of their informal caregivers in maintaining these aspects of mastery over the care process. Qualitative interviews (N = 121) were conducted in 2016 with potentially frail, community‐dwelling older adults participating in the Detection, Support and Care for Older people: Prevention and Empowerment (D‐SCOPE) project. A secondary analysis of 65 interviews reveals that, according to frail, older adults, informal caregivers contribute in various ways to the preservation of their mastery. This differs across the four elements of care: caring about (attentiveness), taking care of (responsibility), care‐giving (competence), and care‐receiving (responsiveness). However, in some cases, older adults experienced a loss of mastery; for example, when informal caregivers did not understand their care needs and did not involve them in the decision, organisation, and provision of care. A relational dimension of mastery needs to be acknowledged in frail, older care recipients since stimulating mastery is a crucial element for realising community care objectives and person‐centred and integrated care.     

The gaze and visibility of the carer: a Foucauldian analysis of the discourse of informal care

Working from a Foucauldian perspective, this paper examines the discourse of informal care and addresses three questions. When was it first possible to speak of ‘the informal carer’? What are the characteristics of the discourse of informal care? And, what are the conditions of the possibility of the informal carer’s recognition? Following an analysis of the appearance and conceptualisation of the informal carer in policy and related discourse since the 1970s, the visibility of this figure is situated in the context of the historical transformation of the medical gaze. It is argued that two broad axes of the gaze’s ongoing transformation – its devolution to ‘relays’ and its extension to the whole population and the ‘whole person’–underpinned the shift in emphasis from care in the community to care by the community in the 1970s, and the associated development of the discourse of informal care.     

Extending social health insurance to the informal sector in Kenya. An assessment of factors affecting demand

This paper contributes to analysing and understanding the demand for (social) health insurance of informal sector workers in Kenya by assessing their perceptions and knowledge of and concerns regarding health insurance and the Kenyan National Hospital Insurance Fund (NHIF). It serves to explore how informal sector workers could be integrated into the NHIF. To collect data, focus group discussions were held with organized groups of informal sector workers of different types across the country, backed up by a self-administered questionnaire completed by heads of NHIF area branch offices. It was found that the most critical barrier to NHIF enrollment is the lack of knowledge of informal sector workers about the NHIF, its enrollment option and procedures for informal sector workers. Inability to pay is a critical factor for some, but people were, in principle, interested in health insurance, and thus willing to pay for it. In sum, the mix of demand-side determinants for enrolling in the NHIF is not as complex as expected. This is good news, as these demand-side determinants can be addressed with a well-designed strategy, focusing on awareness raising and information, improvement of insurance design features and setting differentiated and affordable contribution rates.     

Access of Roma to sexual and reproductive health services: Qualitative findings from Albania,Bulgaria and Macedonia

Abstract

The purpose of this study was to explore access of Roma in South-Eastern Europe to sexual and reproductive health services. We conducted 7 focus group discussions with a total of 58 participants from Roma communities in Albania, Bulgaria and Macedonia. Our study revealed a number of barriers for Roma when accessing sexual and reproductive health services. Among the most important were the overall lack of financial resources, requests by health care providers for informal payments, lack of health insurance and geographical barriers. Health systems in the region seem to have failed to provide financial protection and equitable services to one of the most vulnerable groups of society. There is also a need for overcoming racial discrimination, improving awareness and information and addressing gender inequalities.     

Formal and informal care for community‐dwelling frail elderly people over time: A comparison of integrated and usual care in the Netherlands

While integration has become a central tenet of community‐based care for frail elderly people, little is known about its impact on formal and informal care and their dynamics over time. The aim of this study was therefore to examine how an integrated care intervention for community‐dwelling frail elderly people affects the amount and type of formal and informal care over 12 months as compared to usual care. A quasi‐experimental design with a control group was used. Data regarding formal and informal care were collected from frail elderly patients (n = 207) and informal caregivers (n = 74) with pre/post‐questionnaires. Within‐ and between‐group comparisons and multiple linear regression analyses were performed. The results showed marginal changes over time in the amount of formal and informal care in both integrated care and usual care. However, different associations between changes in formal and informal care were found in integrated and usual care. Most notably, informal caregivers provided more instrumental assistance over time if formal caregivers provided less personal care (and vice versa) in integrated care but not in usual care. These results suggest that integrated care does not necessarily change the contribution of formal or informal care, but changes the interaction between formal (personal care) and informal (instrumental) activities. Implications and recommendations for research and practice are discussed. Trial registration: Current Controlled Trials ISRNT05748494.