Informal payments for health care in transition economies

There is considerable evidence that unofficial payments are deeply embedded in the markets for health care in transition countries. Numerous surveys indicate that these payments provide a significant but possibly distorting contribution to health care financing. Unofficial payments can be characterised into three groups: cost contributions, including supplies and salaries, misuse of market position and payments for additional services. There is evidence from across the region on the presence of payment in each category although it is often difficult to distinguish between payment types. Regulatory policy must address a number of issues. Imposing penalties may help to reduce some payments but if the system is simply unable to provide services, such sanctions will drive workers into the private sector. There appears to be some support for formalising payments in order to reduce unofficial charges although the impact must be monitored and the danger is that formal fees add to the burden of payment. Regulation might also attempt to increase the amount of competition, provide information on good performing facilities and develop the legal basis of patient rights. Ultimately, unless governments address the endemic nature of payments across all sectors, policy interventions are unlikely to be fully effective.     

Under-the-counter payments for health care: evidence from Bulgaria

Against a background of falling revenues and increasing expectations, health care systems in central and eastern Europe are facing increasing budgetary gaps. There is extensive anecdotal evidence that these gaps are being filled by informal or 'under-the-table' payments. These are important because of their implications for estimates of future funding requirements, for equity, and for the possible perverse incentives they introduce for those providing and managing health services. There is, however, relatively little information on either their scale or how they are perceived in these countries. We report the results of a small survey from Bulgaria that begins to address these issues. Data were collected by means of an interviewer-administered household survey in which those who had used state-provided health services in the preceding 2 years were identified. The survey took place throughout Bulgaria in 1994. One thousand people were approached and 706 (70.6%) provided information suitable for analysis; 42.9% had paid for services that were officially free. Payments had been for a wide range of services and to differing groups, including medical, nursing and ancillary staff. Payments to individuals during consultations were between 3% and 14% of average monthly income but the average cost of an operation was 83% of mean monthly income. There were large differences in the amounts paid by individuals. Most people were in favour of both official user fees and health care reform, except among the old, the poor, and those in poor health. Despite certain limitations, this study gives some indication of the scale of informal payments in Bulgaria. Several possibilities exist to address them. Contrary to what is often argued, there seems to be a popular willingness for them to be converted into formal co-payments. Before this can be done, there is a need for more research on the impact that this would have on equity and affordability.     

Informal payment for health care: evidence from Hungary

While there is a growing body of evidence that informal payments for health care are widespread and enduring in the former communist countries of Central and Eastern Europe and Central Asia, evidence on the scale of the phenomenon is not only limited, but what is available is often conflicting. Hungary exemplifies this controversy, as the available literature provides conflicting figures, differing by an order of magnitude among various surveys, with a similarly large difference between survey findings and expert estimates. This study advances understanding of the methodological issues involved in researching informal payments by providing a systematic analysis of the methodology of available empirical research and official statistics on the scale of informal payments in Hungary. The paper explores the potential sources of differences, to assess the scope to reduce the differences between various estimates and to define the upper and lower boundaries within which the true magnitude of informal payments can be expected to lie. Our analysis suggests that in 2001 the overall magnitude of informal payments lay between 16.2 and 50.9 billion HUF (euro 64.8- euro 203.6 million, US dollars 77.1-242.4 million), which amounted to 1.5-4.6% of total health expenditures in Hungary. Looked at this way, informal payments do not seem to be an important source of health care financing. However, as informal payments are unequally distributed among health workers, with the bulk of the money going to physicians, with some not taking any informal payments, family doctors and some specialists may have earned between 60 and 236% of their net official income from this source in 2001. This suggests that it is not the overall amount of informal payment that makes it a policy concern, but the consequences of its unequal distribution among health workers. What is remarkable about informal payments in Hungary is that a relatively small amount of money can keep the system running, which gives rise to the hypothesis that, in certain cases, it is the hope of substantial informal payments in the future that motivates physicians to remain in the system. This is a difficult challenge for policy-makers as it would require a much larger amount of money to achieve equilibrium under any formal alternative.     

Hexachlorocyclohexane Use in the Former Soviet Union

Because of the large size of the former Soviet Union (FSU) and the heavy use of organochlorine pesticides (OCPs) in the FSU, usage information regarding OCPs in the FSU is important in compiling global emission inventories and thus in studying the transport of OCPs among different environmental compartments worldwide. The availability of such information is limited. By analyzing the available 1,2,3,4,5,6-hexachlorocyclohexane (HCH) data in the FSU, this article presents estimates of HCH usage in this region from 1950 to 1990, when HCH was officially banned for agricultural use by the FSU government. The creation of HCH usage inventories for the FSU has paved the way to produce HCH emission inventories for this region. Total HCH usages for agricultural purposes in the FSU from 1950 to 1990 were estimated to be 1,960 kt for technical HCH and 40 kt for lindane. The total usage for the isomers was 270 kt for -HCH, 1,270 kt for -HCH, and 170 kt for -HCH. Use of HCH reached a peak in 1965: 130 kt for technical HCH, 2.7 kt for lindane, 18 kt for -HCH, 86 kt for -HCH, and 11 kt for -HCH. Gridded usage data sets in the FSU of technical HCH and lindane—and the -HCH, -HCH and -HCH isomers—on a 1^o × 1^o longitude and latitude grid system for 1980 are freely available to all users at .     

Competence of Children Adopted from the Former Soviet Union

The former USSR led the way with the most children adopted from overseas into the United States from 1997‐1999. This study (a) characterizes overall functioning of adoptees and (b) utilizes hierarchical regression analysis to evaluate both risks and protective influences of adoptive families and their relationships to child competence. Competence levels ranged from challenged to developmentally normal. Family cohesion and expressiveness were significantly associated with higher levels of child competence.     

Informal payments and intra-household allocation of resources for health care in Albania

Background  

Informal payments for health care services can impose financial hardship on households. Many studies have found that the position within the household can influence the decision on how much is spent on each household member. This study analyses the intra-household differences in spending on informal payments for health care services by comparing the resources allocated between household heads, spouses and children.     

Catastrophic health payments and health insurance: some counterintuitive evidence from one low-income country

OBJECTIVES: The purpose of the study is to quantitatively analyze the role of health insurance in the determinants of catastrophic health payments in a low-income country setting. METHODS: The study uses the most recent publicly available household level data from Zambia collected in 1998 containing detailed information on health care utilization and spending and on other key individual, household, and community factors. An econometric model is estimated by means of multivariate regression. RESULTS: The main results are counterintuitive in that health insurance is not found to provide financial protection against the risk of catastrophic payments; indeed, insurance is found to increase this risk. CONCLUSIONS: Reasons for the findings are discussed using additional available information focusing on the amount of care per illness episode and the type of care provided. The key conclusion is that the true impact of health insurance is an empirical issue depending on several key context factors, including quality assurance and service provision oversight.     

Informal payments in the health sector: a case study from Turkey

The practice of making informal payments in the health sector is common in a number of countries. It has become an important policy issue around the world. These payments can jeopardize governments' attempts to improve equity and access to care and policies targeted to the poor. It is widely believed that a considerable amount of out-of-pocket payment in the health sector in Turkey is informal. To examine this issue, we used a questionnaire adopted from a wider international study. We concluded that informal payments in Turkey are significant and have important implications for health care reform.     

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.     

Observations on health care issues in the former Soviet Union

With the demise of the Soviet Union, the health care systems that remain in the component countries face many problems not seen in Western countries since the late 1800s or early 1900s. The author traveled to several countries of the newly independent states (NIS) of the former Soviet Union and observed problems in hospital sanitation, public health, medical equipment and supply distribution, food quality and safety, and the delivery of medical services.The author makes several suggestions to improve the delivery and quality of health care services in the NIS. His recommendations include: developing health care standards similar those that were first implemented in the U.S. by the American College of Surgeons in 1919; the use of practice guidelines and outcomes measures; building on organizational structures from the old state health system for professional and public health education; and restructuring the old delivery system to form a new delivery model based on centers of excellence and group practice managed care. Because of so many needs, the author stresses keeping reforms as simple as possible so as not to overburden the health professionals. The author also calls on Western countries, particularly the U.S., to assist with the rebuilding of the health care delivery system of its Cold War adversary as it helped Germany and Japan after World War II. Such aid should be viewed as humanitarian in nature and should be distributed to private/public partnership efforts. The author says recent Congressional proposals to cut off aid in order to influence the Russian government's position on nuclear technology sales to Iran and the Chechen war are short sighted and will only hurt the citizens of these countries while having little or no impact on the leadership.Stephen L. Davidow is a Chicago-based health policy analyst and communications consultant who has traveled to several countries among the newly independent states (NIS) of the former Soviet Union. He has toured health facilities and consulted with health officials in the NIS. He also made a presentation on standards setting at the Universal Health Conference in Samarkand, Uzbekistan. Mr. Davidow's undergraduate degree from St. Olaf College is in Russian Studies, and he studied Russian language at Boston University's Russian Studies Institute and Moscow State Pedagogical Institute. He has also done graduate coursework in health policy and administration at the University of Chicago. His consulting practice specializes in practices guidelines, outcomes measurement, public policy, and public health education.     

Poverty, out-of-pocket payments and access to health care: evidence from Tajikistan

Most countries of the Former Soviet Union (FSU) have either initiated or are contemplating reform of the health sector. With negative real income growth and falling government revenues, a key concern of many governments is to secure additional finance through non-budgetary sources such as hypothecated payroll taxes, voluntary insurance, and increased private finance through patient cost-sharing. However, before such reforms can be considered, information is needed both on the current levels and distribution of household expenditures on health care, and the extent to which increased charges may affect access to health services, especially amongst the poor. This paper uses the Tajikistan Livings Standard Survey to investigate the level and distribution of out-of-pocket payments for health care in Tajikistan and to examine the extent to which such payments act as barriers to health-care access. The data show that there are significant differences in health-care utilisation rates across socio-economic groups and that these differences are related to ability to pay. Official and informal payments are acting both to deter people from seeking medical assistance and once advice has been sought, from receiving the most appropriate treatment. Despite informal exemptions, out-of-pocket payments for health care are exacting a high toll on household welfare with households being forced to sell assets or go into debt to meet the costs of care. Urgent action is needed to ensure equity in access to health care.     

Equity in out-of-pocket payments for hospital care: evidence from India

BACKGROUND: The lack of formal health insurance and inadequate social safety nets cause families in most low-income countries to finance health spending through out-of-pocket (OOP) payments, leaving poor families unable to insure their consumption during periods of major illnesses. OBJECTIVE: To examine how well the Indian healthcare system protects households of differing living standards against the financial consequences of unanticipated health shocks. DATA: The data are drawn from the 52nd round of National Sample Survey, a nationally representative socioeconomic and health survey conducted in 1995-1996. The sample comprises 24,379 (3.84%) households where a member was hospitalized during the 1-year reference period. METHODS: We estimate, using ordinary least squares, the relationship between household consumption (proxy for ability to pay) and OOP payments for hospitalization. We also estimate the relationship between consumption and OOP share in consumption. RESULTS: Our results indicate that both utilization (payments) and the consequent financial burden (payment share) increases with increasing ability to pay (ATP). While this relationship is retained across the different subgroups (e.g., gender, social code, region, etc.), comparisons across groups indicate horizontal inequities including differences in both degrees of progressivity and the redistributive effect. CONCLUSION: The finding that OOP payments do not decline with ATP could be an indication of: (1) the lack of insurance which implies that the better-off must pay from OOP to secure quality health care and (2) the absence of risk-pooling or prepayments mechanisms which poses financial impediments to the consumption of health care by the poor.     

Informal payments in transitional economies: implications for health sector reform

Since the collapse of the Soviet Union increasing evidence is emerging of informal payments by patients for health care services that are officially free. There is little information, however, on the characteristics of these payments and the effect that they have on health care reform initiatives. This paper examines these issues and concludes that the endemic and complex nature of such payments suggests that a range of policy tools are necessary to address the negative features of informal payments in those countries undergoing transition.     

Maternal and Child Health Supercourse for the Former Soviet Union Countries

Maternal and child health (MCH) is a growing concern among the countries of the Former Soviet Union (FSU) where economic issues and changing infrastructures are seriously deteriorating the public health system. Moreover, in the past decade, lack of primary prevention programs coupled with a shortage of well-trained public health professionals are having an increasingly negative impact on MCH outcomes. In this article, we provide a brief overview of the current state of MCH, health care and public health education in the FSU. We suggest that indices could be improved by developing new inexpensive information exchange systems, and that system is Supercourse (accessible at www.pitt.edu/∼super1). Supercourse is an Internet-based library of public health lectures in PowerPoint format that are accessible, free of charge to anyone, anywhere, who has Internet access including scientists, doctors, and, specifically, educators. As of April 2007, Supercourse has more than 3,200 public health lectures, a network of more than 42,000 faculty members across 151 countries, with Nobel Prize winners and the former head of the CDC being among the lectures’ authors. Supercourse lectures are aimed at the educator with the goal of improving public health training through timely and customizable lectures. The distinguishing features of Supercourse are ease of access in low-bandwidth lecture, minimal cost, a distribution system for lectures in CD format, high-quality content, and the capacity to create and sustain a global network of public health professionals. Additionally, statistical process control procedures for industry developed by W. Edwards Deming are utilized to ensure the quality of Supercourse lectures. Papers on Supercourse already have been published in the British Medical Journal, Nature, and Lancet, and are having a wide impact in the field of public health. Currently, an increasing number of lectures in the Supercourse library are dedicated to the theme of MCH. Low cost, high impact projects such as Supercourse are needed to improve and deploy MCH education worldwide.     

Out-of-pocket payments and utilization of health care services in Albania: evidence from three districts

Like most countries in Central and Southeastern Europe, Albania is currently considering a number of alternative health sector reform strategies to improve the availability, quality and use of primary health care services. However, in order to assess the likely success of such reforms, more needs to be known about the current levels, distribution and determinants of household out-of-pocket spending on health. The purpose of this paper is to use the 2002 Albania Baseline Health Survey, a survey of 2,000 households in Berat, Kucova, and Fier, to understand the magnitude and distribution of out-of-pocket payments for health care services and to identify the factors that operate at the household- and provider-levels that determine whether individuals pay for health care and how much is paid within the month prior to the survey. Of particular interest in the study is examining the extent to which households incur out-of-pocket payments across a number of dimensions-including health insurance status, socio-economic status (SES), type of service, and type of facility. The findings suggest that out-of-pocket payments for care provided in government facilities are widespread, with marked differences in payment practices between inpatient and outpatient care. For outpatients using Primary Health Centers (PHCs), the type of facility that is the focus of the government's primary health care program, average payments appear to be nominal (0.6% of estimated total monthly household expenditure per capita). The multivariate findings indicate that insurance coverage significantly reduces the likelihood of paying for medicines to treat acute and chronic health problems, but not of paying for consultations. The policy implications of the findings on alternative health care financing reforms are briefly discussed.     

The current state of health care in the former Soviet Union: implications for health care policy and reform.

OBJECTIVES. Given the many profound health care problems facing Russia and the other former Soviet republics, there are a number of fundamental policy questions that deserve close attention as part of the reform process. METHODS. Summary data regarding Soviet health care issues were drawn from government agency reports, scholarly books and journals, recent press reports, and the authors' personal research. RESULTS. Smoking, alcohol, accidents, poor sanitation, inadequate nutrition, and extensive environmental pollution contribute to illness and premature mortality in Russia and the other newly independent states. Hospitals and clinics are poorly maintained and equipped; most physicians are poorly trained and inadequately paid; and there is essentially no system of quality management. While efforts at reform, which emphasize shifting to a system of "insurance medicine," have been largely unsuccessful, they have raised several important policy issues that warrant extensive research and discussion. CONCLUSIONS. Without considering the implications and consequences of alternative policy directions, Russia and the other states face the very real possibility of developing health care systems that improve the overall level of care but also incorporate limited access and escalating costs. Russian health care reform leaders can learn from the health care successes in the West and avoid repeating our mistakes.     

Reforming health care in the Republic of Kazakstan

Kazakstan, as in other former communist countries, is currently replacing the soviet system of health care financing for a model based on medical insurance. The main initial purpose has been to generate additional revenue for a sector suffering considerably from reductions in state funding induced by economic transition. Two key issues need to be addressed if the new system is to produce genuine reform. First, the rural areas have suffered disproportionately from the changes. There is an urgent need to adapt the existing system so that adequate funding goes to redress this imbalance. Second, although the fund has concentrated on raising revenue, it will only induce real reform if it begins to exercise its role as an independent purchaser of health care. There is a need for the future roles of both health ministry and insurance fund to be clearly defined to ensure that wide access to medical care is preserved.