Description

Abstract

Informal payments in the health sector of many developing countries are considered as a major impediment to health care reforms. Informal payments are a form of systemic fraud and have adverse effects on the performance of the health system. In this study, the frequency and extent of informal payments as well as the determinants of these payments were investigated in general hospitals Nasarawa state.

In this cross-sectional study, 300 discharged patients were selected using multi-stage random sampling method. First, three hospitals were selected randomly; then, through a simple random sampling, we recruited 300 discharged patients from internal, surgery, emergency, ICU & CCU wards. All data were collected by structured telephone interviews and questionnaire. We analyzed data using Chi- square, Kruskal-Wallis and Mann-Whitney tests.

The results indicated that 21% (n=63) of individuals paid informally to the staff. About 4% (n=12) of the participants were faced with informal payment requests from hospital staff. There was a significant relationship between frequency of informal payments with marital status of participants and type of hospitals. According to our findings, none of the respondents had informal payments to physicians. The most frequent informal payments were in cash and were made to the hospitals’ housekeeping staff to ensure more and better services. There was no significant relationship between the informal payments with socio-demographic characteristics, residential area and insurance status.

Our findings revealed that many strategies can be used for both controlling and reducing informal payments. These include training patients and hospitals’ staff, increasing income levels of employees, improving the quantity and quality of health services and changing the entrenched beliefs that necessitate informal payments.

CHAPTER ONE

1.0                                                                Introduction

1.1                                                    Background of the study

Health systems not only play a critical and important role in improving health, but also are responsible to protect individuals against the financial costs of illnesses and diseases. One of the challenges that governments face is the reduction of out-of- pocket payments through the provision of subsidies, and expansion plans of prepayments (WHO, 2022). Out -of- pocket payments by the poorest people is an unfair way of healthcare financing. This way from both the perspective of equity and financial risk protection is considered as the worst possible way of debt financing and exposes individuals with a lot of risks (Roberts et al., 2018).

From an economic perspective, informal payments are a form of direct out-of-pocket payment because they have similar effect on the demand and financial burden com- pared to the official payments (WHO, 2014). Informal payments in many developing and transition countries is considered as a major source of health care financing and a serious obstacle for health care reforms (Lewis et al., 2017). In general, informal payments are defined as:(a) payments to people or providers in the form of cash or kind but outside of official payment channels, or(b) payments for purchasing medication and medical equipment by patients or their family members – where the responsibility is on public healthcare system or service provider unit. It should be noted that the voluntary purchase of medicines and equipment from the private sector is not considered as informal payments (Witter et al., 2010).

In general, informal payments in the cur- rent empirical studies have been defined as monetary or non-monetary compensation of services provided by healthcare personnel that is not a part of the official salaries of employees. These payments can be expected or unexpected, and may cause receiving additional and luxurious service (Witter et al., 2010). Informal payments are also known by other names including “under-the-table, bribery and corruption, bribery in the form of tea service payment, non-official payments, and corruptive payments” (Thompson et al., 2020). Since informal payments are often paid directly to the individual health service providers, therefore, such payments are classified in the category of “use of public resources for private interests” and as a result, they are considered as a systemic corruption. In fact, informal payment is considered as a form of black market (Szende et al., 2010). They exist for a number of reasons such as lack of state resources for financing healthcare, lack of trust and transparency in the health system, lack of adequate monitoring, low salaries and benefits for health service providers, lack of proper accountability in service delivery, poor management, poor quality services, frustration of service recipients as well as social and cultural features including tip giving culture (Szende et al., 2010).

Informal payments can lead to changes in government investment priorities, inefficiency of health systems, increased corruption, and reduction in reliability and transparency in the system. They can also affect health equity, access to and utilization of services, quality of services, the incentive to provide quality services by service providers, catastrophic costs, misrepresentation regarding the cost and extent of dis- ease, and the patient’s share of these costs which all result in incorrect policy decisions (Szende et al., 2010).

Setayesh and colleagues (2005) surveyed the public opinion towards paying informal payments to doctors in Kerman, Iran. They stated that 70% of the respondents had sufficient knowledge about under the table payments, 78% believed that informal payments would harm the sanctity of the medical profession, and in 87% of the cases people did not have sufficient information about the existence of competent authorities to handle the under-the-table payments (21).

Studies indicate that informal payments in the health care sector occur frequently in all health centres in Nigeria. However, there are a few studies in this regard, therefore, this study aimed to estimate the amount of informal payments and its influencing factors among the hospitals in Nasarawa State. This study can be a useful step in improving Nasarawa State’s health system management.

Statement of the problem

The protection of individuals against the financial risks of illness is one of the most important responsibilities of health care systems. In this regard, one of the most important challenges is the reduction of out-of-pocket health payments because it is the weakest and most unfair way to finance health care (Xu et al., 2007, pp. 972-983). From the health economics perspective, informal payments for health care can be out-of- pocket payments because they have the same effect on health care demand and financial risk of illness compared to formal direct payments (Ghiaspour et al., 2011, pp. 1-14).

Out-of-pocket payments (OOPs) for health care are a barrier to achieving Universal Health Coverage (WHO, 2010) but remain widespread in many low- and middle-income countries (LMICs), despite being inequitable, often regressive, and inefficient as a financing mechanism (Asante et al., 2016). Many countries are working to extend and strengthen prepayment mechanisms (e.g. general taxation and health insurance) to ensure financial protection (WHO, 2010; Kutzin, 2013). However, they have often focused on formal OOP, giving less attention to informal payments (Hutchinson et al., 2019). Informal payments include payments to individual healthcare workers or their facilities, in kind or in cash, made outside official payment channels, including payments for drugs/supplies that should be covered by the health system. They are encouraged by characteristics of clinical encounters, where health workers can exploit information asymmetry, uncertainty and power imbalance the broader context (Schaaf and Topp, 2019).

Aim and objectives of the study

The aim of this study is to estimate the amount of informal payments and its influencing factors among the hospitals in Nasarawa State.

The objectives of the study are:

i.       To study factors that influence informal payments in health facilities in Nasarawa State.

ii.      To in improve Nasarawa State’s health system management

iii.     To highlight strategies that can be used for both controlling and reducing informal payments.

Significance of the study

This study can be a useful step in improving Nasarawa State’s health system management.

This study will also serve a means of studying and becoming familiar with different factors that influence informal payments in health facilities in Nasarawa State.

Scope of the study

The scope of this work covers estimating the amount of informal payments and its influencing factors among the hospitals in Nasarawa State. In this study, the analysis of the study was done using multi-stage random sampling method. First, three hospitals were selected randomly; then, through a simple random sampling, 300 discharged patients from internal, surgery, emergency, ICU & CCU wards. All data were collected by structured telephone interviews and questionnaire. We analyzed data using Chi- square, Kruskal-Wallis and Mann-Whitney tests.