To pay or not to pay? A multicountry study on informal payments for health-care services and consumers' perceptions.

BACKGROUND: Although the literature offers various theoretical explanations for the existence of informal patient payments, empirical research has mostly focused on socio-demographic features as determinants of these payments. The role of health-care users' perceptions on informal payments are rarely taken into account especially in multicountry surveys. OBJECTIVE: Our aim is to examine the association between informal payments for health-care services and perceptions of health-care consumers about paying informally as well as socio-demographic characteristics. DESIGN: We use data from a multicountry quantitative empirical research conducted in 2010. SETTING AND PARTICIPANTS: A national representative sample is drawn in six Central and Eastern European countries - Bulgaria, Hungary, Lithuania, Poland, Romania and Ukraine. In each country, about 1000 respondents are interviewed. MAIN VARIABLES STUDIED: Data related to informal payments for health-care services consumed during the preceding 12 months are analysed in addition to data on respondents' perceptions about paying informally and socio-demographic data. RESULTS: Health-care users in Bulgaria and Poland are less inclined to make informal payments, while health-care users in Romania and Ukraine most often report such payments. The informal payment rates for Hungary and Lithuania fall between these two groups. In all six countries, individuals who feel uncomfortable when leaving the physician's office without a gratuity and who feel unable to refuse the request of medical staff to pay informally, more often make informal payments. CONCLUSIONS: Such consumers' perceptions can undermine policy efforts to eradicate these payments; therefore, health policy measures should reinforce social resistance to informal payments.

Preferences for physician services in Ukraine: a discrete choice experiment.

Evidence on preferences of Ukrainian consumers for healthcare improvements can help to design reforms that correspond to societal priorities. This study aims to elicit and to place monetary values on public preferences for out-patient physician services in Ukraine. The method of discrete choice experiment is used on a sample of 303 respondents, representative of the adult Ukrainian population. The random effect logit model with interactions provides the best fit for the data and is used to calculate the marginal willingness to pay (MWTP) for quality and access improvements. At a sample level, there is no clear preference to pay formally rather than informally or vice versa. We also do not find that visiting a general practitioner is preferred over direct access to a medical specialist. However, there are differences between population groups. Quality-related attributes of physician services appear important to respondents, especially the attitude of medical staff. Thus, interpersonal aspects of out-patient care should be given priority in decisions about investments in quality improvements. Other aspects, that is social quality and access, are important as well but their improvement brings fewer social gains. Measures should be taken to eradicate the informal payment channels and to strengthen the gate-keeping role of primary care.

Willingness to pay for physician services at a primary contact in Ukraine: results of a contingent valuation study.

BACKGROUND: The existence of quasi-formal and informal payments in the Ukrainian health care system jeopardizes equity and creates barriers to access to proper care. Patient payment policies that better match patient preferences are necessary. We analyze the potential and feasibility of official patient charges for public health care services in Ukraine by studying the patterns of fee acceptability, ability and willingness to pay (WTP) for public health care among population groups. METHODS: We use contingent valuation data collected from 303 respondents representative of the adult Ukrainian population. Three decision points were separated: objection to pay, inability to pay, and level of positive non-zero WTP. These decisions were studied for relations with quality profiles of the services, and socio-demographic characteristics of the respondents and their households. RESULTS: The likelihood to object to pay is mostly determined by the quality characteristics of the services. Objection to pay is not related to corresponding behavior in real life. The likelihood of being unable to pay is associated with older age, lower income, and a larger share of household members with no income. The level of positive WTP is positively related to income (+7% per 1000 UAH increase in income) and is lower for people who visited a doctor but did not pay (-22%). CONCLUSIONS: Rather substantial WTP levels (between 0.9% and 1.9% of household income) for one visit to physician indicate a potential for official patient charges in Ukraine. User fees may cover a substantial share of personnel cost in the out-patient sector. The patterns of inability to pay support well designed exemption criteria based on age, income, and other aspects of economic status. The WTP patterns highlight the necessity for payments that are proportional to income. Other methodological and policy implications are discussed.

Informal patient payments in maternity hospitals in Kiev, Ukraine.

Maternity care in Ukraine is a government priority. However, it has not undergone substantial changes since the collapse of the Soviet Union. Similar to the entire health care sector in Ukraine, maternity care suffers from inefficient funding, which results in low quality and poor access to services. The objective of this paper is to explore the practice of informal payments for maternity care in Ukraine, specifically in cases of childbirth in Kiev maternity hospitals. The paper provides an ethnographic study on the consumers' and providers' experiences with informal payments. The results suggest that informal payments for childbirth are an established practice in Kiev maternity hospitals. The bargaining process between the pregnant woman (incl. her partner) and the obstetrician is an important part of the predelivery arrangement, including the informal payment. To deal with informal payments in Kiev maternity hospitals, there is a need for the following: (i) regulation of the "quasi-official" patient payments at the health care facility level; and (ii) improvement of professional ethics through staff training. These strategies should be coupled with improved governance of the health care sector in general, and maternity care in particular in order to attain international quality standards and adequate access to facilities.

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. METHODS: The systematic review was based on the following eligibility criteria: English language publications that reported on empirical studies measuring informal patient payments. There were no limitations with regard to the year of publication. The content of the publications was analysed qualitatively and the results were organised in the form of tables. Data sources were Econlit, Econpapers, Medline, PubMed, ScienceDirect, SocINDEX. RESULTS: Informal payments for health care services are most often investigated in studies involving patients or the general public, but providers and officials are also sample units in some studies. The majority of the studies apply a single mode of data collection that involves either face-to-face interviews or group discussions.One of the main methodological difficulties reported in the publication concerns the inability of some respondents to distinguish between official and unofficial payments. Another complication is associated with the refusal of some respondents to answer questions on informal patient payments.We do not exclude the possibility that we have missed studies that reported in non-English language journals as well as very recent studies that are not yet published. CONCLUSIONS: Given the recent evidence from research on survey methods, a self-administrated questionnaire during a face-to-face interview could be a suitable mode of collecting sensitive data, such as data on informal patient payments.

Patterns of informal patient payments in Bulgaria, Hungary and Ukraine: a comparison across countries, years and type of services.

Informal payments for health care are a well-known phenomenon in many health care systems around the world. While informal payments could be an important source of health care financing, they have an adverse impact on efficiency and access to care, and are a major impediment to ongoing health care reforms. This paper aims to study the scale and patterns of informal patient payments for out-patient and in-patient services in three former-socialist countries: Bulgaria, Hungary and Ukraine. The data are collected in 2010 and 2011 based on national representative samples and are analysed in pooled models to explain variations in payments. The results of the cross-country comparison suggest a relatively higher prevalence of informal patient payments in Ukraine and Hungary than in Bulgaria, where patients also have to pay formal user charges in the public sector. Nevertheless, informal payments for hospitalization in Bulgaria are quite extensive. We observe some differences in informal payments across the years. Variations in payment size are mainly explained by the nature, type and need for services, fee awareness and, on some occasions, by household income. Interpreted within the context of structural differences (e.g. reform paths, regulations, funding, user fees, anti-corruption policies), the findings of our study have implications on how to address informal payments for health care.

Willingness and ability to pay for physician services in six Central and Eastern European countries.

Patient charges for physician services are implemented in high-income countries and often are considered in the Central and Eastern Europe (CEE). However, there is no evidence on the potential consumption effects of service charges in these countries. This study provides evidence on the potential impact of patient charges on the consumption of specialized physician services in six CEE countries: Bulgaria, Hungary, Lithuania, Poland, Romania, and Ukraine. We apply a semi-parametric survival analysis to stated willingness and ability to pay (WATP) in order to identify potential demand pools and their price, income and age semi-elasticity. Data are collected through a survey held in 2010 among representative samples of about 1000 respondents in each country. Our results suggest that median WATP in the studied countries is comparable to the cost of the services. The obtained demand pools appear to be theoretically valid and externally consistent. They provide information on the shares of population that would be WATP certain fee levels, and their heterogeneity across socio-demographic groups gives an idea about the population groups that will need to be exempted.