SOCIOECONOMIC FACTORS AFFECTING INFORMAL PAYMENTS IN THE HEALTH SECTOR.

• Author: Meskarpour-Amiri, Mohammad

1. Introduction

   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).

   Informal payments are a significant source of financing health systems in many developing and transition countries (Ensor, 2004, pp. 237-246; Liu and Sun, 2012, pp. 514-524). As per definition, an informal payment for health care is any kind of direct payment for health (in cash or in kind) which is more than the specified legal payment. Furthermore, informal payments for health care have been described by various terms over the world such as 'under-the-table payments', 'under-the-counter payments', 'envelope payments', and 'red packages' (Chereche[section] et al., 2013, pp. 105-114).

   Informal payments can be created in a health care system because of various reasons including determination of unreal tariff/price for health care services, lack of transparency and inadequate supervision in the health care market, low salary of health care providers and, finally, sociocultural characteristics of society (Lewis, 2007, pp. 984-997).

   Informal payments for health care can increase health system inefficiency, corruption, catastrophic health expenditures, loss of trust and transparency, and inequalities in access to health care. Informal health payments can also lead to making wrong decisions and policies by providing false information about the costs of illnesses and the patient's share of the costs (Thompson and Witter, 2000, pp. 169-187). Moreover, studies showed that the informal health payments can have a negative effect on the quality of health care by inducing rent-seeking behaviors in health care workers and a sense of frustration from knowledge about the unfair allocation of these payments (Maestad and Mwisongo, 2011, pp. 107-115). Evidence also suggests that informal health payment is a regressive health financing method. People with lower income levels make more informal payments than the rich and are more likely to face catastrophic health expenditures (Szende and Culyer, 2006, pp. 262-271). On the other hand, informal payments are often unevenly distributed among health care workers such that more money go to the doctors, while some health care professionals do not receive any share of the informal payments. Therefore, a negative relationship between informal health payments and job satisfaction is also emphasized by some studies (Stringhini et al., 2009, p. 53).

   Although no official statistic about the frequency of informal payments for health care in Iran is released yet, it appears that informal health payments are common in Iran's health care system, according to some studies (Ghiaspour et al., 2011, pp. 1-14). As a response to this situation, from the beginning of May 2014, the Iranian Ministry of Health and Medical Education (MOHME) applied a set of reforms in the health care system called 'Health Evolution Plan' and one of its aims was restricting informal payments (Akhondzade, 2014, pp. 1-2). The cornerstone of the Iran Health Evolution Plan was securing sustainable funds to increase the total health care annual budget by 50%. Through this plan, the government is trying to reduce informal payments through the increase of official tariffs, government financing, and insurance coverage. Thus, the government intends to increase medical tariffs to make them closer to the real price and thereby drop the physicians' excuse of unreal tariffs. In addition, the government has increased its participation in financing health care as well as insurance coverage to eliminate the financial relationship between patients and health care providers as much as possible (Bahadori et al., 2015, pp. 1-2).

   Understanding the socioeconomic factors that influence informal health payments can help policy makers to improve the efficiency of policies to restrict informal payments by identifying and targeting vulnerable groups. Therefore, the aim of our study is to determine the effect of patients' socioeconomic status on their informal payments for health care, which can help us to answer an important question: 'which of the socioeconomic groups are more at risk of paying informally for health care?'.

2. Methods

   2.1. Study design and population

   This study is a cross-sectional and applied study conducted in a general public hospital in Tehran during April 2014.

   The population of the study was 1,035 patients who were discharged during April 2014. All 1,035 patients were asked to participate in the study, but among them only 518 showed interest to participate in the study. Finally, 480 patients have completed the participation and therefore 480 correct questionnaires were completed through face-to-face interviews with patients or their representatives. The low response rate was predictable due to the nature of the study.

   2.2. Instrument and procedure

   Data gathering was conducted using a questionnaire. The validity of the questionnaire was confirmed through content validity index (0.87). Also the reliability of the questionnaire was confirmed with 0.95 correlations by using test-retest method. All questionnaires were completed with direct collaboration/support of 8 trained and educated interviewers, in order to ensure maximum accuracy of data collection process. Also it should be noted that due to illegal nature of informal payments, in order to protect patients' privacy the study was without any question about their name and address.

   A written ethical commitment was given to respondents in order to keep their information confidential.

   2.3. Study variables

   The study variables were the socioeconomic characteristics of patients (including sex, age, education, household dimension, working status and the average monthly income of patients' family), insurance features of patients (basic and supplementary insurance), average monthly health care expenditure of patients during the last year, and also questions about the frequency of informal payments made by patients to receive health care services during the last year. The patients were asked to answer questions such as 'Have you ever informally paid for health care during the last year?'. The response to the question was classified into 4 items as follows: I have never informally paid for health care during the last year; I sometimes informally paid; I often informally paid; and I always had unofficial payments. Then, the ordered values of 1, 2, 3, and 4, respectively, were allocated to each answer.

   Informal health payments were fully explained by the...