Payment of Informal Fees by Patients and Their Families
Informal payments are defined as payments “to individual and institutional providers, in kind or in cash, that are made outside official payment channels or are purchases meant to be covered by the health system” (Lewis, 2007, p. 985). This definition includes payments made to doctors or hospitals under the table and the cost of drugs, supplies, or amenities that are bought by patients or families but that should have been provided by the public facility or program (Lewis, 2007, p. 985; Tatar and others, 2007).
In 2008, Anne Cockcroft and others published a study of informal payments in the Baltic States of Estonia, Latvia, and Lithuania, which had formerly been parts of the Soviet Union. Almost half of the participants in this household survey believed that informal fees are not really corruption. However, the authors concluded that the “lack of consensus on whether informal payment is corruption is a subject for concern. Some believe that the very lack of consensus encourages corruption” (Cockcroft and others, 2008).
How should we react to the payment of informal fees for health services in developing and transitional countries? It seems that people who study the issue tend to go through several stages in their reaction to the use of informal fees for health services. These stages are similar in some ways to the well-known stages of grief. As discussed in the following section, these stages are outrage, multicultural acceptance, research, rationalization, and developing practical solutions.
The Stage of Outrage. The first stage is to be outraged and acrimonious at the unethical behavior of health workers who take advantage of poor patients in developing and transitional countries. These informal fees create barriers to access for essential health care services, cause financial hardship or even ruination for patients and their families, and reduce equity in the health system (Lewis, 2007, p. 990). Because developing countries typically lack systems of health insurance to prepay expenses and pool the risks, a large share of health spending comes from out-of-pocket payment by patients and their families. As Maureen Lewis (2007) has pointed out, compared to populations generally, people in poor countries pay the highest percentage of their income out of pocket for health services, in part because their governments lack the capacity to raise revenues by taxation to finance health services (p. 984). Under these circumstances, requiring payment of additional fees under the table is particularly burdensome. Experts have also noted that informal fees can result in distortion of priorities and misallocation of resources (Ensor, 2004, pp. 241, 244), lead to understatement of actual levels of health spending (Tatar and others, 2007, p. 1037), and interfere with efforts toward health reform (Ensor, 2004, p. 244; Tatar and others, 2007, p. 1038).
The Stage of Multicultural Acceptance. Who are we to judge or criticize the deeply ingrained cultural practice of expressing gratitude to those members of a community who provide necessary services to fellow community members? According to some researchers, making a “donation” to a physician is a cultural or social practice (Tatar and others, 2007, p. 1036). The study by Cockcroft and others (2008) in the Baltic States found that many people consider gifts for health professionals to be an appropriate statement of gratitude. Moreover, the practice of collecting informal fees is arguably analogous to some of the ways in which health care providers in industrialized countries distinguish among their patients on the basis of wealth, insurance status, and source of payment.
The Stage of Research. When all else fails, let’s look at the actual data. The data indicate that informal fees are usually paid before receiving the health service and therefore are not post hoc expressions of gratitude (Tatar and others, 2007, pp. 1035–1037). Rather, informal fees may be paid to obtain services to which patients were already entitled, get more attention, reduce waiting times, increase hospital length of stay, have a choice of physician, or even for mothers in maternity homes to be allowed to see their babies (Tatar and others, 2007, pp. 1035–1037; Lewis, 2007, pp. 989–990; Ensor and Duran-Moreno, 2002, p. 118). Informal fees might also be paid as a type of implicit health insurance for future medical services (Lewis, 2007, pp. 984–985). Finally, data indicate that many patients and their families do not like having to pay informal fees, which undercuts the argument that informal fees are an accepted cultural practice (Tatar and others, 2007, p. 1037).
The Stage of Rationalization. After all, informal fees are small potatoes. The focus on informal fees may distract our attention from the much more important issue of large-scale corruption in health systems of developing and transitional countries (Ensor and Duran-Moreno, 2002, p. 118). Some government officials might even want us to focus on informal fees, in order to distract attention from their own large-scale bribery and diversion of resources. Moreover, informal fees are necessary to support the health system, in light of inadequate government funding and ridiculously low salaries for health workers. “Where earnings are low, individuals have second and third jobs, but they also perceive that low wages entitle them to demand contributions from patients” (Lewis, 2007, p. 993). Under these circumstances, Tim Ensor and Antonio Duran-Moreno (2002) attempted to distinguish informal fees that constitute the extraction of “rents” from other informal fees that are merely a “coping strategy” or “survival strategy.” They reasoned that physicians in industrialized countries (members of the Organisation for Economic Co-operation and Development) usually earn between 2.5 and 4 times the average wage in their countries. Therefore, if physicians in other countries collect informal fees from their patients, it is arguably not corruption or is merely “petty corruption” so long as the physicians are not taking in more than twice the average income in their respective countries (pp. 114–117). From an ethical perspective, however, that approach is problematic. In fact, Ensor (2004) subsequently wrote that “unofficial payments might be given to ensure that staff employed in the facility reach their reservation wage—the wage which ensures retention of staff and provision of a good quality service Yet giving tacit acceptance to the practice of ‘reasonable bribes’ to medical practitioners to perform procedures that they are officially required to provide without charge is hard to accept from an ethical point of view, even if it is understandable from the point of view of personal survival” (p. 239).
The Stage of Developing Practical Solutions. Although it is crucial to address high-level corruption in health systems, it is also important to reduce the burden of informal payments, especially as they affect access to care and financial hardship for the poorest segment of the population. Writing about informal payments in Turkey, Mehtap Tatar and others (2007) explained that when “extended to the whole country, the impact of these payments could exceed that of large-scale corruption, and their consequences could be more serious and direct, both on the health system and on patients” (p. 1039). Similarly, Cockcroft and others (2008) have argued that on a cumulative basis, so-called petty corruption, including informal fees, can have a serious effect on the health system and the delivery of health services. Having decided that we want to eliminate—or at least reduce—the collection of informal fees, how can we best accomplish that goal? If we simply outlaw the collection of informal fees, that could have the adverse results of (1) being unenforceable; (2) reducing the actual income of health workers; or (3) causing health workers to leave public health care facilities for work in the private sector (Ensor and Duran-Moreno, 2002, p. 117) or leave the country altogether. Most experts conclude that it is necessary to raise the official income of health workers (Ensor and Duran-Moreno, pp. 117–118), but governments may be unable or unwilling to provide the additional funding. Moreover, pay increases alone will not solve the problem, unless they are accompanied by other reforms to provide more appropriate incentives for health workers, greater accountability, and elimination of informal fees (Lewis, 2007, pp. 993–994). It is also necessary to consider how to enforce the prohibition against informal fees, so that patients are not required to pay both an increased official fee and an informal fee. It is particularly important that local managers have the ability to discipline and even fire health workers who violate the rules against collection of informal fees or fail to provide appropriate care (Lewis, 2007, p. 994). Under these circumstances, most proposals for reform involve increasing the official fees to be paid by patients, as part of a comprehensive plan to reduce informal fees. This strategy, which is described as formalization of fees, has been implemented with promising results in a few locations such as Cambodia and the Kyrgyz Republic (Ensor and Duran-Moreno, 2002, p. 118; Lewis, 2007, pp. 992–999; Barber and others, 2004). Even after formalization, however, patients might still be forced to pay informal fees, and some patients might even prefer to pay informal fees as a way to have their choice of physician (Ensor, 2004, p. 242; Ensor and Duran-Moreno, 2002, pp. 118, 121). Fundamentally, informal fees in the health system are part of the broader problems of corruption, lack of accountability, and inadequate governance, and the ultimate solution to informal fees will require reform of incentives and regulation on a much broader level (Lewis, 2007, pp. 992, 995; Ensor, 2004, p. 244).
The activity at the end of this chapter presents an opportunity to consider the practical aspects of developing a hospital plan to stop collection of informal fees from patients in a developing country. As described in the activity, the goal is to effectively prevent collection of informal fees from patients, without reducing the income of health workers and without increasing expenditures by the government.
Is Corruption Bad for Your (and Other People’s) Health?
We often hear about things that are bad for our health. What about corruption, including informal fees and other types of corrupt conduct in health systems? Is it possible that corruption could be bad for our health and also bad for other people’s health?
The first part of this chapter analyzed one specific type of corruption, the collection of informal fees, and described some of its adverse effects, such as creating barriers to access and causing financial hardship. The next part of this chapter applies a broader approach, by analyzing the effects of corruption, in all of its various forms, on the health status of a population.
The relationship between good governance and good health is complex (Lewis, 2006, pp. 8–13). One possibility is that poor governance, including a high level of corruption, can cause or contribute to poor health status in a population or even to a large-scale crisis in public health. Another possibility is that a health crisis, or some other type of crisis such as war or natural disaster, can cause or contribute to an increase in corruption. In a time of crisis, extreme shortages exist, and many people struggle to save themselves and their families. Meanwhile, large sums of money may be allocated in a relatively short period of time, with an urgent mandate to spend that money as soon as possible to alleviate the widespread suffering. Under those circumstances, opportunities can arise to take advantage of the needs of other people, by means of theft, bribery, or other forms of corruption. This may involve small-scale theft or bribery, engaged in as a means of survival, as well as large-scale corruption by public officials at the highest levels.
Another possibility is that some other factor can cause or contribute to both corruption and low health status. Among other factors, illiteracy or poverty could lead to both corruption and problems in health. In fact, this might be the familiar phenomenon of the chicken and the egg, in which each factor contributes to the other in a cyclical fashion. By analogy, it has been well documented that poverty leads to illness, which in turn leads to more poverty. Perhaps the relationship between corruption and health is similar, with corruption leading to low health status or a large-scale crisis in health, which in turn leads to even more corruption.
In the article excerpt that follows, Anatole Menon-Johansson explores the relationship between health and poor governance, including a high level of corruption. Menon-Johansson used the level of HIV prevalence in each country as one way to measure the health of a population, and relied on data from the World Bank and UNAIDS. (Readers who are interested in more information about the underlying data should refer to the full text of the article as originally published.)
Excerpt from “Good Governance and Good Health: The Role of Societal Structures in the Human Immunodeficiency Virus Pandemic”
By Anatole Menon-Johansson
Some of the shared societal structures underpinning economic growth and health are the absence of violence, government effectiveness, the rule of law, lack of corruption and the ability to select a government. Even though all of these are clearly desirable the relative weight of each societal structure necessary for a strong nation state is debatable. The risk of infectious disease is determined not only by pathogens and the response of the patient but also by powerful societal forces that override individual knowledge and choice. Paul Farmer has coined the phrase “structural violence” that reflects the limit of life choices, particularly of women, by racism, sexism, political violence, and grinding poverty.
The 2004 World Health Report discusses the challenges of tackling the HIV pandemic. In the African continent, HIV is implicated in poor economic performance and falling gross domestic product (GDP). Within this document it describes the wide range of international support garnered to meet this challenge. However, even though the requirement of local and national government co-operation is stressed within this document, it does not elaborate on the massive heterogeneity inherent within this mandatory component.
In order to investigate the strength of the relationship between the quality of societal structures and the HIV pandemic, World Bank and UNAIDS sources were used to test the null hypothesis: “HIV prevalence is not associated with governance”.
Methods
A recent World Bank paper entitled Governance Matters III collated governance indicators for 199 countries/regions. Governance in this document has been broken down into six dimensions…Using these definitions, this research collected data for each country from 18 sources…Governance data were then aggregated for each country and plotted along a continuum. Only the 2002 governance data has been used in this paper
The 2002 HIV prevalence estimates were obtained for each country. HIV prevalence is the percentage of adults aged between 15 and 49 years of age infected with HIV. One hundred and forty nine of the 199 countries/regions cited by the World Bank paper had published UNAIDS 2002 HIV prevalence estimates
In addition to separate analysis of each governance dimension, an average governance figure was obtained based on the assumption that each governance dimension was of equal importance. The null hypothesis was tested by measuring association between ranked governance and HIV prevalence data across the whole spectrum of countries…
Results
There were fifty distinct HIV prevalence rankings from the 149 countries with UNAIDS HIV prevalence estimates in 2002. Botswana had the highest HIV prevalence estimates (38.8%) in the world that year whilst the majority of countries were placed within the lowest ranking, where HIV prevalence estimates were reported by UNAIDS to be < 0.1% (written as 0.05%)
The negative correlations indicate that HIV prevalence falls as the governance improves for each governance dimension and mean governance. The three most influential dimensions of governance were government effectiveness, the rule of law and corruption. All correlations were significant thus rejecting the null hypothesis.
Discussion
It is possible to divide those nations affected by HIV/AIDS into three groups that approximate to governance ranking. The higher governance group is characterized by significant wealth and effective healthcare systems. The main challenges for these countries…[consist] of the provision of sexual health services, health care access to marginalized groups, continuation of education and research into new and improved prevention and treatment strategies.
The HIV prevalence is generally low in higher governance group however this figure conceals differences found within specific population groups. For example in the USA, HIV prevalence amongst African American women is almost twenty three times that in whites. Whilst in the UK, the prevalence of HIV amongst men who have sex with men (MSM) within London in 2001 was 100 times the national average. The disparity in HIV prevalence amongst “at risk” groups in the UK and US highlight the general difficulty of using the UNAIDS country HIV prevalence estimates. The quality of surveillance methods has been discussed and graded by UNAIDS surveillance teams, and it is clear that some HIV prevalence estimates are inaccurate
The null hypothesis ‘HIV prevalence is not associated with governance’ is rejected for each dimension of governance with variations in the relative importance of different governance dimensions. Previously, Fareed Zakaria has argued that democracy is less important in the development of a strong nation than the rule of law, corruption and political stability. The correlation coefficient of the voice and accountability dimension of governance with HIV prevalence was the lowest in this analysis somewhat supporting this contention.
Those countries in the lowest governance ranking group of governance are defined by poverty, ineffective health care systems, elevated HIV prevalence and significant international debt. The elevated HIV prevalence in many of these vulnerable countries was predicted more than a decade ago following the analysis of health, economic and human rights data. Historically, international support has focused on short-term “vertical” disease control strategies to tackle healthcare problems. Long-term, “horizontal” capacity building strategies are vital if HIV/AIDS is going to be…[effectively] managed in nations with limited healthcare infrastructure. It has been shown in a number of resource poor settings that the provision of voluntary counselling and testing (VCT) for HIV is facilitated by the provision of free primary care services and ART [antiretroviral therapy]. The provision of effective primary care support to pregnant women is the most effective way to provide VCT services for HIV and thereby identify HIV positive mothers, prevent mother to child transmission and facilitate VCT of their partner(s). Like surveillance, this strategy though relatively effective fails to test and treat vulnerable “high risk” groups within the population.
The poor are those most at risk of infectious disease. The role of poverty as a risk factor for disease has been clear for over 300 years. Health and wealth are inextricably linked. All who become chronically ill enter a negative cycle of limited horizons. Indeed, what is true for the individual is equally true for the nation state. The effect of HIV on economic under performance and negative growth is testament to this. It is vital that essential healthcare is free, so that those that catch treatable infectious diseases are allowed to live. Encouragingly there are a few positive examples in resource poor countries, such as Uganda, Senegal and Cuba, where leadership, good communication and support of civil society have made a difference in their respective HIV epidemics. There are however many countries within this group of vulnerable nations that need the bulk of international healthcare and financial institution commitment in order to address their devastating health-care challenges.
Cuba and Haiti are islands with a similar population size and GDP-PPP [gross domestic product—purchasing power parity] per capita yet the HIV prevalence estimates are 0.05% and 6.1% respectively. HIV is thought to have entered Haiti from the USA via the sex trade in the early 1980s. The main exposure risk for Cuban nationals was from military and healthcare worker interaction with sub-Saharan Africa. Cuba was one of the first countries in the Americas to launch a nationwide HIV policy to contain transmission and care for those people living with HIV/AIDS. Healthcare in Cuba is provided free to its citizens by the state and there is strong political commitment supporting health as well as national and international HIV/AIDS action. In contrast, there have been 33 coups in Haiti in the last two centuries of independence. Political instability in addition to other governance factors…[has] been attributed to the lack of development of a responsive healthcare system.
As governance improves fewer women die in childbirth, more physicians exist per population, there is better access to improved water and life expectancy is longer. In addition with improvements in governance there is more GDP-PPP per capita, more equitable distribution of income and greater investment in health and education compared to the military.…Russia has over 3 million intravenous drug users and relatively expensive ART that help to fuel the HIV epidemic. The collapse of the USSR produced significant strain on the health of the people. Life expectancy in Russia fell 9 years following its transition to a market economy and there has been a significant rise in ‘social diseases’ of Tuberculosis (TB), HIV and Hepatitis. Intravenous drug use accounts for approximately 80% of those infected with HIV however recently a new phase of the epidemic has developed that is driven by sexual transmission. It is only since 2003 that there has been an increase in leadership and commitment at higher political levels to combat HIV and AIDS.
UNAIDS reported in 2002 that the number of overall infections in China increased 30% since 1998, with over 1 million people infected with HIV. It is feared that China may soon experience an explosive and widespread HIV epidemic. Intravenous drug use and the sharing of contaminated needles in the south and north-west of China was one mechanism of initial transmission. The other was unsafe practices among paid blood donors. Unsafe blood collections in the 1990s led to the appearance of HIV and subsequent AIDS deaths in China’s central provinces. In response to this the Chinese authorities have recently announced that they are providing free ART in central provinces.
The first main focus of HIV in India was Mumbai where there is a large commercial sex work industry and the HIV prevalence reported amongst these workers is 50%. It is expected that HIV will become the largest cause of adult mortality in India in the coming decade. Despite the government making HIV its national topmost priority, any attempt to address the problem is hampered by its fractured health care infrastructure, poor literacy figures and widespread poverty. At the end of 2003 the Indian government began providing free ART in eight government hospitals with the plan to expand it to a total of 25 centres.
The aim of this paper was to attempt to dissect out the role of governance in the HIV pandemic. It is not possible yet to determine if the relationship seen represents correlation or causation. Even though this first analysis alludes to causation, for those 149 countries with UNAIDS HIV prevalence data, the relationship will become clearer over time when it is possible to compare nations that appear similar today. Currently Brazil and India have equivalent overall governance and HIV prevalence estimates at 0.8% and 0.7% respectively. However when other health and economic indices are examined it is clear that India…[invests] less than Brazil in health and education, has one quarter the number of physicians and double the MMR [maternal mortality rate]. The GDP-PPP per capita is three times greater in Brazil but it is more equitably distributed in India which is likely to contribute to equivalent life expectancy seen in both countries. India and Brazil are the main producers of generic ART. However Brazil, unlike India, has consistently provided strong political support for HIV/AIDS patients after the end of the military dictatorship in 1990. In 1996, the Brazilian government guaranteed by national law the permanent allocation of financial resources and universal access to care, including ART. The current disparities between India and Brazil’s HIV treatment policy predicts that the Indian epidemic will progress more rapidly and is likely to impact on its development
HIV/AIDS control in Russia, China and India will only be possible if they follow the example set by Brazil. International institutions need to support national civil society groups within these nations to focus the attention and resources of their respective governments for progressive healthcare changes. The global plan to stop TB outlines the possibilities and challenges that will be faced treating chronic illness, such as HIV. It is pertinent that international health and financial institutions work together to influence change so that robust healthcare networks and responsive government are developed in order to apply best healthcare and economic practice.
The WHO goal of three million HIV positive persons being on ART by 2005 would be readily met if civil society in resource rich countries was able to precipitate progressive societal changes. Health is a fundamental human right, consequently each global institution, organization and citizen needs to work towards stable and progressive societal structures that can facilitate the provision of healthcare “access for all”. The current HIV pandemic represents collective inaction and indifference towards global health. The promotion of good governance is a necessary step to enable national civil society to engineer long-term healthcare changes to deal with HIV/AIDS and future healthcare challenges.
Conclusion
Using World Bank governance data and UNAIDS HIV prevalence estimates for 2002 this paper tests the hypothesis “HIV prevalence is not associated with governance”. Additional health and economic indices are used to highlight the development needs for each country. The accuracy of both governance and HIV prevalence estimates are discussed and some country comparisons are made. HIV prevalence is significantly associated with poor governance. International public health programs need to address societal structures in order to create strong foundations upon which effective healthcare interventions can be implemented.
Source: Excerpted from “Good Governance and Good Health: The Role of Societal Structures in the Human Immunodeficiency Virus Pandemic,” by A. Menon-Johansson, 2005. BMC International Health and Human Rights, 5(4), doi: 10.1186/1472-698X-5-4, [http://www.biomedcentral.com/1472-698X/5/4] (citations, references, tables, and some text omitted). Copyright 2005 A. Menon-Johansson; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited
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