defining informal payments in healthcare: a systematic review
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Health Policy 110 (2013) 105– 114
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Health Policy
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efining informal payments in healthcare: A systematic review
azvan M. Chereches a, Marius I. Ungureanua,b,∗, Petru Sandua,b, Ioana A. Rusa
Center for Health Policy and Public Health, Institute for Social Research, Faculty of Political, Administrative and Communication Sciences, Babes -Bolyainiversity, 7 Pandurilor Street, 400376 Cluj-Napoca, RomaniaIuliu Hatieganu University of Medicine and Pharmacy, Department of Public Healh and Healthcare Managament, Cluj-Napoca, Romania
r t i c l e i n f o
rticle history:eceived 21 November 2011eceived in revised form 12 January 2013ccepted 15 January 2013
eywords:nformal paymentsefinitionsystematic reviewealth systemsomparative research
a b s t r a c t
Objectives: To explore the literature for the definitions of informal payments in healthcareand critically analyze the proposed definitions. This will serve in the process of getting to acoherent definition of informal payments, which will further support acknowledging andaddressing them globally.Methods: A search strategy was developed to identify papers addressing informal paymentson PubMed, ScienceDirect, Econlit, EconPapers and Google Scholar.Results: 2225 papers were identified after a first search. 61 papers were included in thesystematic review. Out of all definitions provided, we selected three definitions as beingoriginal. All other definitions either cite these definitions or do not provide new insightinto the topic of informal payments. Although informal payments have been nominated byvarious terms over the years, there is a tendency in recent years towards an agreement touse this singular term. Definitions differ in terms of the relation of informal payments with
other informal activities, their legality and the motivation behind them.Conclusions: The variety of forms which informal payments may take makes it difficult todefine them in a comprehensive manner. However, we identified a definition that couldserve as a beginning in this process. More effort is needed to build on it and get to acommonly accepted and shared definition of informal payments.. Introduction
Informal payments in the health care sector are becom-ng an increasingly urgent and debated issue, especially ineveloping and transitional countries in Central and East-rn Europe (CEE); the Former Soviet Union (FSU); Central,astern and Southern Asia; Africa and South America [1–3].he phenomenon is having an impact on patients, health-are providers, and the system as a whole [4]. The topic haseen extensively documented, in terms of the motivations
or informal payments, their diverse form, the magnitude ofhe payments, and their wide implications for health careystem performance. However, in this research informal∗ Corresponding author. Tel.: +40 742 62 40 19; fax: +40 264 40 22 15.E-mail address: [email protected] (M.I. Ungureanu).
168-8510/$ – see front matter © 2013 Elsevier Ireland Ltd. All rights reserved.ttp://dx.doi.org/10.1016/j.healthpol.2013.01.010
© 2013 Elsevier Ireland Ltd. All rights reserved.
payments are defined in various ways, due to the lack ofa generally recognized and accepted definition [5,6]. Theneed has been noted for further research on the defini-tion of informal payments, the motivation for offering andaccepting them, and the related arguments and solutionsfor policy in various health care systems [5,7].
1.1. Impact on the healthcare system performance
In the CEE region, informal payments have beenreported in virtually every country, except for Slovenia [8].In the Czech Republic, the reported rate of informal pay-ments is very small [9,10]. Widespread information has
been reported from Hungary [2,4,5,11], Bulgaria [12,13],Greece [14,15], Turkey [16,17], Albania [18–21], Rus-sia [22], Georgia [23,24], Poland [25,26], and Romania[12,27–29].
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106 R.M. Chereches et al. / HeInformal payments data have been also reported fromSouth Asian countries, such as Bangladesh, India, Nepal,Pakistan and Sri Lanka [30]. In Africa, informal charging hasbeen depicted as customary in Uganda [31], Mozambique[32], Rwanda [33], and Ethiopia [34]. In South America,informal payments have been reported in Bolivia [35]. Thephenomenon is also encountered in China [36], Kazakhstan[37,38] and Kyrgyzstan [39].
The importance and magnitude of the phenomenon areunderscored by recent studies. The declared frequency ofinformal payments, for example, ranged from 3% in Peru,20% in Bulgaria and 21% in Albania, to 87% in Georgia,91% in Armenia, and 96% in Pakistan [3,13]. A compara-tive study in 2002, focusing on four countries in the CEEregion (Czech Republic, Poland, Hungary and Romania),found that informal payments accounted for almost half oftotal out-of-pocket payments; moreover, in Romania theywere found to be a barrier for lower socio-economic groups’access to care [12]. In terms of their prevalence in Roma-nia, 69% of respondents to an AID’s (Association for theImplementation of Democracy) survey in 2010 declaredthat they offered informal payments to health care workers[40]. However, in a 2010 household survey, only a quarterof those interviewed admitted to having offered informalpayments for inpatient care during the previous year [28].
In financial terms, the estimated amount of informalpayments in Hungary in 2001 was 1.5–4.5% of total healthcare expenditures [41]. In Poland and the Russian Federa-tion, informal payments represented 30% and 56% of totalnational health care expenditures, respectively, while inAzerbaijan the amount reached 84% [42]. However, com-parison to Organization for Economic and Co-operation andDevelopment (OECD) data suggests the estimate for Polandmay be higher than in reality. According to OECD, privatehousehold expenditures have been around 30% in the past20 years, and informal payments could not account for allprivate expenditures [43].
Aside from their impact at an individual level, informalpayments also affect the performance of the health caresystem where they appear [5]. The effect is mediated bytheir influence on the distribution of services and resourceallocation. Moreover, informal payments are contributingto the obstruction of health care reform, since they cre-ate a strong incentive for individuals in high hierarchicalpositions to block reform attempts [5,13]. The effect ofinformal payments on health care efficiency and equity ishighly dependent on the mechanisms involved, which arereflected in the definitions of informal payments: (1) arethey offered voluntarily or do people feel obliged to payinformally? Or (2) do they arise from gratitude or repre-sent a price mechanism (copayments)? This discussion hasbeen summed up by Gaal and McKee, who proposed twoalternative hypotheses: donation and fee-for-service [5].The donation hypothesis rests on socio-cultural and eth-ical explanations and involves a totally voluntary action onthe patient’s part, whereas the fee-for-service hypothesisemphasizes shortage and always involves a certain degree
of coercion. As has been observed, coercion is not neces-sarily or primarily external but also internal. Although thetwo hypotheses seem contrasting and mutually exclusive,they may coexist [5]. In fact, it is their co-existence thaticy 110 (2013) 105– 114
challenges the definition of informal payments and policyefforts to address them.
1.2. Addressing informal payments
Most of the papers reporting on informal paymentsrecommend finding appropriate methods to eliminatethem [7]. However, to complicate things further, informalpayments can exert positive effects on health system per-formance. For instance, it has been reported that even smallamounts of money can incentivize physicians to remain inthe public system [5]. Still, the extent to which the posi-tive effects counteract the negative effects depends on howmuch of the payment belongs to the “donation type” andhow much to the “fee-for-servicetype” [5]. But even if weassume that the bulk of informal payments are “fee-for-servicetype”, we still need to demonstrate that informalpayments are inferior to formal out-of-pocket paymentswith regards to the burden on the poor [39].
The mechanisms proposed to help eliminate infor-mal payments include increasing official fees, findingappropriate incentives for health professionals, increasedcompetition, improved accountability, a higher degree ofcommunity oversight and efforts to promote patients’rights [42,44]. The introduction of penalties for healthworkers who receive or ask for informal payments hasalso proved useful, although it is argued that health pro-fessionals’ migration to the private sector could be a sideeffect [44]. Nonetheless, any policy needs to not only ensurehigh-quality services are provided, but also patients can beconfident that they will receive those services without hav-ing to make informal payments [5]. As such, efforts shouldbe made the re-establish the reciprocal trust relationshipbetween patients and physicians. In this respect, defininginformal payments in a manner that is neutral and non-judgmental will contribute to designing the most effectivemechanisms to address informal payments.
1.3. Objective
Although informal payments have been acknowledgedand studied in a multitude of settings, researchers’ def-initions differ, sometimes substantially. The objective ofthis paper is to explore the literature for the definitionsof informal payments in healthcare and critically analyzethe proposed versions. Thus, the paper will contribute tothe effort of developing a coherent definition for informalpayments, without which their study will be significantlyaffected. We are aware that national contextual differencesexist; a definition of informal payments should acknowl-edge these differences, while reducing their influence onthe definition as much as possible.
2. Materials and methods
2.1. Data sources
In order to identify papers relevant to the topic ofinformal payments, a systematic search was conducted onfour major databases: Econlit, EconPapers, PubMed, Sci-enceDirect. Additionally, Google Scholar was used to find
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echnical reports, conference proceedings, position papers,eriodicals or books. After we identified the publicationsy using the selected key-words, their bibliography waslso checked for any relevant papers not found in the firstearch. To decrease the possibility of lost papers, espe-ially grey literature, we used electronic mail to contactesearchers who had previously studied informal pay-ents but some of whose papers were not available online
38].
.2. Inclusion and exclusion criteria
For inclusion in the systematic review, there wereo limitations with regard to the year of publication,ublication type or format. The inclusion criteria werehe use of any of these keywords: “informal payments”,under-the-counter payments”, “out-of-pocket payments”,under-the-table payments”, “envelope payments”, as wells a combination of any of the following words in the pub-ication title, abstract, keywords, or any component partsf the publications: “gifts”, “illicit payments”, “solicitedayments”, “gratuities”, “illegal payments”, “unofficial”,donations”, and “health care”. Only publications writtenn English that provided a definition of informal paymentsn the healthcare system or attempted to explain the term
ere included.The exclusion criteria were failure to identify the author,
ear of publication, publishing house and/or website.
.3. Data extraction
All the papers identified were reviewed by three inde-endent researchers following the same protocol of dataollection. For each paper selected, the following infor-ation was selected: title, authors, year of publication,
efinition of informal payments provided.
. Results
An initial search retrieved 2337 results, with 105 consid-red to be relevant to the topic after a screening of titles andbstracts. A detailed review of these papers found 61 paperset the inclusion criteria and were therefore included in
he systematic review.Our review identified and included research articles,
ooks and official reports. The array of methods used in theelected research articles was heterogeneous. They pur-ued both qualitative and quantitative approaches, and theubjects included in the studies were both healthcare ser-ices receivers and providers. We identified conceptualrticles along with empirical studies. Table 1 presents theggregated data collected from the 61 papers included inhe systematic review.
.1. Terms used to denote informal payments
We analyzed the terms used to denote what we now
now as informal payments and we report their distribu-ion over the years (Table 2). There was a wide range oferms used to designate informal payments and charac-erize their distribution across time. Whereas some papersicy 110 (2013) 105– 114 107
preferred such terms as “under-the-counter payments”,“under-the-table payments”, “envelope payments”, “bribepayments”, or using them alternatively with “informal pay-ments”, the majority of papers used “informal payments”.
3.2. Publication sources
We further analyzed the journals that published paperson informal payments. Our analysis showed there is a cleardifference between Health Policy and other journals in theiraffinity for this topic. The journal published 14 papers deal-ing with informal payments between 1997 and 2011. SocialScience & Medicine published six papers addressing infor-mal payments between 2004 and 2007. Between 1998 and2010, nine papers were published by Health Policy andPlanning. A small number of papers on informal paymentswere published prior to 2000. However, some researchersreport non-English publications being produced prior to2000; in Hungary informal payments have been a persis-tent research topic and therefore the source of most of theknowledge about the topic [5]. Research on motivations forpaying informal fees, as well as policy proposals, was pub-lished more than 20 years ago by Adam, Antal, Balazs andBlasszauer [5].
3.3. Analysis of identified definitions
After we extracted the definitions from the 61 papers,we identified and analyzed their conceptual frameworksand components. We considered the following threeaspects, each intrinsically connected to the others: (1) def-initions of informal payments in relation to other informalactivities; (2) the motivation to make informal paymentsand how it is reflected in the various definitions; (3) the ille-gality of informal payments. This classification had mainlya didactic role, given the close relation of inter-dependencebetween the aspects analyzed. In a later phase, we analyzedthe definitions in terms of their originality.
3.3.1. Informal payments and other informal activitiesKillingsworth et al. (Bangladesh) and Ensor & Witter
include informal payments in a broader framework ofinformal activities [47,77]. Gaal et al. propose the sameinclusion relationship between informal payments andinformal economic activity. They also make a clear distinc-tion between their proposed definition and other informalactivities, such as illegal private practice within public facil-ities [4].
Killingsworth et al. [47] report on “unofficial fees”in Bangladesh, but it is difficult to categorize them asinformal payments, since most of the payment types theauthors identify (fee-for-service, fee-for-commodity, fee-for-access) would fall instead into the broader category ofout-of-pocket payments, within which some researchers[4,24] place informal payments as a component subset.Moreover, “fee-for-service” as described by Killingsworth
et al. [47] differs from the concept as defined by Gaal& McKee [5], who use “fee-for-service” in opposition totheir “donation” hypothesis to distinguish the motivationbehind the payment.
108 R.M. Chereches et al. / Health Policy 110 (2013) 105– 114
Table 1Definitions of informal payments from the papers included in the review.
No. Author(s)/institution Year Definition of informal payments
1. Chawla et al. [45] 1998 “While official medical treatment was provided free of charge, patients started makinginformal payments to physicians in order to obtain faster and more personal service.”
2. Ensor andSavelyeva [37]
1998 “These are payments made to medical staff or institutions, that are not officially required,but are either expected or demanded by providers. Patients may feel that they have tomake a payment in order to ensure prompt treatment or a minimum standard of care.Payment may be in money or in kind. Sometimes these payments are described as bribes.”
3. Mastilica andBozikov [46]
1999 “Private shadow system of informal payments by gifts and gratitude money to healthservices providers is well known but the level of this side payments has never beenseriously studied.”
4. Killingsworth et al.[47]
1999 “Unofficial healthcare fees at government health facilities can be defined as unauthorizedfee payments that co-existed with “ee care” and formally approved “official” health servicecharges collected at public facilities under the sanction of overall public policy.”
5. Lewis [48] 1999 “Payments to individual and institutional providers in-kind or cash that are outsidethe official payment channels, or are purchases that are meant to be covered by thehealthcare system.”
6. Anderson [49] 2000 “The gifts, counter services, and money provided by patients to health care providers,pozornost, are in some instances similar to bribes, for example when the patient feels it isnecessary to receive proper care, and in some instances merely a small token of gratitude.”
7. Lewis [7] 2000 “Payments to individuals or institutions in cash or in kind made outside official paymentchannels for services that are meant to be covered by the public health care system. Suchprivate payments to public personnel have created an informal market for healthcarewithin the confines of the public healthcare service network, and are a form of corruption”
8. Thompson andWitter [1]
2000 “Payments made by individuals to state health workers or institutions but which are notsanctioned by the authorities.”
9. Ensor [50] 2000 “There are a number of ways of distinguishing between types of unofficial payments. Abasic distinction is between those that are paid to facilities and those to individualpractitioners. Institutional payments are sometimes described as quasi-official, informalor grey payments, reflecting their semi-institutionalised status. A second distinction isbetween in-kind and monetary payments.”
10. Kornai [51] 2000 “The expression gratitude money customarily refers to cases where the patient, more orless illegally, gives money to a state employed doctor for a provision for which the doctoris not entitled to a direct payment, according to the regulations.”
11. Anderson et al. [52] 2001 “Throughout the former communist world, unofficial payments in the health sector haveemerged as a fundamental aspect of healthcare financing and a serious impediment toreform.”
12. Bloom et al. [36] 2001 “Red packages mostly take the form of cash payments. Their size varies with the income ofthe local population, the degree of sophistication of the health facility, the seniority of thedoctor and the field of specialization.”
13. Shahriari and Belli[25]
2001 “Payments, in cash or in kind, made by patients, or others on behalf of the patients, to anindividual or institutional public health care provider directly or to any person arrangingfor provision of health care from such public health care providers, for health servicesreceived or expected to be received, that the recipients of these payments are notauthorized to receive under the existing laws of the land, including the Constitution ofPoland, 1997, and the Health Insurance Act, 1997, or under the rules of business of thehealth facility.” a
14. Thampi [30] 2002 “Victims of corruption reported large payments given as bribes to access and use thepublic healthcare systems.”
15. Gatti et al. [35] 2002 “[. . .] informal (and possibly illegal) payments for basic health services that are supposedto be free [. . .]”
16. Lewis [8] 2002 “Informal payments can be defined as payments to individual and institutional providersin kind or in cash that are outside official payment channels or for purchase meant to becovered by the health care system. This encompasses ‘envelope’ payments to physiciansand ‘contributions’ to hospitals as well as the value of medical supplies purchased bypatients and drugs obtained from private pharmacies but intended to be part ofgovernment-financed health care services.”
17. Killingsworth [53] 2002 “Unofficial fees have been defined as payments to individuals or institutions in cash or inkind, made outside official payment channels for services that are meant to be covered(without direct charge) by the public healthcare system. [. . .]These unofficial healthcarefees at government facilities were defined in the following way: Unauthorized feepayments that co-existed with ‘free care’ and formally approved ‘official’ health servicecharges collected at public facilities under the sanction of overall public policy.”
18. Belli et al. [23] 2002 “Informality means that the economic activity is not registered. This is a common featureof all types of informal payments. But not all unregistered payments given to serviceproviders are informal payments according to the above definition. We are not interestedfor instance in those payments that are due to the provider according to a set price for adetermined service, but for which the provider does not give a receipt to avoid paying tax.”
19. Balabanova andMcKee [13]
2002 “Monetary or in-kind transaction between a patient and a health care professional forservices officially free of charge in state health facilities. [. . .] Under-the-counterpayments, especially when in kind, may truly be motivated by genuine gratitude, and sonot regarded as fees.”
R.M. Chereches et al. / Health Policy 110 (2013) 105– 114 109
Table 1 (Continued)
No. Author(s)/institution Year Definition of informal payments
20. World Bank [18] 2003 “Informal payments are unofficial payments to a healthcare provider for services whichare supposed to be provided at no charge for the patient.”
21. Murthy andMossialos [54]
2003 “Informal payments take a number of forms and may exist for a number of reasons. Theyrange from the ex ante cash payment to the ex post gift in-kind. At their worst they maybe a form of corruption, undermine official payment systems, and reduce access to healthservices.”
22. Belli [12] 2004 “Payments (cash or in kind) made to service providers (person or institution) by thosepeople who are entitled for the services, in addition to any legally defined payment.”
23. Gaal and McKee[11]
2004 “An additional direct contribution above what is stipulated by the terms of entitlement,and this ‘additionality’ is the key defining feature of the phenomenon rather than forinstance ‘corruption’.”
24. Ensor [44] 2004 “Gifts are an expected part of professional dealings. The border between gifts and paymentis a hazy one and it could even be claimed, as some philosophers have done, thatidentifying the person that gives the gift necessarily ensures that the relationship iscontaminated and turned into a two-way trade.”
25. Belli et al. [24] 2004 “All payments that patients report to pay directly to their health care individual orinstitutional provider above the legally set co-payments for BBP services and above(or below) the regulated FFS fees for non-BBP services, plus all in-kind contributionsand gifts. Thus, we consider IPs as a subset of the OPPs. According to this definition, itis not really important whether or not transactions between patients and providersare registered for tax purposes, but whether such payments are or aren’t differentfrom the legally set co-payments or regulated fees. We assume that all transactionwhere the patient reports he/she was not given any information about officialco-payment rates or fees are to be considered as informal.”
26. Falkingham [55] 2004 “Payments to individual and institutional providers in-kind or cash that are outside theofficial payment channels, or are purchases that are meant to be covered by the healthcaresystem.”
27. Gaaland McKee [5] 2005 “Informal payments [. . .] involve patients paying physicians and other health workersout-of-pocket for services that they are entitled to receive free of charge, usually in apublicly financed system.”
28. Bonilla-Chacinet al.[56]
2005 “The importance of private expenditures is associated with the increased informality ofthose out-of-pocket payments. Although there is a common practice in many of thesecountries for patients to offer unsolicited gratuity payments to health-care providers,there is evidence that a large proportion of the non-formal payments today are notvoluntary, they are either requested or expected.”
29. Hotchkiss et al. [19] 2005 “Payments to institutions or individuals in cash or in kind made outside official paymentchannels for services that are meant to be covered by the public health system.” b
30. Szende and Culyer[2]
2006 “Informal payments can be regarded as a form of black market. Balabanova and McKeedefined them as ‘a monetary or in-kind transaction between a patient and a staff memberfor services that are officially free of charge in the state sector’.”
31. Vian and Burak [20] 2006 “Cash or in-kind payments for services that were supposed to be offered free of charge atgovernment health facilities, and not [. . .] gifts given freely to express thanks or gratitude”
32. Baschieri andFalkingham [57]
2006 “formal payments have been defined as ‘payments to individual and institutionalproviders in-kind or cash that are outside the official payment channels, or are purchasesthat are meant to be covered by the health care system’.”
33. Gaal [58] 2006 “At the systemic level, informal payments can rather be explained as the response ofpatients and doctors to the shortages generated by the state’s socialist health care system.”
34. Allin et al. [59] 2006 “Informal, ‘under-the-table’ or ‘envelop’ payments are typically defined as direct paymentsby patients for services they are entitled to for free, usually in a public health system.”
35. Akesbi et al. [60] 2006 “While informal payments can be seen as a coping mechanism for poorly paid healthworkers, everyone pays for corruption in this sector. Citizens who do not consent tomaking informal payments do not receive access to care.”
36. Lewis [61] 2006 “Informal payments can be defined as ‘payments to individual and institutional providers,in kind or in cash, that are made outside official payment channels or are purchases meantto be covered by the health care system. This encompasses ‘envelope’ payments tophysicians and ‘contributions’ to hospitals as well as the value of medical suppliespurchased by patients and drugs obtained from private pharmacies but intended to bepart of government-financed health care services’.”
37. Gaal et al. [41] 2006 “There is no generally accepted definition of informal payments, but its most commonform in Hungary is that patients give money to doctors for services that they would beentitled to receive free of charge in the frame of publicly financed health care.”
38. Gaal et al. [4] 2006 “A direct contribution, which is made in addition to any contribution determined bythe terms of entitlement, in cash or in-kind, by patients or others acting on theirbehalf, to health care providers for services that the patients are entitled to”
39. Vian et al. [62] 2006 “Defined as cash or other things given to government staff for services where payment isnot required by the government, informal payments are one of many individual copingstrategies adopted by medical staff and patients in countries where health systems areunder-funded, overstaffed, and burdened with broad mandates for free access to care.”
40. Vian [63] 2006 “Extorting or accepting under-the-table payments for services that are supposed to beprovided free of charge; soliciting payments in exchange for special privileges ortreatment.”
110 R.M. Chereches et al. / Health Policy 110 (2013) 105– 114
Table 1 (Continued)
No. Author(s)/institution Year Definition of informal payments
41. Hunt [64] 2007 “[. . .] unofficial payments (which I call bribes) [. . .].”42. Chiu et al. [65] 2007 “A patient receiving service form a doctor may feel obligated by renqing to reciprocate
with an informal payment or gift. Alternatively, patients who desire new or continuingcare from a doctor may give a gift or payment as a way of ‘seeking relationship’.”
43. Lewis [3] 2007 “Payments to individual and institutional providers, in kind or in cash, that are madeoutside official payment channels or are purchases meant to be covered by the health caresystem. This encompasses “envelope payments” to physicians and “contributions” tohospitals, as well as the value of medical supplies purchased by patients and drugsobtained from private pharmacies, but intended to be part of government-financedhealthcare services.”
44. Tatar et al. [16] 2007 “Informal payments are defined as payments (in cash or in kind) made to service providers(person or institution) by those people who are entitled to the services, in addition to anylegally defined payment.” c
45. Liu and Sun [66] 2007 “Informal payments are those made to individuals or institutions in cash or in kind outsideofficial channels for services that are meant to be covered by the public health caresystem.”
46. Cockcroft et al. [67] 2008 “Petty corruption in the health sector can manifest in several practices, includingunofficial payments.”
47. Liaropoulos et al.[14]
2008 “Informal payments is inevitably linked to corruption, defined as the use of public officefor private gains. [. . .] As informal payments we considered all payments (extra fees andgratuities) to doctors for services which are theoretically provided free-of – charge.”
48. Siskou et al. [15] 2008 “All payments (extra fees) and gratuities to doctors for services which are theoreticallyprovided free-of-charge.”
49. Vian [68] 2008 “Unofficial payments given to medical personnel for services that are supposed to beprovided free of charge at the point of delivery.”
50. Dabalen and Wane[69]
2008 “The most pervasive and studied form of corruption at the point of service delivery isinformal payments. Informal payments can be broadly defined as direct unofficialpayments, in kind or in cash, from patients to health workers for the latter’s personalbenefit. Informal charging is a bribe-taking practice and is clearly classified as an illegalactivity.”
51. Aarva et al. [22] 2009 “Money or gifts given to a doctor, nurse or other personnel directly for free services or overand above any official fee.”
52. Stringhini et al.[70]
2009 “Unreported or unregistered illegal payments that have been received, in cash or in kind,in exchange for the provision of a service (or of a faster or better service) that is officiallyfree.”
53. Radin [71] 2009 “Informal payments (in cash or in kind) are made to service providers (persons orinstitutions) by people who are entitled for the services, in addition to any legally definedpayment.”
54. Fotaki [72] 2009 “Monetary exchanges between a patient and her relatives and the health professional orinstitution providing services that should have been free of charge.”
55. Stepurko et al. [6] 2010 “Informal patient payments could have monetary and non-monetary form, and couldexpress the patient’s gratitude but could also be requested by the health care provider.Overall, informal patient payments are accepted to be unofficial, i.e. they are notregistered by the state and are made without an official receipt of payment, and remainoutside the official payment channels.”
56. Gaal et al. [39] 2010 “Informal payment is a direct contribution, which is made in addition to any contributiondetermined by the terms of entitlement, in cash or in kind, by patients or others acting ontheir behalf, to health care providers for services that the patients are entitled to.” d
57. Lewis [73] 2010 “Payments to individual and institutional providers, in kind or in cash, that are madeoutside official payment channels or are purchases meant to be covered by the health caresystem. This encompasses “envelope payments” to physicians and “contributions” tohospitals, as well as the value of medical supplies purchased by patients and drugsobtained from private pharmacies, but intended to be part of government-financedhealthcare services.”
58. Ozgen et al. [17] 2010 “Payments (in cash or in kind) made to service providers (person or institution) by thosepeople who are entitled for the services, in addition to any legally defined payment.”
59. Fãrcãs anu [28] 2010 “[. . .] Informal payments, defined as ‘all the direct payments made by the patients,excluding the legal official provisions’ (adapted after Killingsworth, 2002), as one of thecomponents of the corruption in the public systems [. . .]”
60. Tomini et al. [74] 2012 “In the literature, informal payments are defined as direct cash/in-kind unofficialpayments to health care providers and/or private purchases of health services and otherproducts meant to be covered by the health system.”
61. Richardson et al.[75]
2012 “Informal payments are also common in this region, representing a means of ‘informalexit’ from systems in which consumers have neither the means of formal exit or of voice.” e
a Citing Chawla (2000) [76].b Citing Lewis (2000) [7].c Citing Belli et al. (2002) [23].d Citing Gaal (2006) [58].e Citing Gaal and McKee (2004) [11].
R.M. Chereches et al. / Health Policy 110 (2013) 105– 114 111
Table 2The distribution of terms used to denote informal payments.
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Bribes/bribe payments 1Envelope payments 1 1 1 1Gratitude payments 1Informal payments 2 2 2 1 5 2 3 3 10 3 3 4 5 1 2Red packages/envelopes 1
3
ptp[ptrwtuttitmetucttc
itacmoraew
3
vobprtdttli
Under-the-table paymentsUnofficial payments/fees 1 1 1
.3.2. The motivation for informal paymentsIdentifying the differing motivations behind informal
ayments is one of the most intriguing research ques-ions [4,58]. Motivations cover a broad spectrum, fromure gratitude to coercion on the health professionals’ part5,7,51].Indeed, most of the papers dealing with informalayments [13,58] define them as stemming from thosewo sources: gratitude and coercion. Balabanova and McKeeeport on under-the counter payments, which “especiallyhen in-kind, may truly be motivated by genuine grati-
ude, and so not regarded as fees” [13]. The same authorsse the term “informal payments”, but in their conceptionhe term distinguishes “semi-official fees from under-he counter payments as far as possible”. Coercion oftenmplies requesting informal payments in advance or duringreatment (ex-ante) whereas in the case of gratitude, pay-
ents are made after the service (ex-post) [13]. Similarly,vidence shows that gifts are more frequently given afterhe treatment, as a way to express gratitude, and money issually given before or during the treatment and suggestsoercion. However, these two aspects are often difficulto distinguish. Payments and gifts maybe given at variousimes, especially if the treatment is prolonged, as in thease of many chronic diseases.
Referring to the motivation behind informal paymentsn the Hungarian health care system, Gaal [58] states firmlyhat “the concept of ‘gratitude payment’ is no more than
convenient myth that has been used to make an unac-eptable phenomenon acceptable”. Hence, focusing on theotivation for offering informal payments in the process
f defining them may not be central to getting an accu-ate definition. Despite this, motivation has been proposeds responsible for the consequences on health care servicefficiency and equity and also as the key factor in decidinghether and how to address informal payments [4].
.3.3. Informal payments and illegality/corruptionLewis defines informal payments as “payments to indi-
iduals or institutions, in cash or in kind, made outsidefficial payment channels for services that are meant toe covered by the public health care system. Such privateayments [. . .] are a form of corruption”. Other definitionselating informal payments to corruption and bribes arehose provided by Hunt, and Cockroft et al. [64,67]. Lewisistinguishes informal payments from gratuity payments,
he difference being the discretionary character of the lat-er. Killingsworth [53] cites the same definition as Lewis,inking informal payments to corruption. His report, focus-ng mainly on Bangladesh and China, also uses the terms21 2
“unofficial fees”, “informal fees”, “informal payments” and“red packets” to reflect different local particularities [7]. Hereports that their legality “is at least ambiguous”.
A number of other papers link informal paymentsto corruption. A Transparency International report onBangladesh, India, Nepal, Pakistan and Sri Lanka found that“extortion was found to be rampant in the public healthcare system in all five countries. Victims of corruptionreported large payments given as bribes to access and usethe public health care systems” [30]. In these countries,informal health care payments are only an indicator of gen-eralized corruption, and the health care sector is reportedby citizens as one of the most corrupt fields.
In the Slovak Republic, Anderson uses “informalpayments,” “pozornost” and “bribery” interchangeably,although according to empirical data, pozornostare volun-tary in almost half of the cases. Nonetheless, Anderson’spaper is sensitive to the distinction between a paymentresulting from gratitude and payments made by patientsbecause they feel “it is necessary to receive proper care”(“the gifts, counter services, and money provided bypatients to health care providers, pozornost, are in someinstances similar to bribes, for example when the patientfeels it is necessary to receive proper care, and in someinstances merely a small token of gratitude”) [49].
3.3.4. Originality of the definitionsIn chronological terms, the earliest definition that
covers the components of informal payments was thatprovided by Lewis in 1999: “payments to individual andinstitutional providers in-kind or cash that are outside theofficial payment channels, or are purchases that are meantto be covered by the health-care system” [48]. The samedefinition, with only minor changes of wording, is found insubsequent papers from the same author [3,7,42].
Several authors have cited Lewis’ definition: Falking-ham [55], Liu & Sun [66], Allin et al. [59], Stepurko et al.[6], Killingsworth [53]. Later on, Killingsworthwas cited byFãrcãs anu [28].
Stringhini et al. [70] used a definition that cites Bala-banova & McKee [13], Gaal et al. [4] and Lindelow & Serneels[78]. However, they used illegality as a characteristic ofinformal payments, which was debated by Belli [12] whodid not consider it central to informal payments. Aarvaet al. [22] did not cite any previous definition, and their
definition did not further clarify the topic.Belli proposed two distinct definitions in 2004. The firstone, focusing on informal payments in Georgia, made thepoint that what makes a payment informal is its difference
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112 R.M. Chereches et al. / Hefrom the “legally defined set co-payments or regulatedfees” [24]. In another paper, the same author refinedthe definition, broadening the framework of copaymentsand regulated fees to “any legally defined payment”, andintroduced the notion of people “entitled” to a service [12].In 2006, Gaal et al. built on the term “entitlement” to comeup with a definition of informal payments that is by far themost comprehensive available [4]. They defined informalpayments as “a direct contribution, which is made inaddition to any contribution determined by the termsof entitlement, in cash or in-kind, by patients or others,acting on their behalf, to health care providers for servicesthat the patients are entitled to”. The definition differ-entiates between the formal and informal character of apayment based on the changes in the legally establishedentitlements for health care services.
To sum up, we selected three definitions, those ofLewis(1999), Belli et al., (2004)and Gaal et al. (2006), asbeing original (definitions number 5, 25 and 38 in Table 1).
Belli, made a distinction between informality and ille-gality. The characteristic of informality, according to Belli,refers to a payment not formally registered with any gov-ernment agency, while the legal/illegal issue is determinedby the laws and regulations in each country. According tothis definition, informal payments also include those legalpayments offered as gratitude, but unrecorded. Belli’s def-inition has been cited by Radin [71] and Ozgen et al. [17].
Two informal payment definitions, provided by Vian &Burak [20] and Fotaki [72], excluded “the gifts given freelyto express thanks or gratitude”. In 2006, Vian providedanother definition, different only in wording not content.
On the other hand, Kornai [51] defined gratitude pay-ments as “the cases where the patient, more or less illegally,gives money to a state-employed doctor for a provisionfor which the doctor is not entitled to a direct payment,according to the regulations”. However, Kornai’s definitiondid not offer information about the patient’s motivationand the author presented gratitude payments in a man-ner that brought the term very close to what other authorscall informal payments. This similarity is further supportedby the four interpretations of gratitude payments that heoffered: wage supplement, bribe, rent-seeking and blackrent. In this case, it should be observed that, relating toother papers, the term “gratitude” is inappropriate in sucha context.
4. Discussion
4.1. Categories of definitions for informal payments
Based on the three issues identified in the definitionsavailable for our analysis, we suggest three categories ofdefinitions for informal payments: (1) informal paymentsas illegal payments, (2) informal payments as unofficial orinformal, (3) informal payments as additional payments ontop of any formal out-of-pocket payments dictated by theterms of entitlement.
According to Gaal et al., definitions based on categories1 and 2 are incorrect and inapplicable across countries,because there are a large number of accounts of spe-cial types of informal payments, which are not illegal
icy 110 (2013) 105– 114
and not even informal (i.e. they are not outside of offi-cial payment channels). One such example is the so-called“brick payment” reported by Shareware et al. from Poland(patient or their families buying a brick that symbolized thecontribution to a healthcare facility) [25].
On the other hand, the value added by Gaal et al. isthe concept of entitlement as a point of comparison abovewhich (or in addition to which) informal payments aremade.
Like any other informal economic activity, informal pay-ments are frequently regarded as a form of corruption.Whereas some authors regarded them as the most perva-sive form of corruption [69], others stressed their positiveeffects on some health care systems [12]. The distinc-tion, however, is a difficult one to make because. One ofthe confounding factors is that informal payments usuallyflourished in countries facing with significant corruptionlevels. This way, tagging informal payments as corruptionwas making sense in that context.
4.2. Benefits of a uniform definition
The benefits of a uniform, operational, comprehen-sive definition of informal payments are both scientificand policy related. The major scientific gain is thepossibility of running cross-country studies on the occur-rence of informal payments, the extent to which theyare influencing health systems performance, the reasonsfor their existence, and the distinct characteristics cor-related with particularities of arrangements in healthsystems. This research would create a more comprehen-sive multinational database, a starting point for aligningand coordinating nationals and regional policies meant toaddress informal payments.
A key implication for policy is the classification of infor-mal payments either as legal or illegal, options that willinvolve different approaches. The policies should follow thescientific results and be implemented with considerationfor the socio-economic, political and cultural frameworkof each country. As Vian states, “in order to be effective,reforms to combat corruption must be informed by the-ory, guided by evidence and adapted to context” [68]. Inthis process, the manner in which informal payments aredefined with regards to their legal or illegal character willdefinitely have an influence on the policy measures andtheir outcomes.
Furthermore, as revealed by our analysis, most informalpayments are generally regarded by researchers as ille-gal, hence a form of corruption. However, few countrieshave so stipulated in their legislation, and current informalpayments definitions do not clarify the relation betweeninformal payments and corruption. The fact that researchdoes not clearly place informal payments in the legal orillegal area is a barrier to the policy makers’ regulation ofthem.
Gratitude payments and requested payments are twopossible forms under which informal payments are made,
but making a clear delimitation between them is diffi-cult. Given this ambiguity, many of the payments aresituated somewhere between the two above-mentionedextremes.
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As presented by us, there are numerous terms for pay-ents that people make for services they are supposed to
eceive according to the terms of entitlement, the mostrequent being “informal payments”, “under-the-counterayments”, “under-the-table payments” and “envelopeayments”.
Although they are sometimes used interchangeably,here are differences between them. To make these dif-erences clearer, two categories can be delineated. Theerms in the first category describe the way that paymentsre made, such as under-the-counter, under-the-table, ornvelope payments, but do not offer information about therigin or the destination of the payments. The second cat-gory refers to different terms like informal payments ornofficial payments. Unofficial payments, as compared to
nformal payments, refer to payments made for goods orervices which should be either free of charge or includedn the basic package of services. Informal payments refer toayments made above the official established level.
Moreover, informal payments are part of a broader con-ept of out-of-pocket payments. To differentiate betweennformal payments and out-of-pocket payments is chal-enging, due both to a lack of patients’ awareness ofheir legal rights and legal ambiguity within and betweenountries.
.3. Outlook for a commonly accepted definition
Studying the proposed definitions of informal pay-ents, we may conclude that most of them reflect the
articular characteristics of the health care systems inhich they are reported. Taking this into account, compar-
tive research on informal payments would meet seriousarriers. Although a generally accepted definition of infor-al payments is much needed, our analysis of the current
efinitions and trends indicates that much effort woulde needed to accomplish this. However, we suggest thathe definition proposed by Gaal et al. is the best availabletarting point.
The advantage of this definition over others is its neu-ral and non-judgmental tone, derived from the fact thatt does not attempt to explain patient motivation or char-cterize informal payments as good or bad. Its neutralitylso allows for its use in different healthcare systems. Outf all definitions available at the moment, that of Gaal et al.s the closest to the desideratum to overcome any nationalr regional trait and provide a more general framework fornformal payments.
.4. Limitations and challenges
One of the challenges that we encountered in thisystematic review was the heterogeneity of definitionsrovided, as well as the differing inclusion of certainspects of informal payments in specific categories. Aicious circle is created when the lack of a comprehen-
ive and generally accepted informal payments definitioneads to difficulties of categorization while the differentategories complicate the process of getting to a uniqueefinition.[
icy 110 (2013) 105– 114 113
5. Conclusion and implications
The variety of forms which informal payments may takemakes it difficult to define them in a comprehensive man-ner, which would also acknowledge local characteristics.However, we identified a definition that could serve as abeginning in this process. More effort is needed to build onit and get to a commonly accepted and shared definition ofinformal payments.
Conflicts of interest
None.
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