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Corruption in public health 97
physicians and ‘contributions’ to hospitals as well as the value of
medical supplies purchased by patients and drugs obtained from
private pharmacies but intended to be part of government-financed
health care services.” (Lewis, 2000, 2002). More specifically they are
under-the-table payments to doctors, nurses and other medical staff
for jumping the queue, receiving better or more care, obtaining
drugs, or just simply for any care at all.
Informal payments create a parallel market for services within
public health care systems, and, like the informal sector, informal
payments are typically illegal and unreported. They can be considered
a form of corruption, but may just be symptomatic of bad management.
While only recently defined and discussed, what emerges
from the data is, surprisingly, how widespread informal payments
have become.
A major challenge is differentiating informal and gratitude
payments given the official co-payment, bribes and gifts that
patients pay. Where all fees have been banned any payment by
households is clearly unofficial, but in many countries formal fees
exist, blurring the dichotomy. It then becomes the level of payment,
the nature of the transaction and its timing that become relevant for
distinguishing the nature of the payment. For example, in Kyrgyz
Republic in 2001 95 per cent of those who paid for services did not
receive a receipt while only 3 per cent reported giving a gift to the
health personnel and the time of service (Falkingham, 2002). A
Bolivia study showed that perception of corruption was associated
with the size of informal payment with a significant coefficient of
.34 (Gatti, Gray-Molina and Klugman, 2004).
Ex post transactions are particularly problematic because postservice
gratitude gestures are common and often expected. Where
providers insist on direct pre-payment without involvement of
official cash windows, refuse patient care without the fee, receive
direct payments for specific tasks, or refuse basic services without a
“tip” (e.g., such as moving patients from room to room, or giving
injections) informality of payment is likely.
Figure 5 summarizes the frequency of informal payments to