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100 Fighting the Diseases of Poverty
tent with other findings. Public providers with a monopoly
position are in a stronger position to charge patients extra for their
services.
Kosovars have not had access to public health care for decades
and have financed care out of pocket to private providers. Thais too
rely on the private sector for some of their health care. The higher
rates reported for Colombia and Bolivia, however, would question
that explanation since Colombia has a large private health system
not too different from Peru’s. The differences may reflect different
degrees of oversight in public clinics and hospitals, but more indepth
work would be necessary to reach a firm conclusion since the
approach to measuring informal payments varies across countries.
Figure 6 extends the informal payment distribution to encompass
differences in outpatient and inpatient payments and includes
some countries from Figure 5. With the exception of Bulgaria, inpatient
care is more likely to be financed via informal payments, and
often the disparity between the two types of services is dramatic, as
is the case with Bangladesh, Tajikistan, Armenia and Albania.
Evidence for four Eastern European countries (Czech Republic,
Hungary, Poland and Romania) reveals that formal payment are
associated with primary and outpatient specialist care and informal
payments with surgery and inpatient services (Belli, 2002). Households
either feel the need to pay for hospitalizations or providers
don’t give them a choice insisting on payment if services are to be
rendered.
Perception surveys of providers or citizens offer additional
insights. In Costa Rica 85 per cent of medical staffs indicated that
under-the-table payments to physicians were common, and half of
patients said they made payments in public facilities roughly equivalent
to 50 per cent of a private sector consultation. In Bolivia the
incidence of informal payments was significantly correlated with
perceptions of corruption in specific public hospitals, and 40 per
cent of interviewed patients acknowledged making illicit payments
for care (Gray-Molina et. al, 2001), this is similar to the results of a
household survey in 106 Bolivian municipalities reportedly that 45