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102 Fighting the Diseases of Poverty2002). In Bangalore, India citizen feedback surveys revealed thatinformal payments were made to ensure proper treatment, butthey were typically demanded by providers and 51 per cent ofthose interviewed indicated they had paid bribes in governmenthospitals and 89 per cent in hospitals in small cities, but they alsopaid informally in the private hospitals (24 per cent). More dramatically,bribes were paid to nurses in maternity homes somothers could see their infants (Gopakumar, 1998). In Albaniaamong the 60 per cent of patients who received care 43 per centsaid the gift was requested (World Bank, 2003a). Using focusgroups of patients and providers Shahriari, Belli and Lewis (2001)explain the virtual market for publicly provided care in Poland.Informal payments have become the way to obtain the services ofspecific physicians, with pricing reflecting reputation and demand.It is an implicit form of insurance for possible future needs, andprices are commonly known. Thus the process of negotiation andpayment for health services may be informal but it has become avery sophisticated market in Poland.The motivations of health staff and patients in relying on underthe table payments are strong. Physicians argue that low pay, irregularsalary payments, lack of government attention and the need tokeep services going requires drastic action, and patient contributionsoffer the only source of funds to fill the gap (Bloom Han andLi, 2001; Belli, Shahriari, Lewis, 2001; Lindelow, Serneels andLemma, 2003; Kutzin et al., 2003). Patients on the other hand alsosee low pay as an impetus to contribute, but traditions of gratitudeas well as concerns for some future need also play a role.In Ethiopia feedback from policymakers, experts and healthworkers revealed that inappropriate payments are rife in the healthsector. Patients typically must pay for every service and each item,from registering to paying bribes for changing bed sheets to drugsand supplies (Lindelow, Serneels and Lemma, 2003). Similar reportsof itemized charging emerged from qualitative work in Georgia(Belli, Shahriari and Gotzadze, 2004) and Poland (Belli, Shahriari andLewis, 2001) where there too the public system has become a fee-for