Informal Payments for Health Care in Iran: Results of a Qualitative Study.

BACKGROUND: Informal payments to health care providers have been reported in many African, Asian and European countries. This study aimed to investigate different aspects of these payments that are also known as under-the-table payments in Iran.
METHODS: This is an in-depth interview-based qualitative study conducted on 12 purposively chosen clinical specialists. The interviewees answered 9 questions including the ones about, definitions of informal payments, the specialties and hospitals mostly involved with the problem, how they are paid, factors involved, motivation of patients for the payments, impact of the payments on the health care system and physician-patient relationship and the ways to face up with the problem. The findings of the study were analyzed using qualitative content analysis method.
RESULTS: Six topics were extracted from the interviews including definitions, commonness, varieties, motivations, outcomes and preventive measures. It was revealed that under-the-table payments are the money taken (either in private or public portions) from patients in addition to what formally is determined. This problem is mostly seen in surgical services and the most important reason for it is unrealistic tariffs.
CONCLUSION: Regarding the soaring commonness of informal payments rooted in underpayments of health expenditures in some specialties, which deeply affect the poor, the government has to boost the capitation and to invest on health sectors through supporting the health insurance companies and actualizing the health care costs in accord with the real price of the health care delivered.

Introduction

There is no comprehensive acceptable definition for informal payments. The terms attributed to such actions are also different such as gratuities or gratitude payments, envelope payments, under-the-table payments, under-the-counter, and unofficial payments (1). In some Central and Eastern European countries, informal payments are often referred to as “gratitude money” or “bribery”. The term “gratitude” hardly describes this kind of payment because the physicians expect or demand to receive it. On the other side, the term ‘bribery’ for informal payments would imply that all receivers of the payments are corrupt. Whether it is true or not, this is a fact that informal payments are part of the culture in some countries. Therefore, it is preferable to use the term informal payments for these payments (2)

Available reported information shows that informal payments happen in at least 22 African, Asian and European countries. Unfortunately, there are no empirical evidences to prove such a phenomenon in these countries (1). These payments are common in East and Central European countries as well as Russia and countries with low and middle income. Though not statistically confirmed, it seems that even countries with high level of income such as West European countries are experiencing the same problem (3). The amount of informal payments for the cares the public sectors render in Armenia is 91% and it comprises 60% to 22% for Slovakia and Albania respectively (4).

Fifty six percent of the total health care costs in Russia is through informal payments (5). In Bangladesh and Cambodia, 10% to 45% of the out-of-pocket payments are informal payments (6). Two third of the health care costs in Tajikistan is also out-of-pocket payments and most of which is paid informally (7). A study conducted in Kerman (Iran) on 500 patients or their companions in public hospitals and private clinics revealed that 56.6% of the subjects were somehow involved with informal payments (8).

After the Islamic revolution in Iran, health care system has witnessed drastic qualitative and quantitative changes. The soaring health expenditures due to population growth, change in people’s expectations, and people’s tendency for using expensive high tech services as well as unequal access to health care services which is mainly due to vast-ness of the country, the population distribution in different climatic conditions and some economic factors have led to some deficiencies in Iran’s health system(9)

One of the drawbacks of Iran’s health care system is under-the-table payments by the patients to some doctors. It is believed that these kinds of payments are very common among certain specialties but since informal payments are received behind closed doors, the real entity of the problem is concealed and no study has claimed to find the hidden nature of the problem. This is why the related questions such as why the physicians receive the informal payments, its consequences and many other aspects of the problem have remained unanswered.

In this study, different aspects of under-the-table payments in Iran were investigated through semi structured in-depth interviews with 12 medical specialists.

Methods

It is a qualitative study and inclusion criteria for the study population was to be clinical expertise in the field of medicine and preferentially surgical disciplines. The participants were selected based on purposive sampling in which either the researchers knew the subjects or other physicians of different specialties introduced them to the researchers. Informed consent in depth semi structured interviews was conducted on 6 surgeons and 6 non-surgeon specialists. The surgeons consisted of an otolaryngologist, an urologist, a general surgeon, and 3 orthopedists and non-surgeons included a neurologist, a dermatologist, a pathologist, a radiologist, a cardiologist and a radiotherapist. Nine of them worked in both private and public hospitals and 2 of them worked only for public sectors and one of them worked for the private sectors. All participants who were employed in public sectors worked at two major medical universities in Tehran city. The why behind choosing the participants from among the people who worked in both public and private sectors was to have the information of both sectors. The reason behind choosing the surgeons was that surgeons have higher chance of receiving informal payments and since many surgeons may be for some reasons reluctant to correctly self-report the cases, 6 other non-surgeons were in cluded in the study. The study was performed in Tehran in May to July 2013.

The interview questions were as follows:

What is the definition of the so-called under-the-table payments in Iran?

Which specialists mostly receive the payments and why?

In which hospitals do the payments have more commonness, private or public? Why?

How are the payments paid? In cash or by other means?

Why do some physicians receive the money?

Why do patients pay the money?

What is the impact (positive or negative) of such payments on the health care system?

What is the impact of the payment on the physician-patient relationship?

What solutions do you suggest for preventing such payments?

The time and place of the interviews were decided by the interviewees and the minuting of the interviews was done by an assistant. Each interview took about an hour and all the interviews were recorded. The interviewees were free to quit the interview or to decide whether their voice should be recorded or not. They were ensured about the confidentiality of the information. To increase the reliability and validity of the study the answers were double-checked by the interviewees. The interviews continued to reach the level of saturation with all 12 participants. To analyze the data, content analysis method was employed. The transcriptions of the interviews were read several times to derive some codes, then the redundant codes were deleted, and finally the remaining codes were categorized in 6 groups.

Results

Considering the questions and the answers, the findings are summarized under 6 general categories as follows:

Definitions of informal payments

Since the health care tariffs are determined by the government for private and public sectors in Iran, all the participants in different wordings explained that under-the-table payments are the money taken from patients in addition to what formally is determined. One participant had his own definition of the problem:

“The definition of people of informal payments is the money they give to public health providers to have privilege including confidentiality of records, privacy —not safeguarded in public hospitals- or for asking particular physician to visit them. This kind of payment is very rare in public hospitals. The definition common in physicians is that they believe the tariffs determined for the clinical practice and surgical operations are not accepted by the practitioners, and they demand patients more than the state determined tariffs. This kind of payment is very common and 70% to 80% of the physicians ask for such money.”

Commonness

Almost all the subjects stated that under-the-table payment is mostly common among surgeons doing some technical procedures and as they claimed, the reasons are the unfair and unrealistic determined tariffs. One of the participants said:

”In vital operations such as open heart surgery in which the patients are helpless or the surgeon is famous for being the best in the field, patients are more susceptible of being bullied by the surgeons.”

Another subject said:

“When people are helpless they give bribery. Informal payments, I believe, are common in acute and cosmetic surgeries and neurosurgeries.”

Another participant said:

“Nowadays, the payment is not hidden; the patient openly asks the physicians the prices. Under-the-table payments though illegal are so common that everybody considers it as commonplace. The fees are astonishingly varied from 5000,000 to 50,000,000 Rials ($ 170 to $1700) for the same surgery.”

There were disagreements about the commonness of the payments in different hospitals. Six of the participants believed that it is more common in private hospitals and 4 of them maintained that it is more so in public (mostly non-teaching) hospitals. One of them said it is common in hospitals affiliated to social security organization and one of them had no idea in this respect.

The subjects who argued that informal payments are more common in private sectors had two reasons, first, the direct monetary physician-patient relationship and second, absence of strict control on private sectors comparing to public sectors. Those who argued for public sectors said that the reason is very low tariffs in public hospitals compared to private sectors.

Another participant had a different viewpoint:

“Since there are more problems in public sectors, to facilitate the process of treatment, the patients have to pay informal payments.”

The varieties of informal payments

In this study, all participants confirmed that informal payments in Iran are in cash (direct or indirect). Some participants claimed that in some cases gold coins are given to the physicians as a gift, too. Some participants said when the payment is direct and in cash, it is not detectable and therefore preferable.

The reasons stated for giving and receiving informal payments

All participants in this study claimed that unrealistic tariffs, which lead to low income of the physicians, are the most important reason for under-the-table payments. One participant said:

“What we receive for performing a C-section equals the price of a turkey, and if some medical errors happen to the patients we have to pay the blood money which almost equals the price of one or more camels.”

Another participant also stated:

“When a surgeon performs an intricate surgery s/he tries her or his best not to hurt the patient but receives too little in return. So they convince themselves to receive under-the-table payments as their rights.”

In addition to underpayment tariffs, the participants mentioned other non-prioritized reasons for giving informal payments. Generally, the reasons are categorized in Table 1.

Table 1

Factors involved in getting informal payments

No.	Factors
1	Underpayment tariffs
2	Direct physician-patient relationship
3	Lack of control of authorized organizations
4	Not complying with codes of ethics by some physicians
5	Too much financial expectation of some physicians
6	Low payments of insurance companies(insufficient government investment)
7	Personal financial problems of physicians
8	Normalization of this kind of payment because of its commonness
9	Inefficacy of health care system

About the lack of efficacy of health system, one participant said:

“Since the patients prefer to choose their own doctors, they tend to go for the well-known physicians who have a waiting list but accept to do their operation out of the list by receiving under-the-table payments.

On the other hand, other physicians who don’t have enough patients tend to bribe ambulance drivers to find patients for them.”

About insufficient government investment, one of the participants said

“The health system welcomes informal payments. It means the government is well aware that insufficient investment leads to these payments and in a way does not prevent physicians from receiving the money in order to compensate for the insufficient investment from people’s pocket, unless a lawsuit is filed against the physician.”

About the direct financial relation between the physician and the patient, one of the participants said:

“Though logically there should not be such a relation, the main reason is the existence of financial relation between the physician and the patient. The reason for this sick relation is that the insurance companies do not play their real role in this respect. In fact, they can break this cycle and consequently break the financial connection between the physician and patients.”

About the motive of patients for paying informal payments all participants believed that receiving better and faster health care is the main reason for paying informal payments from the patients.

Four participants expressed their ideas about this point as follows:

“For patients, their lives are more important than money.”

“Today, it is the patient who asks the physician about the amount of under-the-table payments. The patients think that a surgeon who gets more for a gallbladder surgery, for example, performs a better surgery than others do. While it is the duty of the surgeon to do his/her best for the patients with whatever payment they get.”

“I think when patients are helpless, they pay the payment and the most they can do is to bargain. The patients accept to do this because their lives are worth paying the money. They may sell their houses to afford the payments and even accept to fall below the poverty line.”

“Some think if they pay more or if a well-known surgeon operates on them, they will certainly get better results.”

Additionally, some participants mentioned other factors:

“Some patients are proud of paying too much for their treatment.”

“The unfair distribution of services throughout the country has brought about monopoly of some treatments by certain physicians and the patients have to attract the favor of the physicians somehow.”

The impact of informal payments on health system and physician-patient relationship

In this study, the participants did not have the same viewpoints about the negative aspects of informal payments. Five of them mentioned the increase of health costs.

One of them said:

“This is a reality in our country that at the end of each year some people slip below the poverty line because of the catastrophic costs of special diseases.”

The summary of negative aspects of under-the-table payments stated by one or some of the participants is categorized in Table 2.

Table 2

Negative consequences of informal payments

No.	consequences
1	Increase in the patients’ health costs
2	Imposing additional expenditures on health system and damaging limited health resources of the country
3	Increase in the price of health care delivery
4	Decrease in quality care delivery
5	Damaging health economy because of incorrect cash flow in health services
6	Ruining the social status of physicians
7	Normalization and dissemination of illegal and immoral behaviors
8	Establishment of injustice in health care system- the richer a person, the more they benefit from services
9	Performing unnecessary procedures
10	Impairment physician-patient relationship
11	Increase in the lawsuits of physicians

Regarding the damage to social status of physicians, one participant said:

“It leads to mistrust towards the physicians. Criminals usually start from simple things; it can trigger physicians to start dealing with things irrelevant to medicine.”

About doing unnecessary procedures one participant said:

“Nowadays, physicians perform some unnecessary things in order to earn money. It is heard that in some social security affiliated hospitals (in which tariffs are low) surgeons do non-indicated operations.”

About the impact of informal payments on physician-patient relationship, all participants stated that under-the-table payments impair the physician-patient relationship. Some of the participants said:

“It impairs the trust between the physician and the patient; the patients think the physicians are getting more than what they really deserve and the physicians think they are getting less than what they are worthy of-- a lose-lose game.”

“This is a case of impairment in physician-patient relationship and the patient sees the physician as a businessman.” ; “The relation is transformed to a business deal activity.” ; “The trust between the physician and patient is disturbed. When something bad happens to the patients, they think if they had paid the under-the-table payments, such a bad thing wouldn’t have happened.” ; “This action, however, is illegal and the patients don’t like it and as a result they hate the physicians.” ; “The relation will be perverted and instead of thinking of the health of the patients, the physicians think of their personal gain.”

Two participants also mentioned positive outcomes of the problem as follows:

“The only positive consequence of under-the-table payments is that the patients get the required health care easier.” ; “It drops off the physicians’ expectations from the health system. If they can’t get the under-the-table payments, they can’t run their lives well and consequently they complain.”

No other positive outcomes mentioned by other researchers were pointed out by the participants.

How to approach the problem

Most of participants (10 people) believed that making tariffs realistic and reflecting the real costs of services provided could be the best solution to the problem.

Regarding this point, one of the participants said: “If the tariffs are not in accord with the health expenditures, two things may happen: either the facility should be closed or the expenditures of the facility should be supplied in other ways such as receiving informal payments from the patients”.

Another participant said:

“To improve the financial condition of the physicians is very important and as long as the financial problems exist, other solutions cannot help the problem”

In addition, some participants had more suggestions. Generally, the suggestions are summarized and categorized as follows in Table 3:

Table 3

Approach to the informal payment

No.	Approach
1	To realize tariffs
2	To cut the direct physician-patient financial relationship
3	To support the insurance companies
4	To increase the physicians’ salaries
5	The strict control on health care services by authorized organizations
6	Fair distribution of services throughout the country
7	To reform the referral system and family medicine
8	To inform and educate the physicians about the side effects of under-the-table payments

About informing and educating physicians, one participant said:

“No reason can justify under-the-table payments. I think paying attention to humanity and conscience is an important factor. Education is very influential for some people. I think physicians learn and comply with new things better than others in this respect.”

Speaking about the direct financial connection between the physician and patients, one of the participants said:

“Direct financial relationship between the physicians and patients should be reduced wherever possible. The effective way to get this purpose is to have strong support of insurance organizations.”

About monitoring the system, another participant claimed:

“Only making the tariffs realistic does not work. It also requires monitoring. These two have to be together because if the tariffs are not realistic the monitoring system still does not work and vice versa.”

Discussion

As stated earlier, there is no comprehensive acceptable definition for informal payments (1). However, there are some definitions for the informal payments. According to one of these definitions, for example, the informal payment is the money given to health providers or health institutes, which is not officially required but they expect to receive the payments or ask for it(10). By another definition, it is called the monetary or in-kind transaction between the patient and health providers for public services officially free of charge in public portions (11).

Regarding the definition of informal payments in different countries and the results of this study, this type of payment is not limited to private or public or even free health services in Iran, all sectors of health, public or private, may get the money in addition to the determined formal tariffs. However, only a reliable quantitative study can substantiate the prevalence of informal payments in private or public sectors.

In addition to cash payments, informal payments can be given through other ways such as gifts and offering special services to the physicians or their relatives. Another kind of informal payments is to ask the patients to provide the hospital with goods and services which are actually the responsibility of the hospitals such things as bed sheets, washing clothes, some medical supplies, and also make the patients’ relatives stay in the hospital overnight to take care of their patients(1). For example, during the fall of the Soviet Union, because of the scarcity of medical supplies (10%-20%) such as needles, gloves, intravenous tubes, surgical tools and essential surgical instruments, the patients or their relatives were asked to provide them through informal ways (12). It seems that in most cases the kinds of payments (in cash or gifts) are similar to other countries. Providing some medical supplies because of insufficient financial resources is not considered a type of informal payments in Iran and therefore the participants did not mention it. The studies on the informal payments in some countries show different reasons for giving or receiving informal payments, some of which are as follows:

Insufficient investment of some governments on health care (7, 11 -16)

To fill the gap between the insufficient investment of some countries on health care and what the real prices of health care are, the informal payments come true (11). Evidence show in countries with low or middle income, informal payments is the main source of supplying the health care costs (17, 18). Few evidence available show that in countries such as Georgia, Azerbaijan and Russia, informal payments are the most important source for health care delivery (3).

The low income of health providers: The low income of health providers is one of the main reasons for demanding and accepting, in-kind or in cash, informal payments (11, 12, 15, 16). In the former Soviet Union and socialist countries of Central and Eastern Europe, because of the intentionally low-kept (delayed paid) salaries of physicians which was about 70% to 80% of the average salary of people, there was a tendency to ask for informal payments (12). In Poland, informal payments accounted for twice as much as the physician’s salary and were the main source of income for physicians (18).

Lack of a strong private sector: One of the reasons for unofficial payments is monopoly and misuse of market position (4). Breaking down the monopoly, wide spread private sectors constrains informal payments received by public health providers (12).

The tradition of gratitude in some cultures: In some cultures, the informal payments are just a gift given for appreciation and gratitude for receiving health care (7, 12, 15, 16). In other cultures, tipping is at work and it makes the distinction between tipping and informal payments very difficult (12). A qualitative study in Georgia, for example, showed that one of the reasons for out-of-pocket and unofficial payments is culture-based and normal among people. Some patients, for example, said it is embarrassing to visit the physicians when we do not have money to tip (19).

Access to fast and better quality services: Insufficient investment in health sectors and consequently lack of sufficient supplies and technical services lead to low quality services and a waiting list, which in turn lead to informal payments to get faster and better quality health care. According to the anecdotal reports where the relocation of scarce resources of supply is possible by the staff, informal payments may be at work. A study in Kazakhstan showed 47% of people paid informal payment to receive better services (12).

Regarding the participants’ responses, the etiology of informal payments, at least in some cases in Iran, is similar to what we have in other countries. The insurance companies are mostly governmental in Iran and because of insufficient government investment in insurance companies and the inefficacy of these companies; physicians do not receive satisfactory reimbursement. Making the tariffs realistic increases patients’ expenses and because they cannot pay such prices, the government is reluctant to make the tariffs realistic and this motivates the physicians to demand under-the-table payments. On the other hand, since there is fee-for-service system in both private and public hospitals in Iran, low tariffs for health services lead to low income of the physicians who would in turn try to compensate it by getting informal payments.

About the outcomes of informal payments, some researchers documented some positive aspects of informal payments in some countries. For instance, some studies show these payments facilitate the relationship between health providers and patients, instigate better behavior of the providers and act as an incentive for the staff to stay within the public sector. It is also a way, which helps the patients show their gratitude (19). However, most studies have revealed the negative facet of the issue. In a qualitative study on the health workers in Tanzania, for instance, the participants admitted they felt enslaved when receiving informal payments from the patients. They said it ruins their dignity and self-confidence (6).

Generally, some of the negative impacts of the informal payments can be as follows:

Deterring poor people from having access to health care: Obligatory payments may deter the poor from having access to health care services and thereby putting heavy burden on the shoulders of the poor. Since they are caught in an emergency, the poor may sacrifice other needs for the sake of their health (19). Ensor suggests that informal payments may lead to quasi redistribution of wealth in which physicians play the role of “Robin Hood” conducting cross subsidizing. A study in Poland showed that the poor pay more informal payments than the rich. This study falsifies “Robin Hood” theory (3). Another qualitative study in Georgia showed that people who cannot afford the health care costs do not go to the doctors’ or postpone going to doctors’ or leave the treatment incomplete (19). This fact shows that money plays an important role in receiving better treatment for the rich than for the needy people (7).

Corruption in the health care system: Since informal payments are directly paid to the person delivering the health care, this person is among the people accused of abusing public office for personal gain and therefore, this action can be called corruption (13). Evidence show that a wide range of informal payments indicates bribery and corruption in the country and health care sectors (7).

Unnecessary and unimportant treatments: Informal payments shift resources to more profitable and not necessarily effective health care delivery (6). The government in China, for instance, tends to force the health sector to deliver health services below real costs. As a result Chinese hospitals initiated new diagnostic and treatment services attractive to the patients. These new services were not in the government price list, therefore, facilities started using them. Shanghai province, for instance, had more CT scan than Britain. Kazakhstan and other former socialist Soviet Union countries have the same condition, too (10).

Boosting prices: Informal payments remarkably increase the patients’ total expenditures (7). One reason is that people have to satisfy their needs from retail market and thus leads to increase in the prices of goods in health (10).

Informal payments motivate immoral and unprofessional behaviors (15)

The results of the study about the negative outcomes of informal payments are supported by researches conducted in other countries. As the results of the study showed, like the ones shown in other countries, the participants just mentioned the negative aspect of the problem. Cases such as soaring expenditures of patients, high costs of health services, lack of access of poor people to health services and doing unnecessary surgeries and procedures are among the findings supported by other studies. Regarding the positive aspects of taking informal payments mentioned by other studies, no participants mentioned any of them.

Conclusion

Despite the growing developments in Iran’s health care system, the soaring health expenditures have led to some shortcomings in Iran’s health system. One of these shortcomings is informal payments for better services. Almost all the participants in the study claimed that unrealistic tariffs are the main reason for asking for informal payments. Therefore, doing a reform in this respect should start with making the tariffs realistic based on the real price of the services delivered as well as the investment of the government in health care system and supporting the insurance organizations. If no measures are taken in time, informal payments will continue to widen the gap in physician-patient relationship and damage the public trust in physicians

Ethical Consideration

Ethical issues (Including plagiarism, Informed Consent, misconduct, data fabrication and/or falsification, double publication and/or submission, redundancy, etc.) have been completely observed by the authors.