Informal Payments in Healthcare: A Case Study of Kerman Province in Iran

Document Type : Original Article


1 Research Center for Health Services Management, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran

2 Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran


Informal payments for health care, which are common in many countries, can have negative effects on health care access, equity and health status as they lead people to forgo or delay seeking care, or to sell assets to pay for care. Many countries are putting reforms in place with the aim of reducing informal payments. In order to be successful, such policies should be informed by the underlying causes of such payments. This study attempts to explore why, how, and in what ways informal payments occur.
We conducted face-to-face interviews with a purposeful sample of 45 participants, including patients, healthcare providers and officials, in Kerman province in Iran, in 2010. The research participants were asked about the nature of informal payments, the reasons behind both asking and making those payments. We analysed the data using content analysis.
We found that people make informal payments for several reasons, namely cultural, quality-related and legal. Providers ask for informal payments because of tariffs, structural and moral reasons, and to demonstrate their competence. Informal payments were found to be more prevalent for complex procedures and are usually asked for directly.
Informal payments are present in Iran’s health system as in other countries. What makes Iran’s condition slightly different from other countries is the peculiarity of reasons behind asking informal payments and the disadvantages associated with these kinds of payments. Iran could overcome this dilemma by precise investigation of the reasons to inform appropriate policy formulation. Some policies such as raising salaries, justifying the tariffs and cost-sharing, defining a benefits package of services, and improving accountability and transparency in the health system could be taken by the government to alleviate the problem.


Main Subjects

1. Setayesh M, Nakhaee N, Rohani A. [Assessment of people viewpoint about informal payment to Kerman physicians]. Iranian Journal of Ethics in Science and Technology 2007; 2: 81–8.
2. Onwujekwe O, Dike N, Uzochukwu B, Ezeoke O. Informal payments for healthcare: Differences in expenditures from consumers and providers perspectives for treatment of malaria in Nigeria. Health Policy 2010; 96: 72–9. doi: 10.1016/j.healthpol.2009.12.014  
3. Vian T, Grybosk K, Sinoimeri Z, Hall R. Informal payments in government health facilities in Albania: Results of a qualitative study. Soc Sci Med 2006; 62: 877–87. doi: 10.1016/j.socscimed.2005.07.005
4. Chereches RM, Ungureanu MI, Sandu P, Rus IA. Defining informal payments in healthcare: A systematic review. Health Policy 2013; 110: 105–14. doi: 10.1016/j.healthpol.2013.01.010
5. Liaropoulos L, Siskou O, Kaitelidou D, Theodorou M, Katostaras T. Informal payments in public hospitals in Greece. Health Policy 2008; 87: 72–81. doi: 10.1016/j.healthpol.2007.12.005
6. Chawla M, Berman P, Windak A, Kulis M. Provision of ambulatory health services in Poland: a case study from Krakow. Soc Sci Med 2004; 58: 227–35. doi: 10.1016/s0277-9536(03)00006-6
7. Killingsworth J, Hossain N, Hedrick-Wong Y, Thomas S, Rahman A, Begum T. Unofficial fees in Bangladesh: price, equity and institutional issues. Health Policy Plan 1999; 14: 152–63. doi: 10.1093/heapol/14.2.152
8. Stringhini S, Thomas S, Bidwell P, Mtui T, Mwisongo A. Understanding informal payments in health care: motivation of health workers in Tanzania. Hum Resour Health 2009; 7: 53. doi: 10.1186/1478-4491-7-53
9. Barber S, Bonnet F, Bekedam H. Formalizing under-the-table payments to control out-of-pocket hospital expenditures in Cambodia. Health Policy Plan 2004; 19: 199–208. doi: 10.1093/heapol/czh025
10. Gaal P, Belli P, McKee M, Szócska M. Informal payments for health care: definitions, distinctions, and dilemmas. J Health Polit Policy Law 2006; 31: 251–93. doi: 10.1215/03616878-31-2-251
11. Vian T, Burak LJ. Beliefs about informal payments in Albania. Health Policy Plan 2006; 21: 392–401. doi: 10.1093/heapol/czl022
12. Akashi H, Yamada T, Huot E, Kanal K, Sugimoto T. User fees at a public hospital in Cambodia: effects on hospital performance and provider attitudes. Soc Sci Med 2004; 58: 553–64. doi: 10.1016/s0277-9536(03)00240-5
13. Delcheva E, Balabanova D, McKee M. Under-the-counter payments for health care: Evidence from Bulgaria. Health Policy 1997; 42: 89–100. doi: 10.1016/s0168-8510(97)00061-4
14. Lewis M. Informal payments and the financing of health care in developing and transition countries. Health Aff 2007; 26: 984–97. doi: 10.1377/hlthaff.26.4.984
15. Lewis MA. Who is paying for health care in Eastern Europe and Central Asia? Washington D.C.: World Bank Publications; 2000.
16. Thompson R. Health sector reform. Int J Health Plann Manage 2006; 15: 169–87.
17. Ensor T. Informal payments for health care in transition economies. Soc Sci Med 2004; 58: 237–46. doi: 10.1016/s0277-9536(03)00007-8
18. Ghiasipour M, Abolghasem P, Arab M, Mahmoodi M, Abutorabi A. [The Analysis of Informal Payments Among Hospitals Covered Under Tehran University of Medical Sciences (TUMS) 2009]. Hospital Quarterly 2011; 10: 1–14
19. Miller WL, Koshechkina TY. If you pay, we’ll operate immediately. J Med Ethics 2000; 26: 305–11. doi: 10.1136/jme.26.5.305
20. Ozgen H, Sahin B, Belli P, Tatar M, Berman P. Predictors of Informal Health Payments: The Example from Turkey. J Med Syst 2010; 34: 387–96. doi: 10.1007/s10916-008-9251-8
21. Tourani S, Amiresmaili MR, Maleki MR, Hadian M. An interview survey on health priority setting practice in Iran. Research Journal of Biological Sciences 2009; 4: 1193–201.
22. Takian A, Rashidian A, Kabir MJ. Expediency and coincidence in re-engineering a health system: an interpretive approach to formation of family medicine in Iran. Health Policy Plan 2011; 26: 163–73. doi: 10.1093/heapol/czq036
23. De Bruin A, Picavet HSJ, Nossikov A. Health interview surveys: towards international harmonization of methods and instruments. WHO Reg Publ Eur Ser 1996; 58: 1–161.
24. Stepurko T, Pavlova M, Gryga I, Groot W. Empirical studies on informal patient payments for health care services: a systematic and critical review of research methods and instruments. BMC Health Serv Res 2010; 10: 273. doi: 10.1186/1472-6963-10-273
25. Tomini S, Maarse H. How do patient characteristics influence informal payments for inpatient and outpatient health care in Albania: Results of logit and OLS models using Albanian LSMS 2005. BMC Public Health 2011; 11: 375. doi: 10.1186/1471-2458-11-375
26. Aarva P, Ilchenko I, Gorobets P, Rogacheva A. Formal and informal payments in health care facilities in two Russian cities, Tyumen and Lipetsk. Health Policy Plan 2009; 24: 395–405. doi: 10.1093/heapol/czp029
27. Azadarmaki T, Bikaranbehesht M. [Offering In the Iranian Daily Life]. Barge Farhang 2010; New: 196–209.
28. Shahriari H, Belli P, Lewis M. Institutional issues in informal health payments in Poland. World Bank Draft Report, 2001.
29. Tourani S, Maleki MR, Hadian M, Amiresmaili MR. [A survey on present status of health services priority setting in Iran]. Payesh 2011; 10: 217–30.